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.