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Hysteroscopy for Fertility and Reproductive problems

Hysteroscopy is the inspection of the uterine cavity that allows for the diagnosis and treatment of various uterine conditions. Some of which, could lead to fertility problems.

Hysteroscope - rigid variety

 

A hysteroscope is a fiber optic telescope. Some hysteroscopes are “rigid” and straight. Others hysteroscopes are semi-flexible. The hysteroscope contains several channels all with a specific purpose. In addition to the “optic” channel that allows the doctor to see inside the uterus, one channel carries a fiber optic light in order to see inside the ordinarily dark uterus. One channel allows the introduction of fluid or gas to hold open the uterine walls and another channel is to allow the fluid back out again. Some hysteroscopes have an additional “operative” channel that allows the doctor to introduce instruments to do various tasks inside the uterus.
Operative sheath for hysteroscope

Hysteroscopy Procedure

Hysteroscopy may be performed in a doctor’s office, surgicenter or hospital. The more complicated cases are typically done in a surgicenter or hospital. During the procedure, the patient can be fully awake, under light anesthesia or completely asleep under general anesthesia. Again, the choice of anesthesia depends on the complexity and length of the surgery being performed.
Insertion of a hysteroscope
The patient will lie on an operative table. Her legs will be elevated in “stirrups”. A speculum is placed into the vagina to allow the doctor to see the cervix which is the natural opening to the uterus.

The cervix is gradually stretched open or “dilated” in order to allow the doctor to slide the hysteroscope into the uterus. “Dilators” are metal rods of increasing diameter. The surgeon first chooses a rod with a small diameter that will fit into the cervical canal. Then a slightly larger dilator is passed. This is repeated until the cervix has been stretched open enough to allow the hysteroscope to be inserted.

Cervical dilation can be uncomfortable and is one of the reasons why anesthesia is sometimes used for hysteroscopy. Operative hysteroscopes are larger in diameter than hysteroscopes that are for diagnostic use only and thus require dilation of the cervix to a larger diameter.

Normally, the inside of the uterus has no open space. The inside walls of the uterus are pressed against each other in the same was that the tongue presses against the roof of the mouth when it is closed. The walls of the uterus can be held open by introducing fluid or gas through the hysteroscope under pressure. In a doctor’s office, where diagnostic hysteroscopy is performed, carbon dioxide gas is usually used to open the walls of the uterus. In the surgical center or hospital, fluid is usually the distending medium of choice. One of the safest fluids to use for hysteroscopy is simply saline (salt water). This is the same type of saline that is contained in intravenous (IV) fluids that patients receive in the hospital and so is very safe compared to other types of synthetic fluids.

Cervical canal as seen through hysteroscopy The view of a uterus through a hysteroscope Uterine cavity as seen through hysteroscopy

At this point, with the hysteroscope inside the uterus, the uterine walls held apart and the hysteroscope light on, the doctor can begin viewing the inside of the uterine cavity. The cervical canal leading to the uterine cavity is like a long tunnel. The uterine cavity is like a large cave at the end of the tunnel. The “cave” has a “floor” (which is the back side of the uterine cavity), a “ceiling” (the front side of the uterine cavity), a back wall (the top of the uterine cavity), and left and right side walls. On the left and right sides near the top of the uterine cavity, there are two small opening which are the openings to the fallopian tubes. The uterine cavity shape is roughly triangular.

Hysteroscopy is usually an outpatient or same day procedure – meaning that patients do not typically need to be admitted overnight to a hospital. Once the procedure is completed, the patient is taken to the recovery area. After the patient is fully awake, vital signs are normal and stable and the patient can go to the bathroom and having something to eat or drink, she can be released to go home.There are many types of problems that can be diagnosed and fixed through the use of hysteroscopy.

Uterine Septum (Septate uterus)

This is the most common uterine malformation and a common cause of miscarriage. It is unclear whether a uterine septum increase the chances for infertility or not. A wedge of tissue is present inside the uterine cavity, which divides it into two halves (also called uterine horns).

When seen through a hysteroscope, the uterine horns are seen as two dark openings separated by a wedge of tissue. By introducing an electrode through the hysteroscope, the septum can be shaved or vaporized all the way to the top of the cavity. The finished product is a uterine cavity that is unified into one large space instead of divided in two.

Uterine septum Drawing of a uterine septum Resection of a uterine septumSeptum after resection

Polyps

These are uterine growths a few millimeters to centimeters in size. Polyps arise from the uterine lining (endometrium). A polyp may be attached to the uterine wall directly or by a thin “stalk”.

Patients often have no symptoms from polyps but will occasionally notice irregular vaginal bleeding. This bleeding may occur in between periods or cause the period to be longer in duration or heavier than normal.

