The role of hysteroscopy in miscarriage

Elias Tsakos MD, FRCOG
Medical Director , Embryoclinic

Miscarriages and RPL, Reproductive surgery

From this video you will find out:
  • What are the main factors of miscarriage occurrence?
  • What is hysteroscopy, and how is this procedure performed?
  • What types of hysteroscopy are there?
  • When should a hysteroscopy be indicated?
  • Can hysteroscopy be a diagnostic tool in women with recurrent pregnancy loss?

The role of hysteroscopy in miscarriage

During this session, Dr Elias Tsakos, FRCOG, Medical Director of Embryoclinic – Assisted Reproduction Clinic in Thessaloniki explained the role of hysteroscopy in miscarriage management.


Miscarriage is defined as the loss of pregnancy before 20 weeks of gestation. It is the most common form of pregnancy loss, occurring in approximately 1 in 4 pregnancies. The rate of miscarriage increases with a woman’s age, and it varies among different age ranges. For women in their early 30s, the rate may be as low as 10-15%, while for women in their 40s, it could be as high as 30%. In the mid-40s, the rate can reach 50-70%. These rates refer to women conceiving naturally or using their own eggs in fertility treatments. However, even with egg donation, there is still a higher association of miscarriage with age, although the rate is lower compared to using their own eggs. It’s important to note that around 80% of miscarriages occur within the first trimester.

Various factors contribute to miscarriages, and their significance differs based on a woman’s age. In younger women, chromosomal anomalies are more common, while uterine anatomy anomalies play a more significant role. Thrombophilia, hormonal factors, immunology factors, and metabolic factors are also potential contributors. Sometimes, there can be a combination of these factors, and it requires investigation to identify them accurately.


Hysteroscopy is a simple and cost-effective procedure that allows direct visualization of the uterine cavity. With a hysteroscope, which is a small-diameter instrument, we can examine the uterine cavity by inserting it through the cervix. No incisions or cuts are required. The hysteroscope typically includes a camera, a flashlight, and a working channel for operative hysteroscopy if necessary.

There are two types of hysteroscopy: diagnostic and operative. Both can be performed in an outpatient clinic. There has been much discussion about where to perform hysteroscopy, ranging from general anaesthesia in a hospital setting to performing it without anaesthesia or with mild sedation. We need to strike a balance between minimal access and outpatient procedures while ensuring patient comfort and safety.
In my practice, I often use anaesthesia to ensure the patients have a better experience.

The term “minimally invasive” is used to describe hysteroscopy, as there are no incisions or scars involved. It is considered a standard of care and offers a one-stop approach to diagnosis and treatment. However, there is debate about how much can be treated in the outpatient setting or in an IVF clinic. I believe we should carefully select patients and consider the complexity of the surgery before performing hysteroscopic interventions. In some cases, the diagnostic part can be done in the outpatient setting, while the operative part may require a hospital setting.

The applications of hysteroscopy include restoring the anatomy of the uterine cavity, diagnosing and treating congenital uterine anatomical pathologies, and assessing unexplained infertility or recurrent miscarriages. Additionally, hysteroscopy can be used to manage miscarriages. Instead of blindly evacuating the products of a miscarriage, hysteroscopy allows for the removal of retained products while evaluating the uterine cavity, eliminating the need for a separate diagnostic hysteroscopy.

Hysteroscopic assessment

During the hysteroscopic assessment, we may encounter normal and pathological findings. With the advancement of ultrasound technology, we can often suspect pathology before the hysteroscopic procedure and prepare accordingly. If a polyp, fibroid, or septum is found, it can be treated during the hysteroscopy, depending on the setting and circumstances. Tissue biopsies can also be performed for the safety of our patients, especially those in their mid to late 40s or early 50s.
Overall, hysteroscopy offers valuable diagnostic and therapeutic benefits in the management of various uterine conditions.

Probably, you are aware that the law now in Greece allows performing fertility treatment and IVF for women up to the age of 54, just under 54. This means we are dealing with women who may potentially have malignancy. Therefore, we must recognize the value of hysteroscopy in order to eliminate the risk of malignancy.

In my practice, I encounter two to three cases of uterine malignancy every year. You can imagine the consequences if such cases were missed and the patients proceeded with IVF, only to have the diagnosis delayed during pregnancy and delivery. So, the importance of hysteroscopy extends beyond the success of IVF to ensure the safety of our patients.

Hysteroscopic treatments

The main pathologies we treat via hysteroscopy include fibroids, congenital anomalies, polyps, and adhesions. There are various types of hysteroscopes and energy sources available, offering a wide range of options and techniques. Over the past 20 years, we have gained extensive experience in the field of hysteroscopy.

