Hysteroscopy

What is Hysteroscopy:  A  procedure where an endoscope is used to visualize the uterus and the uterine tubes.  Several pathologies of these organs can be identified and treated. Indeed some of these disorders may be the cause of infertility in the female. Hence this is a good diagnostic and therapeutic  (operative) tool for female infertility. It is normally done immediately after the menstrual periods during which time the uterine lining is thin and access to uterine cavity is better.

What is a hysteroscope?

This is a flexible fibreoptic device that can be passed into the vagina and guided through the cervix into the uterus. This is less traumatic to the patient as otherwise we have to inspect the uterus by approaching through the anterior abdominal wall (open abdominal access) which involves a surgical incision. It is also less expensive and the hospital stay is for one day only. The diameter  of the tube is chosen such that it can pass through the narrow cervix.  The cervix may need to be dilated a little bit in some cases. The instrument has a illumination device at the tip and a set of lenses help to bring the image to the television screen on which the doctor can clearly see the interior of the uterus. Facilities exist for insufflation of gas or fluids through the instrument for distending the uterus. For therapeutic purposes, hysteroscopes also have provision to introduce tiny scissors, graspers, resecting instruments, electrical loops and  lasers.

Common indications for hysteroscopy:

• Heavy or abnormal uterine (like bleeding in between normal cyclical bleeds)  and severe abdominal cramps.
• Unusual vaginal discharge
• To check the size and shape of the uterus during investigation of infertility. Congenital uterine malformations can also be diagnosed
• Diagnosis and evaluation of polyps and fibroids in the uterus. Polyps can be removed through the procedure. Biopsied can be taken through appropriate instruments inserted through the hysteroscope. Thus malignancies can be diagnosed and appropriate treatment strategies planned in due course.
• Intrauterine adhesions (Asherman’s syndrome). They can also the cleared using laser or heat.
• Sometimes there may be retained products of conception that is causing bleeding. These can be removed.
• Similarly intrauterine devices may be found which may be removed.  Alternatively it can also be used to place intrauterine devices in the uterus.
• Can be extended to visualise the tubo uterine junction and the tubes. Prodecures as necessary can be undertaken for e.g tubal blockages can be cleared and luminal continuity restored.
• Repeated miscarriage
• For routine investigation of infertility
• As a part of a therapeutic procedure like dilatation and curettage, laparoscopy

How is the procedure performed:

A date is fixed depending on the menstrual cycle. It is preferable to undergo the procedure in the pre-ovulatory phase as possibility of an established pregnancy is zero and hence there is no question of disturbing it, especially if investigating for infertility.  A date is taken immediately after the monthly menstrual bleed is over.  The doctor will ask details of any medicines being taken, any allergies to specific drugs and if any anticoagulants like aspirin is being taken.  Recent pelvic infection and the details of the treatment must be brought to the attention of the doctor.  The patient will be advised not to use any tampons in the vagina for 24 hrs before the procedure.
A local, regional or general anesthesia can be used for this procedure, besides a sedative and a painkiller. The doctor will decide which is best for the case.
The patient will change to the OT gown provided in the operation theatre.  The bladder must be emptied before the procedure.  The patient is made to lie on her back with the legs wide apart and raised and supported by table footrests. This is called the lithotomy position and offers the doctor the best view and access to the external and internal genital organs. The external genitals will be thoroughly cleaned with an antiseptic solution that will remove all microbes and reduce any local infection. . A speculum will be inserted into the vagina to provide a clear view of the cervix.  The tip of the hysteroscope is gently inserted into the cervical opening and guided upwards until it reaches the uterine cavity.  The illuminator ensures that the interior of the uterus is clearly visible and the camera transmits real time images to the TV screen which is viewed by the doctor and team.  The tip of the hysteroscope can be moved in different directions so that no part of the wall is missed and also the tubal openings are visualized. The tubes can also be examined.
The procedure take about half an hour following which the patient is rested for some three to four hours  in the recovery room  and then asked to go home. The exception is when general anesthesia is used where a post operative stay for a longer duration is done.  Patient is advised to abstain from sex and the use of vaginal tampons for some days.  There may be mild abdominal cramps and light bleed from the vagina, but this will stop in a few days.

Risks of the procedure:

Occasional perforation of the uterus, uterine tube  and neighboring viscera like intestines may occur resulting in peritonitis. Sometimes gas or fluid used during the insufflation may result in embolization as they may be absorbed into the blood stream. Patient is asked to keep in touch with the hospital and come immediately if the doctor feels that further attention is required.  In particular the patient is advised to report fever, severe lower abdominal pain and severe vaginal bleeding.

Psychological Battle against Infertility

The inability to get pregnant after a year or more of trying, most commonly termed as “infertility”, can lead to depression, anxiety and other psychological problems. Infertility triggers feelings of shame and failure to live up to traditional expectations. Often these feelings result in strained relationships. Individuals and couples can struggle when it comes to taking grim decisions about how far they would take forward the quest for children.

