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It is well documented that hysterosalpingogram has a false positive rate with a range being reported at 8. Other disadvantages include discomfort and pain experienced by patients, radiation 33 to millirads infection 0.
Many clinicians feel that hysterosalpingogram is useful for screening for infertility and recurrent pregnancy loss, and that hysteroscopy is most useful following an abnormal hysterosalpingogram or for otherwise unexplained infertility.
Hysteroscopy has the obvious advantage of avoiding ionizing radiation and iodine-containing contrast material, as well as having a lower false positive rate than hysterosalpingogram.
Disadvantages to hysteroscopy are the potential for producing artifactual polyps or adhesions during the performance of the procedure and the fact that this is a minor operative procedure. However, the increasing utilization of office hysteroscopy with paracervical block and small endoscopes has markedly reduced the costs and risks associated with hysteroscopy.
Ultrasonography and Sonohysterography Ultrasonography is a useful adjunct in the diagnosis of infertile patients. Ultrasonography is most useful for the diagnosis of myomas, adnexal or pelvic masses, and polycystic ovarian disease.
It has an increased ability to identify calcified myomas or other calcified lesions, such as osseous metaplasia. Studies have shown a high level of sensitivity and specificity as well as predictive value of normal and abnormal tests. In particular, for the evaluation of submucous myomas, sonohysterography appears to be the most accurate technique for detecting submucous myomas and evaluating their size, location, and degree of intracavitary growth.
The technique is also very sensitive for identifying intrauterine polyps, and can be utilized to diagnosis congenital abnormalities as well as adhesions. Since this technique is also a simple office procedure, it has an adjunctive role to play with hysteroscopy. Magnetic Resonance Imaging Magnetic resonance imaging is rarely needed for identification of intrauterine lesions. However, it can be useful for differentiating the adenomyomatous from myomatous uterus, and for complex congenital uterine abnormalities as well as other rarer uterine abnormalities or pelvic masses.
Its high cost limits its general utilizability, but it is helpful in selected circumstances. Hysteroscopy Hysteroscopy is performed approximately half the time for the diagnosis of infertility. It is generally best performed in the postmenstrual proliferative phase. Different locations for hysteroscopy include the office, surgery center, or hospital operating room.
Endoscopes can range from 2 mm in size to 6. The choice of location, medium, and instrumentation depends on the availability of facilities and resources, the anticipated diagnosis, and the surgical plan. The optimum approach involves one which has a high probability of resolving the clinical issue at hand, with the major difference in approach depending on whether or not operative intervention will be required, safety, and cost.
Adjunctive procedures such as hysterosalpingography and sonohysterography can be of significant help in identifying the patient who requires hysteroscopy, and the best hysteroscopic approach for that patient given the clinical conditions.
Carbon dioxide gas has the advantage of excellent clarity, and it is very safe. Disadvantages are that CO2 gas bubbles can form and blood can quickly obscure the view.
CO2 hysteroscopy is diagnostic only, and there is a small potential for systemic absorption resulting in acidosis, arrhythmias, and even fatal complications. Five percent dextrose in water has the advantage of good clarity and being safe, but disadvantage of being primarily diagnostic.
However, recently developed instrumentation which will allow the use of bipolar electrosurgery in normal saline may dramatically improve the utility of the use of normal saline for operative hysteroscopy.
Nevertheless, there are potential serious complications including pulmonary edema, fluid overload with electrolyte imbalance, cardiovascular collapse, neurologic toxicity, and anaphylaxis. Thirty-two percent Dextran has the advantage of providing good clarity and it is miscible with blood, which is very advantageous for operative procedures.
Disadvantages include potential allergic reactions, noncardiogenic pulmonary edema, and potential coagulation defects. In addition, the material is more difficulty to work with because of its stickiness for the surgeon, operating room personnel, and equipment.
While most gynecologists have their favorite medium, it is usually advantageous to have familiarity and be able to use different media depending on the surgical procedure. The choice of instrumentation will often depend on the choice of medium. Larger instruments tend to be used for operative intervention, and tend to require more anesthesia.
Anesthesia may range from simple reassurance, nonsteroidal anti-inflammatory drugs, and anxiolytics, through conscious sedation with intravenous medication, epidural anesthesia, or general anesthesia. Again, the least interventional, yet effective and safe, anesthetic should be chosen for the particular situation. Contraindications to hysteroscopy include an absolute contraindication for pelvic infection or endometrial cancer, and relative contraindication in the case of pregnancy, excessive bleeding, cardiovascular disease, or severe vaginitis.
These include cervical laceration, uterine perforation, bleeding, reactions to the distention media, or anesthesia. Potential long-term complications include femoral injury resulting in intrauterine scarring or tubal obstruction, as well as injury to contiguous organs. Contemporaneous Laparoscopy For many clinical conditions it is recommended that contemporaneous laparoscopy be performed. This includes situations in which a laparoscopy is clinically indicated as an independent procedure, when there are also indications for hysteroscopy.
The combination of these two procedures at one operative setting is clearly of potential benefit to most patients. Additionally, laparoscopy may be directly helpful in assessing and treating the uterine cavity in the case of uterine myomas, tubal obstruction, and in the evaluation of congenital uterine abnormalities as well as in complex diagnostic situations.
When performing a diagnostic laparoscopy at the same time as hysteroscopy, it is my practice to place the vaginal tenaculum and Conn cannula, and then perform a diagnostic laparoscopy and hydrotubation.