Hysteroscopy has been proven to improve fertility, not only in operative procedures but also in diagnostic hysteroscopy. Our own studies at Embryoclinic, have shown that even with normal pathology, hysteroscopy can increase the chance of conception by about 10%.

A new application of hysteroscopy is the targeted removal of products of conception. The team at Embryoclinicn are enthusiastic about this approach due to the amazing evidence in the literature. Instead of a blind procedure, it is now possible to perform a targeted removal with better precision, minimal injury to the endometrium, and simultaneous evaluation of the uterus. This approach provides multiple benefits, including a high success rate, low complication rate, high live birth rate, and low pregnancy loss rate.

Studies demonstrate the significant advantages of hysteroscopic management compared to the standard blind surgical evacuation of miscarriages currently practised worldwide.

Take home messages

In conclusion, miscarriages can, unfortunately, occur following spontaneous or artificial conception. Hysteroscopy plays a valuable role in diagnosing and treating anatomical anomalies associated with miscarriage. It can also be used as a management tool for miscarriages, resulting in improved pregnancy rates, reduced complications, decreased re-operation rates, and decreased bleeding.

- Questions and Answers

Before embryo transfer, do you recommend doing a hysteroscopy? Is it true that after hysteroscopy, the chances of successful embryo implantation are much higher?

I believe in individualizing the approach. In my opinion, performing an outpatient diagnostic hysteroscopy on all IVF patients in an outpatient setting with either local anaesthesia or mild sedation is not a significant undertaking in the overall management of our fertility patients. Considering that hysteroscopy is likely part of the standard fertility workup, it holds significant value. However, for young, fit women with normal presentations and male cycle infertility, I may consider skipping hysteroscopy before the initial IVF treatment, as the chances of finding pathology are very small. Additionally, such patients are not very common nowadays. The majority of patients I treat have had multiple failures and are often international patients who have had at least 2 failures before coming to us. This is a select group in whom the likelihood of identifying something through hysteroscopy is higher, such as cervical stenosis, hyperplasia, fine adhesions, endometriosis, or suspected polyps. Therefore, we need to consider whether hysteroscopy may be indicated before embryo transfer for each patient and discuss this with them. We should also acknowledge the uncertainty of diagnosing with 100% accuracy through scans alone or even with the addition of Hysterosalpingography (HSG) techniques. The combined diagnostic accuracy of these techniques may not exceed 85%. Thus, it is important to share our feelings and make decisions together with our patients. For older patients, specifically women over the age of 40, I believe hysteroscopy is fairly mandatory before embryo transfer. The value of hysteroscopy remains for about a year, and although we may not need to repeat it within that timeframe, it is often useful. Hysteroscopy facilitates embryo transfer by providing a tissue diagnosis of normal endometrium without endometritis or hyperplasia. In cases of additional pathology, it gives us confidence that the endometrium is normal. I recall a case a couple of years ago where we detected uterine sarcoma in a mid-40s patient who had a non-diagnosed myoma of only 3 and a half centimetres in diameter. This emphasizes the importance of considering the possibility of rare malignant pathologies. I am currently treating a young lady in her mid-30s with stage 1A endometrial carcinoma. She has obesity, a history of polycystic ovaries, and endometrial hyperplasia. Hysteroscopy allowed us to detect endometrial cancer at a very young age. Therefore, hysteroscopy may protect against undiagnosed dangerous pathologies, although they are rare. Furthermore, in terms of fertility, hysteroscopy will most certainly improve the fertility outcome.

You mentioned using hysteroscopy to help with embryo transfer. My first few transfers were painful, but 6 weeks after the diagnostic hysteroscopy, the embryo transfer was fairly noticeable, albeit unsuccessful. Is this effect on easing transfer sometimes time-limited, or would it last for the next transfer?

I don’t think that embryo transfer should be painful. If it is painful, it means that it’s difficult and probably a little bit bloody. It indicates that your body has produced substances that may increase uterine contractions and could be associated with failure. We don’t want that; we want it to be easier. Let me put it this way, embryo transfer is the single most important skill, technique, phase, and stage of your fertility treatment, in my opinion. That’s why it should be performed by the most experienced fertility specialist available on the day in the IVF unit. In my unit, for example, no one with less than 5 years of experience following the fellowship and fertility training would be allowed to perform embryo transfers. Just to show you how important it is, if I want to give you one of my favourite examples, it’s like shooting a penalty. You have the whole team, coaches, and all the preparation to gain a penalty, but then somebody has to put it in. We expect it to go in, usually, it does, but if it fails, it’s a disaster. And it’s not excusable; it’s a disaster. You’ll remember those football scenes of a missed penalty. That’s how I feel about it. I believe embryo transfers should go in smoothly with no stress to the patient, doctor, embryologist, or nurses. They should be painless and swift, taking less than two minutes. They should be nice and clean when it comes out. We should be using a soft catheter to avoid potential difficulty and trauma. It’s important to have rehearsed the procedure a couple of times before. Yes, a hysteroscopy facilitates the process. One of my biggest stresses is when I perform an embryo transfer on a patient whom I haven’t seen before or haven’t done a mock transfer or hysteroscopy on. I think your first example shows the difference a hysteroscopy can make, ensuring an easy embryo transfer and confidence in the normality of the endometrium. There are many other factors in investigating fertility that we cannot be 100% sure about, but at least let’s make sure the endometrium and cervix are normal.

