In The Name of GodIn The Name of God

Abortion &Hysteroscopy Abortion &Hysteroscopy

Shirin GhazizadehTehran University of Medical Sciences

Aban 1393

Role of Hysteroscopy in AbortionRole of Hysteroscopy in Abortion

• Recurrent pregnancy loss (RPL)

• Retained tissue

• Polyp/myoma

• Uterine synechia

• Septate uterus

• Recurrent pregnancy loss (RPL)

• Retained tissue

• Polyp/myoma

• Uterine synechia

• Septate uterus

Recurrent pregnancy loss (RPL) Recurrent pregnancy loss (RPL) • >3 (non)consecutive losses of clinically

recognized pregnancies <20th w <500gr– (ectopic, molar, and biochemical pregnancies

are not included) – It may be primary or secondary

• ASRM >2 failed pregnancies (ultrasound or histopathological) 

• >3 (non)consecutive losses of clinically recognized pregnancies <20th w <500gr

– (ectopic, molar, and biochemical pregnancies are not included)

– It may be primary or secondary

• ASRM >2 failed pregnancies (ultrasound or histopathological) 

Retained tissue Retained tissue

• Hysteroscopy removal is much less traumatic

• Hysteroscopy removal is much less traumatic

Retained fetal bonesRetained fetal bones• Iatrogenic secondary infertility caused

by residual intrauterine fetal bone after midtrimester abortion.

• An intrauterine device-like effect

• Iatrogenic secondary infertility caused by residual intrauterine fetal bone after midtrimester abortion.

• An intrauterine device-like effect

Sub mucousal myoma / polyp Sub mucousal myoma / polyp

• Abnormal uterine bleeding

• Recurrent pregnancy loss

• Infertility

• Abnormal uterine bleeding

• Recurrent pregnancy loss

• Infertility

Polyps Polyps

• Premenopausal – symptomatic polyps – asymptomatic polyps >1.5

• Postmenopausal – all endometrial polyps (Grade 1B)

• Premenopausal – symptomatic polyps – asymptomatic polyps >1.5

• Postmenopausal – all endometrial polyps (Grade 1B)

Hysterscopic MyomectomyHysterscopic Myomectomy

•  European Society of Hysteroscopy (ESH)– Type 0 - completely within the cavity– Type I - extend < 50 % into the myometrium– Type II - extend >50 % within the myometrium

•  European Society of Hysteroscopy (ESH)– Type 0 - completely within the cavity– Type I - extend < 50 % into the myometrium– Type II - extend >50 % within the myometrium

Distinguishing myoma versus myometrium  

Distinguishing myoma versusmyometrium  

Intrauterine adhesionsIntrauterine adhesions

Intrauterine adhesionsIntrauterine adhesions

• Trauma– missed or incomplete abortion,

postpartum hemorrhage, or retained placental remnants 

• Genital tuberculosis

• Trauma– missed or incomplete abortion,

postpartum hemorrhage, or retained placental remnants 

• Genital tuberculosis

Intrauterine adhesionsIntrauterine adhesions

• Foley cath. compared with IUD – ↑ Normal menses (81 versus 63%) – ↑ conception rates (34 versus 23 %) – ↓ Need for reoperation 

• 5 mg estrogen daily for 30 days

• Foley cath. compared with IUD – ↑ Normal menses (81 versus 63%) – ↑ conception rates (34 versus 23 %) – ↓ Need for reoperation 

• 5 mg estrogen daily for 30 days

Uterine septum Uterine septum

Uterine septumUterine septum

• semirigid or rigid scissors (5-7 French)

• Bi/unipolar wire

• (KTP/532), (Nd:YAG), or argon lasers.

• semirigid or rigid scissors (5-7 French)

• Bi/unipolar wire

• (KTP/532), (Nd:YAG), or argon lasers.

hysteroscopic correction of arcuate uterus prior to IVF?

hysteroscopic correction of arcuate uterus prior to IVF?

• Measurement by sonohysterography – Fm (fundal myometrial thickness) – Cm (cornual myometrial thickness)

• Incision of the incomplete septum. • Fm >11 mm • Fm-Cm >5 mm,

• Measurement by sonohysterography – Fm (fundal myometrial thickness) – Cm (cornual myometrial thickness)

• Incision of the incomplete septum. • Fm >11 mm • Fm-Cm >5 mm,

Arcuate uterusArcuate uterus• Metroplasty, as well as making the

uterine cavity wider, leads to better uterine perfusion.

• Improvement of uterine artery Doppler velocimetry indices after metroplasty

• Metroplasty, as well as making the uterine cavity wider, leads to better uterine perfusion.

• Improvement of uterine artery Doppler velocimetry indices after metroplasty

Outpatient hysteroscopy and subsequent IVF cycle outcome Outpatient hysteroscopy andsubsequent IVF cycle outcome

• Meta-analyses of five studies – Improving result in subsequent IVF cycle

• (relative risk = 1.75, 95% CI 1.51-2.03).

• Mini-hysteroscopy with no intervention before IVF treatment

• Meta-analyses of five studies – Improving result in subsequent IVF cycle

• (relative risk = 1.75, 95% CI 1.51-2.03).

• Mini-hysteroscopy with no intervention before IVF treatment

"Chromohysteroscopy""Chromohysteroscopy"

• 5 ml of 1% methylene blue dye

• Group I: 19 patients focal dark staining • 10 cases of endometritis

• Group II: 15 patients diffuse light blue staining

• normal histopathology

• 5 ml of 1% methylene blue dye

• Group I: 19 patients focal dark staining • 10 cases of endometritis

• Group II: 15 patients diffuse light blue staining

• normal histopathology

Conclusion(1)Conclusion(1)

• Diagnostic hysteroscopy should be a routine procedure during diagnostic laparoscopy in infertile women

• Diagnostic hysteroscopy should be a routine procedure during diagnostic laparoscopy in infertile women

Conclusion(2)Conclusion(2)

• Office mini-hysteroscopy should be incorporated in infertility work up

• Office mini-hysteroscopy should be incorporated in infertility work up