Benefits of Hysteroscopy in Infertility

Infertility is a complex condition which can have multiple causes. A comprehensive examination of all possible causes of infertility includes an analysis of the general health of a couple, as also a detailed and thorough assessment of the woman’s reproductive tract including the uterus, fallopian tubes, ovaries & the vaginal canal in addition to her hormonal profile . While most of this information can be obtained through a combination of clinical examination, blood tests & a good pelvic ultrasound, the assessment of the inside of the uterine cavity & cervical canal requires the use of an advanced technique called Hysteroscopy. Hysteroscopy involves the use of a special instrument – A Hysteroscope, to not only visualize the cavity of the uterus and cervix but also simultaneously treat some of the pathologies that may be detected at the time of visualization.

Very often, certain conditions that cannot be detected by routine physical examination, may be detected through hysteroscopy and can then also be corrected immediately, avoiding the need for a repeat surgery. Hysteroscopy has thus  become a frequently recommended procedure for the evaluation of infertility, recurrent miscarriages and abnormal uterine bleeding.

Hysteroscopy is generally undertaken for :

  • Checking any abnormality in the shape or size of the uterus or looking for any septum (midline separation) in the cavity of the uterus. The septum can be removed by hysteroscopy but a much more complex surgery may be needed for bicornuate uterus (a situation where the cavity is divided into two parts by birth).
  • To look for any scar tissue in the cavity of the uterus which can be removed in the same sitting . The scar tissue may have formed after a previous surgery or infection & could be preventing a pregnancy from implanting well, leading to recurrent miscarriages.
  • To diagnose any abnormality in the shape of the uterine cavity due to the presence of a fibroid tumour or a polyp in the cavity. Any fibroid or polyp can also lead to infertility & miscarriage. Certain fibroids & almost all polyps can be removed during the same sitting of hysteroscopy, using an operative hysteroscope.
  • To assess the status of the ostia , i.e the openings of the fallopian tubes into the uterine cavity. If these are found to be blocked then your doctor may attempt to cannulate & open them while doing hysteroscopy.
  • To take a biopsy of the Endometrium ( uterine lining that lodges & nourishes a pregnancy ). This collected tissue can then be tested for any tubercular infection, evidence of a precancerous or cancerous tissue and also for any discordance between the hormonal cycle & the growth of endometrium.
  • To assess any abnormality in the cervical canal.
  • Occasionally, a displaced IUCD may be found in the cavity and removed in the same sitting.

What is a Hysteroscope ?

A Hysteroscope is a narrow, telescope-like instrument having a camera and an integrated light source. It is inserted into the uterine cavity through the vagina and the cervix and enables the doctor to visually examine the cavity of the uterus & cervix, the Endometrium and the ostia. The images are displayed on a monitor, which helps the doctor to also conduct any procedure or undertake any corrective surgery, as required.

What happens in Hysteroscopy ?

Hysteroscopy is generally undertaken by a Gynaecologist in the Operation theatre after the patient has been administered anaesthesia. The cervical canal is gradually dilated by stretching till it is possible to introduce the hysteroscope into the uterine cavity. This procedure does not involve any incision or cut over the cervix. Once the cavity of the uterus has been distended by introducing fluid, to enable a better visualization of its contents, the doctor carefully examines the cavity and the lining  of the uterus, so that any abnormality that is detected can then be treated accordingly. The doctor may also decide to take a biopsy from any area that appears visually abnormal and send the tissue to the lab for testing. The hysteroscope is withdrawn after the examination and the patient can usually go home 4-6 hours after the procedure. Occasionally, an overnight stay in the hospital may be recommended for exceptional cases.

Nowadays the option of office hysteroscopy, which is undertaken in the OPD without anaesthesia, is also becoming available. In this, a very narrow Office Hysteroscope (of diameter less than 5 mm) is used, but only for diagnostic purposes. Any operative intervention, if needed, must be undertaken later in the OT under administration of anaesthesia.

What can be expected after the procedure ?

Usually, one may be discharged from the hospital on the day of the procedure itself. One may experience mild pain in lower abdomen or some cramping for a few days along with a little bit of vaginal bleeding or spotting. The doctor may prescribe some medications for these.

In most cases, one is able to resume normal physical activity in a couple of days unless the doctor specifically advises otherwise. Restarting sexual activity may however take a while depending upon the findings of the hysteroscopy.

What are the risks involved?

Hysteroscopy is a relatively safe procedure when undertaken by a competent gynecologist. A few unforeseeable complications may however occur in rare cases:

  • Perforation of the uterus happens quite rarely and is usually treated conservatively by monitoring vital parameters and keeping the patient under observation. Occasionally, a surgical intervention may be needed to correct the defect.
  • The possibility of an infection exists as with any other surgical intervention
  • There may be excessive bleeding in some cases, which is also usually managed conservatively
  • Very rarely, there are chances of the distending fluid or air entering into the blood vessels & causing a life threatening embolism, electrolyte imbalance or abnormalities related to blood clotting.

Serious or life threatening complications are however extremely rare and Hysteroscopy is generally considered a very safe & effective way of diagnosing gynaecological or fertility problems. In case of any concerns, whatsoever, it is advisable to discuss all the issues with the doctor before deciding to undergo a hysteroscopy.

