Unexplained Infertility Clinical Trial
Official title:
Role of Routine Hysteroscopy in Management of Cases of Unexplained Infertility
The aim of this work is to assess the value of hysteroscopy in unexplained infertility.
The diagnosis of unexplained infertility is one of exclusion and is made only after an
infertility evaluation has failed to reveal abnormalities. There is no consensus on which
tests should be performed before making this diagnosis (Salim et al., 2011).
The Europe society for human and embryology (ESHRE) suggested standard diagnostic tests for
infertility evaluation. These tests include semen analysis, demonstration of tubal patency by
hystosalpingography (HSG) or laparascopy and laboratory assessment of ovulation (Polisseni et
al., 2003). Moreover post coital test has been included by some authors as a fundamental
requirement before the diagnosis of unexplained infertility while other authors found that it
is unnecessary however conducting additional investigation and treating any abnormalities
detected may be effective in management of women with unexplained infertility especially in
older couples (Wortman et al., 2013).
For evaluation of the uterine cavity, the basic work-up consists of transvaginal sonography
(TVS) with or without the use of saline or gel as a contrast medium, possibly followed by
either HSG or hysteroscopy to directly assess the uterine cavity.
Both TVS, as well as saline infusion sonography (SIS) and gel instillation sonography (GIS)
are inexpensive, non-invasive and have been shown to be excellent diagnostic tool to detect
subtle intrauterine abnormalities (Rodrigues et al., 2014).
However, hysteroscopy allows direct visualization of the endometrial lining and detects
multiple lesions and subtle uterine abnormalities that cannot be identified by the previous
techniques. Moreover, hysteroscopy enables treatment of small uterine pathology in the same
setting. Therefore, it is frequently referred to as the golden standard. Many studies have
concluded that whenever laparoscopy is performed, it should be combined with hysteroscopy in
order to complete the assessment before starting the infertility treatment (Chan et al.,
2011).
In the assisted reproductive technique, a number of studies was conducted on women before in
vitro fertilization (IVF) cycle revealed that the prevalence of un suspected intra uterine
abnormalities, diagnosed by hysteroscopy prior to IVF cycles was 11% - 45% (Shokeir et al.,
2011).
Although the role of these subtle lesions as a cause of infertility is debatable,( Kilic et
al., 2013) hysteroscopic assessment and treatment of any abnormalities detected has improved
the clinical pregnancy rate , live birth, and considered cost effective before IVF cycles
(Grimbizis et al., 2003) .
It is widely accepted that a complete infertility workup includes an evaluation of the
uterine cavity (Chan et al., 2011). Uterine abnormalities, congenital or acquired, are
implicated as one of the causes of infertility. In fact, infertility related to uterine
cavity abnormalities has been estimated to be the causal factor in as many as 10% to 15% of
couples seeking treatment (Romani et al. 2013).
Hysteroscopy enables visualisation of the uterine cavity and allows the diagnosis and
surgical treatment of intrauterine pathology. (Umranikar et al., 2016). Direct view of
uterine cavity offers a significant advantage over other blind or indirect diagnostic
methods. Although , hystrosalpingography (HSG) is reported to be as accurate as hysteroscopy
in the diagnosis of normal and abnormal cavities, the nature of intrauterine filling defects
is more accurately revealed by hysteroscopy (Jenneke et al.,2013).
The role of hysteroscopy in infertility investigation is to detect possible intrauterine
change that could interfere with implantation or growth, or both, of the conceptus (Scholten
et al., 2013) and to evaluate the benefit of direct treatment modalities in restoring a
normal endometrial environment (Prasanta et al., 2013).
Several studies have been also performed to find out that if hystroscopic treatment of
intrauterine pathologies increases the cause of failure of IVF-ET (Fatemi et al., 2010) and
therefore hysteroscopy should be a part of infertility workup for all patients prior to
undergoing IVF treatment and have also recommended screening of the uterus by hysteroscopy
before proceeding with IVF/ICSI, to minimize implantation failure (Ryan et al. 2005).
The potential risk of diagnostic hysteroscopy are rare in most series (0-1%) especially in
office procedure (John et al., 2013), while (5-24%) of operative cessions may result in
intraoperative or early postoperative complications which include infection, bleeding, and
even perforation of the uterus. Certain factors are considered contraindication to
hystroscope like PID (Aydeniz et al., 2004).
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