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.

Ailments affecting conception & pregnancy

If one is facing difficulty in getting pregnant i.e. suffering from unexplained infertility, then probably it’s time to look at some underlying medical causes  like obesity, hypothyroidism and asthma, which can interfere with one’s reproductive health, in many more ways than imaginable. Addressing these conditions can not only improve an individual’s overall health and fitness but also increase the chances of successful conception and pregnancy:

  • Hypothyroidism– Despite the recent increase in the problem of under-active thyroid gland, little is understood when it comes to its implications on our body and its functioning. While hypothyroidism can be managed with the right medication and lifestyle modifications, it can be very challenging to attain the exact level of thyroid activity  required to achieve and sustain pregnancy.

Also, during pregnancy fetal growth and development is controlled by the hormones produced in the thyroid of the mother. Hence, it is advisable to get your thyroid checked, and if you are already on medication for thyroid, get it rechecked even after you have conceived, as levels can vary during the course of pregnancy.

  • Diabetes- The presence of diabetes on this list may take you by surprise, but the fact is that deranged blood glucose levels can seriously lower your chances of having a baby. While high blood sugar level itself does not prevent someone from getting pregnant, it hinders the retention of pregnancy. This is because diabetes can prevent the implantation of the embryo in the uterus, causing a miscarriage sometimes even before a woman can realize that she has conceived.

For the same reason, multiple miscarriages can be a red flag for undiagnosed diabetes in women. As per the American Diabetes Association, high blood glucose levels are reported to increase a woman’s chance of miscarriage by 30-60%.

  • Obesity- While there is no direct correlation between obesity and infertility, the extra body weight inflicts physical complications like insulin resistance and hormonal imbalances, which not just reduce the chances of getting pregnant but also of maintaining it. So, maintaining a healthy body weight should be your first priority if you are trying to get pregnant.
  • Asthma- According to a research paper by Juul Gade, Elisabeth et al. “Female asthma has a negative effect on fertility: what is the connection?.” ISRN allergy 2014 (2014), asthma in the lower airways in women, due to a systemic reaction, can simultaneously cause inflammation in the mucosa of their uterus. If not treated correctly, this inflammation can inhibit normal implantation of the fertilized ovum, thereby leading to infertility. Hence in cases of unexplained infertility, especially if you have asthma, a more effective management of the condition can help achieve pregnancy.
  • Lupus- Lupus is an autoimmune disorder that can negatively influence female fertility. Due to the potential risks to the mother and baby, until sometime back, doctors used to advise women with this condition to avoid getting pregnant. But with advanced medical technology, having a child while suffering from Lupus is not that difficult.

However, the first step towards getting pregnant, in this condition is to have a complete control over the disorder. Regular review of the medication and timely consultation with the experts is also important because few medications may need to be stopped just before pregnancy.

  • Migraines- The benign migraine, which apparently has no direct relation to fertility, also reduces the chances of getting pregnant. This is because the adverse effects of the medications used to treat migraine has not been clearly identified for pregnant and breastfeeding women. Hence women who are taking long-term suppressive therapy for migraine are first advised to stop the medications for a few weeks, after consultation with their doctor, before planning a pregnancy.

It is observed that women with endometriosis are more than twice as likely to suffer from migraine as compared to women without the condition. While recurrent migraine attacks and its medication could directly interfere with fertility, it could as well be a associated with undiagnosed endometriosis,

So if you suffer from frequent migraine attacks and have difficulty  in conceiving, then it is high time to get your migraine medication reviewed and to also get a diagnostic test done for endometriosis.  Endometriosis is a disease that involves growth of endometriotic tissue in places outside the uterus. Endometriosis may grow on the lining of the abdomen and pelvis, that may sometimes cause scarring, involving the ovaries and blocking the tubes, thereby leading to infertility.

  • Epilepsy- According to the study by Singh, Pratibha et al. “Effect of epilepsy on female fertility and reproductive abnormalities.” Journal of human reproductive sciences 4.2 (2011): 100., compared to the general population, reproductive abnormalities and infertility are two to three times more common in epileptic females. This is because epileptic seizures can lead to an increase in the serum prolactin level and fluctuation in women’s reproductive hormones (Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH). Around 50% of all epileptic women are also reported to have menstrual abnormalities and a higher frequency of anovulatory cycles, which also adversely impact fertility.

People with epilepsy desirous of conceiving, should talk to their doctors to get epilepsy medications prescribed that do not impair fertility, are safe in pregnancy and seek hormone therapy under proper medical advice, if required.  

  • Male Infertility – Even though women may obsess over their inability to conceive, the reason for the same may often lie in various degrees of male infertility in their partners. Obesity and Diabetes are well known for causing sexual disorders like erectile dysfunction, late ejaculation and low sperm counts. Lupus in males can also cause infertility. Epilepsy medication can reduce testosterone levels or cause impotency (reduction in amount or quality of sperms).

So, if you are facing problems in getting pregnant and you or your partner already have or suspect any of the above medical conditions, then it is high time to take some corrective steps, especially because the right medical advice and action can significantly increase your chances of conceiving. After all when it comes to becoming a parent you don’t want to leave any stone unturned.