All about Menstruation and Fertility Cycles

Menstruation is the periodic & cyclical shedding of the uterine lining, i.e the Endometrium, in women, accompanied by  loss of blood. Usually, it takes place at an interval of 28 days, although this  interval may normally range from 21 to 35 days in some women. The blood flow lasts between 4-5 days, but again a variation in the duration between 2-7 days is considered normal.

The menstrual cycle is linked to the production of various hormones in the body, which regulate the various reproductive & other body functions including the preparation of the uterus for pregnancy. Menstruation thus represents the breakdown & casting off of  an endometrium prepared for pregnancy, which has not materialized. As such, menstruation has even been described as the ‘weeping of a disappointed uterus’.

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The cyclical occurrence of menstruation is controlled by the cyclical rise & fall of various hormones in the body. It is interesting to note that every girl is born with a certain fixed number, about 2 million, of eggs (Primary oocytes). This number further reduces by the time of puberty to about 300,000 to 500,000 due to the spontaneous atresia & destruction of oocytes. Out of these, it is estimated that no more than 500 oocytes will actually mature in a woman’s lifecycle & the rest will simply degenerate. The maturation, release & disintegration of oocytes as well as the growth and shedding of the endometrium during the menstrual cycle is controlled by hormones produced in the brain & the ovary.

In the first half of the cycle, under the influence of Follicle Stimulating Hormone ( FSH), produced by the Pituitary gland in the brain; the oocyte/egg begins to grow in the ovary. This growing oocyte produces more & more of the hormone Estrogen, which stimulates the growth of the uterine lining (Endometrium) and also affects the cervical mucus making it thin & stretchy. Estrogen also plays an important role in maintaining bone health & cardiac function. This phase of growth of the oocyte i.e the follicle,  is called the Follicular phase. It is also called the Proliferative phase from the perspective of the uterine lining as at this time the Endometrium grows and proliferates to prepare itself for the implantation of a pregnancy, if fertilization occurs.

It  takes an oocyte about 14-16 days (sometimes a little longer or lesser) to reach maturity & be ready for release by the ovary. At this time, it is surrounded by a capsule of Granulosa and Theca cells in the ovary. The process of release of oocyte from the ovary is called Ovulation. This process again is controlled by a complex interplay of hormones produced by the Pituitary gland & the ovary.

It is the sudden rise in Luteinising Hormone (LH), produced by Pituitary gland in brain, which is the principal trigger for ovulation. The released oocyte is picked up by the fimbriae of the Fallopian tubes and transported towards the uterine cavity. Once released, an oocyte can survive for approximately 24 hours.

Meanwhile, the remaining cells of the capsule of the oocyte in the ovary form a structure called the Corpus Luteum, which produces the hormone Progesterone. This hormone is responsible for further growth of the Endometrium and, along with Estrogen, makes it suitable for nurturing a pregnancy. Under the influence of Progesterone, the Endometrium becomes edematous, more vascular, the glands enlarge & secrete nutritious substances into the stroma so as to provide nourishment to a growing uterus & pregnancy. This phase, that occurs after ovulation, is called the Luteal phase or the Secretory phase of the menstrual cycle.

If the oocyte is fertilized within its survival period by a sperm, then the fallopian tube transports the zygote towards the uterine cavity where it gets implanted & the pregnancy  progresses. If  however,  the  oocyte  is  not fertilized, it degenerates after 24 hours. In the absence of fertilization, the Corpus luteum gradually disintegrates and the levels of Progesterone & Estrogen fall. This leads to a shrinkage and disintegration of the glands and superficial layers of the Endometrium. Eventually, the necrosed superficial layers of the Endometrium & the ends of blood vessels in these layers, breakdown &  the bleeding starts. This marks the beginning of the vaginal bleeding, which is counted as the first day of menstruation. Simultaneously the next oocyte starts to grow in the ovary and the whole cycle is repeated.

The cyclical production of hormones during the menstrual cycle leads to various cyclical changes in a woman’s body & these changes have been studied and used for predicting the ovulation & the fertile/unsafe or safe period while planning to achieve or avoid a  pregnancy.

Cervical mucus changes-  The cervix is the terminal part of the uterus which leads into the vagina. It is lined by several glands which secrete mucus under the influence of hormones. The cervical mucus plays an important role in fertility because it gets altered in character & amount depending on the influence of the hormones. In the days immediately after menstruation, the cervical mucus is dry & scanty. Gradually, under the effect of Estrogen, it becomes profuse, watery & stretchy. This happens around the time of ovulation & it facilitates the passage of sperms from the vagina into the uterus while also nourishing the sperm at the same time. This increases the chances of conception when the sperm fuses with the egg.  After ovulation, in the premenstrual phase, the mucus becomes sticky, dry & thick; thus preventing any further entry of sperms into the uterus. This change in character and amount of cervical mucus has been often used to predict the fertile period.

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Basal Body Temperature monitoring–  Basal body temperature is the body temperature at complete rest. It has been established that the Basal Body Temperature increases on ovulation. A woman is likely to be most fertile 2-3 days prior to the body temperature rise and around the time of ovulation. Hence , tracking the early morning basal body temperature daily is often used to predict ovulation. The temperature rises by about 0.5 deg F on ovulation & persists for about 3 days, thereafter it falls to normal values. A persistent rise in basal body temperature for 2 weeks or more can also be an early sign of pregnancy.