Most women are raised with the customary belief, that someday they’ll become mothers. From the first baby doll to the last baby shower, girls are expected to someday reach their final goal of motherhood. This pressure is from within as well as without – from parents to peers, from media to society. When men learn about their infertility, they experience the same levels of low self-esteem, stigma and depression as infertile women do. Financial concerns on the other hand exert enormous amount of pressure on relationships. A couple’s intense, frustrated desire to have a child in addition to risks involved and the high cost of fertility treatments can escalate conflicts to unbearable levels.
In vitro fertilization (IVF), while not as expensive as it used to be, is still significantly costly for many. Other routes like adoption or surrogacy can be just as, or more, expensive and pose their own challenges. Although the causes of infertility are overpoweringly physiological, the resulting distress may take a huge psychological toll on affected individuals and couples.

Here are a list of ways by which you can cope with the psychological stress, anxiety and depression associated with infertility:
• Don’t blame yourself. Resist the temptation of getting angry at yourself. Nobody gets a chance to earn the situation they are in.
• Stay updated on infertility. Find out more about infertility, through your doctor and other credible sources.
• Consult a therapist. Counseling offers great relief. It eases the strain developed in the relationship.
• Be aware of other options. Adoption or surrogacy can always relieve you from the helplessness you feel.

Radiological and Ultrasound Investigations

Imaging plays a key role in the diagnostic evaluation of women for infertility. It is undertaken after a thorough history taking and clinical examination. The consultant will have come to an opinion of the possible diagnosis and may want a confirmation. The pelvic causes of female infertility are varied and range from tubal, peritubal, uterine and cervical, to ovarian disorders.

Tubal causes:
Tubal block is a major cause of infertility and tubal patency test using hysterosalpingography is the first choice. This is a radiographic procedure where in contrast dye is injected into the uterus and the tubes, then visualised using X rays. Patency of the tubes can be confirmed by spillage of the contrast medium into the peritoneal cavity. Hysterosalpingography also depicts the course, size and contour of the tubes.

The location of the block can also be ascertained. For example, a block at the junction of the tube with the uterus is detected, a recheck can be done after treating for a possible spasm. If it still persists, a recanalization procedure can be undertaken under fluoroscopic guidance.
Blocks at the end distal to the uterus (ampullary end) appear as hydrosalpinx here the contrast material will pool up proximal to the block and there will be no spillage into the peritoneal cavity.
If there is evidence of tubal block due to endometriosis, an MR imaging will be helpful.

Peritubal causes:
Peritubal abnormalities due to adhesions and endometriosis (ectopic uterine tissue) can also be detected. This is reflected by accumulation of abnormal amounts of contrast material adjacent to the ampullary end of the tubes. Besides endometriosis, pelvic inflammatory disease may be another factor. A pelvic MRI is indicated to confirm the peritubal cause. Pelvic ultrasound may detect large endometriosis that have reached the size of a cyst. A laparoscopy will be the final diagnosis if both US and MRI fail to provide a conclusive interpretation.

Uterine causes:
Uterine filling defects and contour abnormalities may be discovered at hysterosalpingography but typically require further characterization with hysterographic or pelvic ultrasonography (US) or pelvic magnetic resonance (MR) imaging.
An ultrasound is a procedure where sound waves are used to image the internal organs of the abdomen and pelvis. It is absolute safe to confirm a pregnancy using ultrasound and is the accepted device of choice among doctors as well as patients. There are three types of US:
Abdominal US
Transvaginal US
Transrectal US

Abdominal US: It is also known as transabdominal US. Structures that are solid and uniform show up well in pelvic ultrasound. Hence, it can detect large masses in the uterus or the ovaries. It can also show up large fluid filled cavities like the urinary bladder. The transducer is a hand held device that is moved over the lower abdomen and the real-time image is seen on the TV screen.
Transvaginal US: Here the transducer is little modified in size and shape so that it can be passed into the female vagina. Besides imaging the pelvic viscera, transvaginal US can be used with additional attachment to take tissue biopsies, to tap fluid and egg from the ovary etc.
Transrectal US: Similarly the US device is modified to pass to the rectum. This is more commonly used in the males to view the prostate and seminal vesicles. Biopsy can also be taken of the tissues using suitable additional instruments.

Pelvic MR
A MRI uses powerful magnets and radio waves to image the interior parts of the human body. Being devoid of X-rays it is much safer. It provides high contrast resolution and can provide slides in any axis which can then be interpreted. However, it is expensive and is used as a second line of investigation if the front line investigations do not provide satisfactory results. MRI should be considered for the evaluation of adnexal pathology when USA characteristics are not definitive to determine whether an adnexal mass is ovarian in origin and to determine the likelihood of malignancy.

Uterine US and MR imaging are used to study the presence, size, and shape of the uterus, in particular the external fundal contour. The presence, location and appearance of the kidneys also should be routinely evaluated because of the high frequency of associated renal anomalies in patients with mullerian duct anomalies. Image acquisition in true coronal and true axial planes of the uterus allows accurate evaluation of the uterine contour and cavity.

Ovarian causes:
Biochemical evaluation throws light on certain functional ovarian disorders like non-functional ovaries, premature ovarian failure, or congenital absence of the ovaries. However, disorders like polycystic ovary syndrome, endometriosis, and ovarian cancer are better diagnosed with radiological and US investigations.

The present trend it to have a multimodal diagnostic approach to investigation of infertility. These investigation provide either a confirmation or a lead for further investigation.