My wife is 25, and she hasn’t had menstruation. All laboratory and HSG results are normal, and nothing happens. What shall I do? Any advice?

If the HSG is normal and the laboratory results are normal, I find it hard to believe. Invariably, there’s either a hormonal or anatomical anomaly that needs further investigation. It’s important to look deeper and find the reasons behind this. Hysteroscopy may be valuable, along with more elaborate laboratory tests. We should be able to find a reason why a young woman has no menstruation.

In 2022, I took 12 weeks of DHEA at 75 milligrams due to a poor response in two previous cycles. I had 4 follicles for egg retrieval, ranging from 2 to 4 in size, which were considered too small or too big. I am 35 years old. Before proceeding with DHEA, I had a scan to assess the baseline antral follicle count (AFC). The clinic had only measured AMH before, not AFC. The day 3 scan showed a large follicle on each ovary, and no smaller antral follicles could be counted. Could starting DHEA during the luteal phase have caused this? If this had happened at the start of stimulation, would it be bad for the response? My clinic does not do baseline scans before starting FSH injections, only at the 10th scan before the trigger. Should I be asking for a baseline scan and more monitoring during stimulation?

If I can just pick out a couple of topics, I mean, DHEA has a long-term effect on the sensitivity and responsiveness of the ovaries during follicle stimulation. So, I don’t think it’s that important whether you start DHEA in the luteal phase or follicular phase. We are expecting to hear new evidence on DHEA, including the types, duration, timing, and dosage of administration, at the upcoming ESHRE conference in Copenhagen in June. However, I can assure you that it doesn’t matter if it’s the luteal or follicular phase, and you probably need to take it a few weeks in advance. The specific dosage, duration, and timing are still being determined. Regarding the baseline scan, I understand that it can be a hassle to perform, as it requires a seven-day service and short-notice appointments. Many clinics don’t perform baseline scans for all patients, but in my practice, I don’t start anything without a baseline scan. It’s crucial for assessing the pelvic organs and ensuring there are no cysts, pathologies, or abnormalities that could affect the stimulation process. Baseline scans are like checking an athlete before a marathon to ensure everything is normal and safe. In my practice, I also combine it with hormonal testing for a complete evaluation. Hormonal testing is essential for identifying any grey areas and determining the hormone levels of follicles. This helps in deciding whether to proceed with stimulation and when to start it. It’s also important to assess the hormonal status closer to the stimulation date, especially if there has been a gap between the pre-IVF assessment and the start of stimulation. Hormonal testing provides a comprehensive view of the patient’s condition and helps detect any missed pathologies or persistent follicles that could affect the cycle. In summary, I believe baseline scans and hormonal testing before stimulation are crucial for ensuring the safety and effectiveness of the process. It’s a significant responsibility to start ovarian stimulation, and these assessments help minimize potential risks and optimize the chances of success.

Could endometritis or endometriosis be noticed during a hysteroscopic investigation?

Yes, endometriosis can definitely be diagnosed during a hysteroscopic investigation. Not only can it be clinically observed, but it can also be confirmed histologically through tissue biopsy. In my practice, I almost always perform a tissue biopsy during hysteroscopy for diagnostic purposes. This allows for the identification of endometriosis or the absence of endometriosis. Endometriosis refers to the presence of endometrial-like tissue outside the endometrial cavity. Additionally, we may have suspicions of adenomyosis, which is endometriosis within the uterine wall. However, it is important to note that endometriosis specifically refers to tissue outside the uterus.

How long is the hysteroscopic result reliable? For example, if the endometrium was normal.

