Hysteroscopy is a minimally invasive procedure that allows the doctor to check the insides of your uterus by inserting a thin, lighted tube. In some situations, it is the best way to examine your uterus but is it necessary in every case to do a hysteroscopy before IVF?
Many clinics routinely practice hysteroscopy routinely before IVF to ensure that the uterine cavity is normal and ready to receive embryos.
However, many people are critical of this practice calling it If it is absolutely crucial, why don’t all doctors recommend it? The more important question to ask here is: are IVF results affected if hysteroscopy is not done before the IVF procedure?
How is hysteroscopy done?
Diagnostic hysteroscopy is a minimally-invasive procedure performed under general anesthesia or sedation. A telescope attached to a narrow tube is then passed into your uterine cavity through your vagina and cervix.
The surgeon moves it around to check the uterine wall and looks for malformations like fibroids, polyps, septa, scar tissue, etc. If anything is found, it can usually be removed at the same time.
How is hysteroscopy used in infertility?
Some clinics perform hysteroscopy before IVF for every patient, suggesting that this is the best method to ensure the uterine cavity is healthy.
Especially if you’ve had failed IVF cycles or recurrent miscarriages, hysteroscopy may be advised to get a close view of the insides of the uterus.
In a retrospective study of 292 women, who attended a clinic for IVF treatment, the doctors found that 74 (25 percent) of them had some intrauterine pathology, which when corrected with hysteroscopy, resulted in a considerable improvement in pregnancy rate.
While the researchers in this study insist that examining the uterine cavity is an important step before IVF, it does not justify the need of an invasive hysteroscopy in every patient.
Does hysteroscopy improve IVF results?
A much larger study funded by the Dutch Organization for Health Research and Development (ZonMW), involved over 750 women, of which half were assigned to undergo hysteroscopy while the other half went straight to IVF.
In the women eligible for hysteroscopy, 209 out of 369 (or 57%) successfully conceived and had a live birth, while among the women who went straight to IVF, 200 out of 373 (or 54%) were able to have a livebirth.
One (<1%) woman also developed endometritis after hysteroscopy.
The researchers concluded that routine hysteroscopy before IVF does not improve the treatment outcome, hence, it is not recommended.
There are less invasive techniques like transvaginal ultrasound of the uterine cavity, which can be done to check the insides of a uterine cavity and be followed up with an operative hysteroscopy, only if any problem is found.
A different study in 2019 found that women having recurrent implantation failure after IVF did not benefit from hysteroscopy. While, the implantation rates in these women improved, and they were also able to get pregnant, there was no improvement in live birth.
In recurrent miscarriage, the most commonly responsible factors are the embryo quality or the mother’s immunity, neither of which can be improved with a hysteroscopy.
Why do doctors perform hysteroscopy before IVF?
The doctors who routinely perform hysteroscopy on patients claim that this is a minimally invasive procedure and if it allows to increase the chances of pregnancy for even one patient by detecting some uterine problem, which may otherwise have been missed, the procedure is justified.
However, not everyone agrees and some call it mindless medicine.
A superfluous procedure means extra expense for the patient with no apparent benefit.
With a simple transvaginal ultrasound, the doctor can easily see the thickness of the endometrium and if the doctor suspects anything, a sonohysterogram can be done to get a better picture of the uterine cavity.
These procedures are much cheaper and non-invasive and if everything in these investigations is normal, there is little chance that the doctor will find anything in hysteroscopy.
Should IVF patients have a hysteroscopy or not?
Given that there is no obvious advantage and lesser invasive procedures are available for the same investigation, a routine hysteroscopy before IVF seems like an unnecessary trouble and expense for the patient.
If your doctor/clinic insists, don’t hesitate to get a second opinion to check if hysteroscopy is really required in your situation. If, however, you have any uterine growths that make it obligatory, do not hesitate to go through with it.
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Smit, JG, Kasius, JC, Eijkemans M … Torrance H L (2016). Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial. Lancet (London, England), 387(10038), 2622–2629. https://doi.org/10.1016/S0140-6736(16)00231-2
Mao, X., Wu, L., Chen, Q., Kuang, Y., & Zhang, S. (2019). Effect of hysteroscopy before starting in-vitro fertilization for women with recurrent implantation failure: A meta-analysis and systematic review. Medicine, 98(7), e14075. https://doi.org/10.1097/MD.0000000000014075
Palshetkar, N., Pai, H., & Pisat, S. (2009). Role of hysteroscopy prior to assisted reproductive techniques. Journal of gynecological endoscopy and surgery, 1(1), 27–30. https://doi.org/10.4103/0974-1216.51906