Polyps are also associated with an increased risk for miscarriage. Large polyps, which occupy the majority of the uterine cavity, are also probably responsible for infertility. Small polyps can be most easily vaporized in place. Polyps which are attached by a stalk can sometimes be removed by cutting through the stalk and removing the entire polyp through the cervix. Larger polyps may have to be removed by shaving small strips one at a time until the polyp is completely gone.

fibroid just before resection fibroid during resection

Fibroids

These benign tumors arise from the muscle layers of the uterus. Often they will stay in the muscle layer but on occasion, fibroids can grow into the uterine cavity. Like polyps, fibroids can cause bleeding, infertility, and as well as miscarriage.

Removal of fibroids from the uterine cavity is performed using the same methods as for polyps.

Scar tissue

Scar tissue inside the uterine cavity, also called adhesions, can arise from infection or trauma to the uterine lining. Although rare, the most common cause for uterine adhesions to form is from a previous D&C procedure.

Scar tissue inside the uterus can be small and isolated to a certain spot. This type of adhesion looks like a band running from one wall of the uterus to another. Sometimes adhesions take the form of two walls that are stuck together causing the cavity at that spot to be completely obliterated. In rare instances, the entire cavity can be obliterated.

Uterine adhesions can cause infertility or miscarriage. If the uterine cavity is partially or completely obliterated, a woman may notice that her period are lighter or even stop altogether.

Band adhesions can be easily cut restoring the normal anatomy of the uterine cavity. When the walls are stuck together, the surgeon must carefully dissect between them in order to separate the walls. This can be a very difficult process if there is little normal uterine cavity that remains to serve as a guide.

Risks of hysteroscopy

Uterine perforation

By definition, a perforation is when a hole is created in the uterine wall. Perforation can occur during cervical dilation. This is especially true if the cervical canal is tight and difficult to stretch open. Uterine perforation that occurs with a dilator does not typically cause severe problems. The tips of the dilators are blunt and so they do not often cause injury to anything outside of the uterus in the abdomen.

From a practical standpoint however, uterine perforation the surgeon usually can’t complete the hysteroscopic surgery since the fluid or gas used to open the uterine cavity simply leaks out of the hole. As a result, the surgeon cannot see clearly and the procedure must be stopped. Repair of the hole is usually unnecessary; it will heal on its own. However, the patient must wait for the hole to heal and then return at a later time to finish the surgery.

Uterine perforation that occurs from the use of an electrical instrument can be more serious if the electricity used caused damage to some organ outside of the uterus such as the bowel or bladder. If such an injury is suspected, the surgeon may opt to do additional surgery to explore the abdominal cavity to locate and or fix the damaged organ. This may require the patient to be admitted to the hospital.

Damage to internal organs

As noted above, damage to internal organs is most likely to occur if uterine perforation occurs. If the damage was recognized, it could require additional surgery to repair. If not recognized, however, it could result in serious illness for the patient or even death.

Risk of fluid overload

Saline fluid (salt water) is used for uterine distension. Some of this fluid is absorbed through blood vessels in the uterus into the patient’s circulation. Too much fluid absorption can overload the heart or lungs.

Before the surgery begins, the surgeon may inject medication to constrict the uterine blood vessels and reduce the amount of fluid absorbed. During hysteroscopy, the surgeon and the operating room team will monitor the amount of fluid that goes into the uterus and the amount that comes back out. The difference will be the amount the patient has absorbed. Young healthy patients can usually absorb a fair amount of fluid without any adverse consequences.

If a patient is determined to have too much fluid absorption, the surgeon may elect to stop the surgery before it is done to avoid “overloading” the patient with fluid. However, if the surgeon is close to finishing, he may try to complete the surgery.

If there is concern about the amount of fluid that a patient has absorbed, she may be given medication to increase the amount of urine her kidneys make in order to reduce the amount of excess fluid. These medications are called diuretics. In more serious cases, the patient may be hospitalized for further medication or monitoring.

Bleeding Risk

Bleeding is a risk for any type of surgical procedure. For hysteroscopy, the risk for excessive bleeding is very low.

Infection risk

In order to place a hysteroscope into the uterus, the surgeon must pass it through the vagina. The vagina normally harbors large amounts of bacteria. It is theoretically possible, that bacteria could be carried on the hysteroscope into the normally bacteria free uterus causing an infection. This seems to be a very rare complication however.

Anesthesia risk

Anesthesia for hysteroscopy can range from nothing in an office diagnostic hysteroscopy to light sedation through an IV or complete general anesthesia where the patient is completely asleep and unable to feel any pain. For most young healthy patients, anesthesia presents little risk except for possible adverse or allergic reactions to the medications involved. The highest risk is for the elderly, obese, and those with chronic medical problems.