In my opinion and practice, if the endometrium is normal, I would say one year. So if I perform hysteroscopy and everything is normal, and I’m satisfied with the scans in the next few months, I don’t need to do it again. There’s no need for further interventions. However, if it is abnormal, it depends on the specific abnormality. In my opinion, the most challenging abnormalities are adhesions and fibroids that may be touching and distorting the uterine cavity. Regarding adhesions, even with the best treatment and expertise, adhesions may come back or maybe inadequately treated due to the nature of the pathology. In such cases, I am always sceptical, and I counsel my patients about the possibility of repeated hysteroscopies. As for fibroids, if it’s a visible fibroid or polyp that can be removed easily, then it’s fine. However, if it’s an intramural fibroid within the uterine wall touching the sub-endometrial aspect, especially if it’s a fairly large fibroid, we may need to reassess and consider further intervention. Another area that can be challenging is cervical stenosis. The severity of the stenosis determines the treatment approach. Mild to moderate stenosis can often be managed with modest dilatation, while severe stenosis associated with adhesions or anatomical issues may require more careful consideration. In my experience, for the majority of women with mild to moderate stenosis, a dilatation of 7 or 8 is sufficient and does not create future problems. I prefer not to go beyond that limit to avoid the risk of an incompetent cervix.

We had 3 implantation failures and 1 chemical pregnancy with a donor egg. We have been advised to have hysteroscopy and laparoscopy. Do you think laparoscopy is also needed or useful?

Hysteroscopy is necessary. We try to be as hands-off and non-invasive as possible, but we also need to balance the need for knowledge and understanding of what’s going on in your case. With four implantation failures, it’s a complex situation, and we need to confidently determine if there are any pathologies or issues in your anatomy that may affect implantation. Anatomy includes not only the endometrium but also the myometrium (uterine wall) and the surrounding areas that can impact implantation. In your case, it would require a thorough discussion. One approach to possibly avoid laparoscopy would be to perform hysteroscopy first and evaluate if everything appears normal. If there is no suspicion of infection or endometriosis, then a laparoscopy may not be necessary. However, if there are any suspicions of infection or endometriosis, a laparoscopy can help ensure that nothing is missed. Infections and inflammation, including those caused by endometriosis, can have a significant impact on implantation. It’s important to balance all these factors while aiming to be as minimally invasive as possible.

You mentioned that there are two types of hysteroscopy: diagnostic and operative. Can the two be combined in one go if something is discovered during the diagnostic hysteroscopy?

The answer is that they can be combined, but it depends on the setting. This should be discussed with your doctor. In most fertility clinic settings, we are not prepared to perform operative hysteroscopy for anything beyond mild abnormalities. If no serious pathology is expected, then I typically perform the hysteroscopy in the fertility clinic setting. In 90% of cases, I can address any issues right away. However, if an unexpected pathology is identified in the remaining 10% of cases, then I would keep the diagnostic hysteroscopy and proceed to perform the operative hysteroscopy in a hospital setting. This is more convenient and less costly in the fertility clinic setting. If we need to move to the hospital setting, there may be arrangements to discount the additional cost. Our goal is to perform the appropriate hysteroscopy in the appropriate setting to be cost-effective, safe, and effective for our patients.

Can the tubes be checked by hysteroscopy for inflammation or abnormalities or to determine the presence of hydrosalpinx?

Unfortunately, the tubes cannot be assessed through hysteroscopy. The evaluation of the tubes requires specific tests such as hysterosalpingography or laparoscopy. Hysteroscopy and standard ultrasound scanning technology, whether 2-dimensional or 3-dimensional Doppler, are not designed to diagnose hydrosalpinx. In my practice, it is crucial to accurately determine the absence of hydrosalpinx and infection, with a certainty of more than 90%. To avoid the more invasive and expensive laparoscopy, I usually perform hysterosalpingography followed by hysteroscopy. If hysterosalpingography results are inconclusive, then hysteroscopy and laparoscopy may be performed together. I want to emphasize the importance of considering blocked tubes. Some doctors may suggest bypassing or disregarding blocked tubes for IVF, but I disagree. Blocked tubes can indicate a serious infection that may create an unfavourable environment for implantation and pregnancy development. Blocked tubes should not be dismissed, as they can lead to severe complications, including septic miscarriages. It is essential to prioritize the health of both the uterus and the surrounding environment for a successful pregnancy and delivery.
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Elias Tsakos MD, FRCOG

Elias Tsakos MD, FRCOG

Dr Elias Tsakos, FRCOG, is a Medical Director of Embryoclinic - Assisted Reproduction Clinic in Thessaloniki, Greece. He has received extensive and certified training in the United Kingdom and is a Fellow of the Royal College of Obstetrics & Gynaecology. Dr Tsakos is also a Board Member Representative of the Royal College for Greece and Cyprus and a Board Member of the Hellenic Society of Assisted Reproduction. He is a Member of the British, European and American Fertility Societies (BFS, ESHRE, ASRM). Dr Tsakos has been living and working in Thessaloniki, Greece, since 1999.
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