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Hysteroscopy and IVF – is it a “waste of money” or a real help?

Dr José Félix García España
Fertility Specialist & Medical Director , UR Vistahermosa

Category:
Endometriosis, Fertility Assessment, Reproductive surgery

hysteroscopy-and-ivf
From this video you will find out:
  • What is a hysteroscopy?
  • What is diagnostic hysteroscopy and operative?
  • Who is a candidate for hysteroscopy?
  • When should a hysteroscopy be performed?
  • How long does it take to recover from hysteroscopy?

Hysteroscopy and IVF – is it a “waste of money” or a real help?

During this event, Dr José Félix García España, Medical Director of UR El Ángel talked about hysteroscopy and whether it can improve IVF outcomes, its indications, and how the procedure is done.

Dr José Félix García España sated that:

50% of what we are firmly established in medicine today will be refuted in 15 years’ time, but the problem is that we don’t know what 50% is.

Understanding Hysteroscopy

Hysteroscopy, a procedure involving visual examination of the uterus, merits distinction between its diagnostic and surgical forms. The diagnostic variant aids in spotting abnormalities while the surgical kind involves interventions to rectify detected issues.

A crucial aspect involves discerning the circumstances under which diagnostic hysteroscopy proves invaluable. Exploring this facet unveils disparities in expert opinions. While some emphasize its role, others contend its significance isn’t fully validated. A quote exemplifies this dilemma:

Hysteroscopy in asymptomatic women prior to the first IVF cycle could be associated with improved treatment outcome.However, it also underlines the necessity for rigorous research to confirm findings.

 Surgical Hysteroscopy

Surgical hysteroscopy emerges as a critical tool for addressing specific uterine pathologies. These include issues like fibroids, polyps, and adenomyosis that can hinder successful implantation. Surgical correction, often involving minimally invasive procedures, becomes paramount in optimizing the uterine environment for embryo development.

The medical community grapples with understanding conditions like dysmorphic uteri and chronic endometritis. The former pertains to irregular uterine shapes, and opinions differ on its impact. Similarly, chronic endometritis, an asymptomatic condition, is subject to debate regarding its significance. Conflicting evidence underscores the need for robust research to ascertain their clinical relevance.

The challenge of determining when to recommend hysteroscopy is multifaceted. Navigating between standardized protocols, evolving medical knowledge, and patient expectations is complex. Different medical settings—public versus private—also influence decision-making, creating a dynamic landscape.

Hysteroscopy vs. laparoscopy

Hysteroscopy and laparoscopy are both minimally invasive procedures that use cameras to diagnose and treat conditions that affect your uterus and other reproductive organs.

Hysteroscopy does not require any incisions (cuts) because the tools for the procedure are inserted through the vagina. However, a laparoscopy requires the surgeon to make one or more small incisions in your abdomen (stomach). Laparoscopies have a slightly higher risk of complications from infection and bleeding since the surgeon has to make one or more incisions, unlike a hysteroscopy.

Some patients will need a laparoscopy if a procedure cannot be done through the vagina, or your surgeon is concerned about the risk of injury to other organs during hysteroscopy.

Conclusions

In conclusion, the subject of hysteroscopy in fertility treatment embodies a myriad of complexities. Balancing diagnostic and surgical applications, understanding varied pathologies, and adapting to a rapidly evolving medical landscape all contribute to the intricate nature of this field. As we grapple with uncertainties and await further research, a spirit of adaptability and openness becomes crucial.

- Questions and Answers

My immunologist recommends hysteroscopy even though there is no suspicion of endometriosis. I have polycystic ovaries but had negative ALICE tests. He says it’s not because he suspects there is something wrong, more that a hysteroscopy can be good for other reasons before FET. What are your thoughts?

I’m surprised that the immunologist is recommending the hysteroscopy, our immunologists don’t think about that. They treat the patients, and they normally come with a corticoid treatment, or more aggressive treatments, we call them in as a last step, when everything else fails. Before going to the immunologist, I would have done a hysteroscopy, but then, if you had 4 transfers done, as I said, there is a failure of implementation and so I would sit with a couple and then not only the immunologist would be suggested, but some more things would be checked. The male will be investigated, DNA fragmentation, etc. Definitely, one of the things that should be done is hysteroscopy before having sometimes very aggressive and complicated immune treatments.

Is it possible for fibroids to disappear without surgery?

No, with medical treatment it’s not possible. There are 3 ways of treating fibroids, surgery, and a radiological intervention where we need to open the tummy with the laparoscope. Nowadays, we can also burn fibroids without opening the tummy or doing a laparoscopy. However, if you’re talking about medical treatment, they can reduce the size of the fibroids, but they don’t disappear with medical treatment, we may decrease the size or not or make them not grow more, but they cannot disappear.

Why would clinics perform more than one hysteroscopy on a woman, surely 1 would be enough.

Sometimes, we may perform 2, as I said, in the case of chronic endometritis, we treat it with antibiotics, but we don’t know as we cannot see that inflammation of the endometrium by ultrasound scan. We have to trust that after those antibiotics, the problem is sorted out. Therefore, if the specialist has the diagnostic hysteroscopy in the clinic, and they can do it in a few minutes, why not do it? On some occasions, it is necessary to repeat surgical hysteroscopy, there are fibroids which are coming inside the cavity in a few months, and that fibroid has come more into the other part that we left inside the muscle, and it is coming again, so we have to remove it again, but that doesn’t happen very often.

I am almost 44, I have a low ovarian reserve, 1 failed IVF cycle, 2 embryos were transferred on day 3, and I saw a gynaecologist after the failed implantation. I was told I had a large polyp and had the best recipe to remove the polyp, I had a hysteroscopy to remove it, and this month I’m having PRP in Spain. Anything else you can recommend to maximize the next round of IVF success?

Our UR group in Alicante they are doing PRP, and IVI, a very well-known clinic, are doing this as well. However, preliminary results say that if the woman is relatively young, less than 38, maybe ovarian rejuvenation could be useful, in the way that maybe instead of 4 eggs, next time we’re going to have 5 or 6. However, if a woman is more than 40, nowadays, it’s being demonstrated that it is useless and not working. We still need very serious paperwork with many patients involved. What I would recommend at your age, as you are 44, is to look into egg donation. I had many patients from abroad, from Iraq, for example, Muslims that wanted to get pregnant, but we have to say that if the patient is 45, we are not going to do any more IVF because this is not ethical. I know patients that get pregnant under 43 or 44 naturally, these are not the women that come to the IVF clinic, although this is always very difficult to understand. The polyp has to be removed, you have to have faith, and if that is your decision, go and do it, but I wouldn’t be faithful if I told you that is the best thing and you’re going to get pregnant. I’m afraid PRP is not going to be a solution.

If the uterus has many scars due to multiple surgeries, is it safe to do IVF?

Providing the uterine cavity is clean, and there are no adhesions, but I understand that you probably had fibroids removed and there are scars in the uterus, IVF is safe, but I would recommend transferring just 1 embryo, nowadays, we always recommend 1 embryo to transfer unless the patient is more than 40 and she’s having IVF with own eggs. If that surgery took place recently, less than 6 months ago, we should wait for this to be completely healed.

I had 2 failed transfers with PGT-tested embryos. I did hysteroscopy, ERA, EMMA, and ALICE. What should be my next steps?

Some things are generally accepted, and then every doctor has their opinion. In my own practice if I got a patient with a failure of implantation and then she had a PGT-A, these embryos are gold medals, and then the patient has spent a lot of money, has suffered a lot of anxiety, and I put this embryo and then later on she has a T-shaped uterus or adhesions, and we didn’t know that because we couldn’t see those adhesions, I have to be very precise. I normally do these things before transferring those very good embryos. I would do a hysteroscopy, of course. Regarding the ERA test, the last paper done by the people who designed this test, they have published at last after many years, they studied lots of patients who did the ERA receptivity study and another group who didn’t do it, and the results showed that the group that got pregnant were the group of patients who didn’t do ERA test, now they say that the ERA is not useful. We don’t know what is coming next, but I would do the biopsy, and I would do the hysteroscopy because I want to have everything covered before wasting those embryos.
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Authors
Dr José Félix García España

Dr José Félix García España

Dr José Félix García España is a Medical Director of UR El Ángel since 2011. He obtained his Bachelor of Medicine from the University of Malaga. After finishing his studies, he worked in emergency medicine, until starting the speciality of Gynaecology and Obstetrics in the United Kingdom in 1992. During his training he worked in several hospitals, highlighting the University Hospitals of Withington and St Mary's in Manchester. At this stage, he passes the examinations of the speciality. He is a member of the Royal College of Obstetricians and Gynaecologists (RCOG). Back in Spain, he worked as a reproduction specialist at the Gutenberg Center for 14 years.
Event Moderator
Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.
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