Subsequent to that a hysteroscopy is performed. This allows the hysteroscopy to be carried out with much greater information than would be otherwise. The hysteroscopy is performed immediately after the diagnostic laparoscopy and before any operative laparoscopic procedures in order to minimize trauma to the uterine cavity and to limit the creation of artifactual lesions or bleeding.
The initial step at hysteroscopy is to identify the uterine cavity and ostia and to evaluate the right and left cornua, fundus, anterior and posterior walls, and lateral walls for specific lesions, as well as to evaluate the overall contour of the uterine cavity.
The endocervical canal is then carefully evaluated also. Uterine sounding is performed at the end of the hysteroscopy to minimize the creation of intrauterine artifactual lesions. Conditions which should be identified include foreign intrauterine objects e. IUD , adenomyosis, polyps, adhesions, fibroids, synechiae, or congenital abnormalities. The endocervical canal is also carefully evaluated on withdrawing the instrument. Endometrial Biopsy and Polypectomy Endometrial biopsy and polypectomy are usually performed at the time of hysteroscopy.
Biopsy is easily carried out with use of a biopsy instrument or grasper, or curettage of the cavity. Uterine Myomas Intrauterine myomas can usually be identified easily at hysteroscopy.
However, large myomas which only produce a subtle deformation of the cavity can be difficult to recognize. Additionally, large myomas, even though easily recognizable, can be very difficult to treat. Uterine myomas are a clinical condition in which preoperative evaluation with ultrasonography and preferably sonohysterography can improve our ability to diagnose and treat the condition appropriately.
Usually treatment of intrauterine myomas with GnRH agonists prior to hysteroscopic resection is beneficial. It is important to recognize that the uterine volume would also be reduced and that the uterus would be hypoestrogenic and therefore more susceptible to perforation, even in the premenopausal woman, who has been treated with GnRH agonists. Resectoscopic myomectomy is a highly effective procedure, but fraught with potential hazards with respect to uterine injury from the electrosurgical energy, perforation of the uterus, bleeding, infection, and most importantly, serious complication as a result of fluid overload.
A Foley catheter should be used during long and complex cases to allow measurement of urine output. All fluid measurements should be taken every 15 minutes and documented. Once a 1, cc fluid deficit is identified, the case should be terminated. When Hyskon is used consideration for termination of procedure should be made at mL differential, and absolutely at mL without exception.
Despite the inherent risks of hysteroscopic myomectomy, the advantages of hysteroscopic resection include the avoidance of laparotomy and a uterine incision, as well as the avoidance of a need for cesarean section and avoidance of the creation of tubo-ovarian adhesions.
Overall, this is an excellent procedure if performed by skilled surgeons. The pathophysiology involves damage to the stratum basalis and bridging of denuded uterine walls with variable cavity obliteration. Symptoms associated with intrauterine adhesions include hypomenorrhea, amenorrhea as a result of endometrial destruction, cyclic pain, infertility possibly as a result of sperm migration disruption, tubal ostia obstruction, or impairment of blastocyst implantation.
Recurrent abortions have been reported because of decreased uterine size or insufficient endometrium, and abnormal placentation may result in a defective stratum basalis. Uterine trauma from curettage at surgery increases the probability of adhesions.
It is felt that infection plays an important role in the development of intrauterine adhesions although its role is still somewhat controversial. Tuberculous endometritis is an etiologic infection, and patients with congenital abnormalities, such as DES, may be at higher risk. It has also been reported that only 1. Classification of intrauterine adhesions by the American Fertility Society Classification requires evaluation of the extent of the cavity, adhesion density, and menstrual pattern, with classification of mild, moderate, or severe.
Treatment involves removal or division of the adhesions with an endoscope, endoscope sheath, curettes, scissors, cautery, resectoscope, or neodymium-YAG laser.
It is controversial whether patients should receive prophylactic antibiotics or postoperative estrogen, or use of an IUD or Foley catheter. It is my practice to give patients Doxycycline mg the night prior to surgery and for three days following surgery, as well as estrogen for four weeks postoperatively at a dose of conjugated equine estrogens 2. Occasionally these doses are increased in the case of extremely severe adhesions.
Hysteroscopy is used to diagnose or treat problems of the uterus. A hysteroscope is a thin, lighted telescope-like device. It is inserted through your vagina into your uterus. The hysteroscope transmits the image of your uterus onto a screen.
Other instruments are used along with the hysteroscope for treatment. Why is hysteroscopy done? One of the most common uses for hysteroscopy is to find the cause of abnormal uterine bleeding.
In some cases, abnormal bleeding may be caused by benign not cancer growths in the uterus, such as fibroids or polyps. Hysteroscopy also is used in the following situations: If you have general anesthesia, you will not be awake during the procedure.
It will be scheduled when you are not having your menstrual period. To make the procedure easier, your health care professional may dilate open your cervix before your hysteroscopy. You may be given medication that is inserted into the cervix, or special dilators may be used. A speculum is first inserted into the vagina. The hysteroscope is then inserted and gently moved through the cervix into your uterus. Carbon dioxide gas or a fluid, such as saline salt water , will be put through the hysteroscope into your uterus to expand it.
The gas or fluid helps your health care professional see the lining more clearly. The amount of fluid used is carefully checked throughout the procedure. What should I expect during recovery? You should be able to go home shortly after the procedure. If you had general anesthesia, you may need to wait until its effects have worn off.
It is normal to have some mild cramping or a little bloody discharge for a few days after the procedure. You may be given medication to help ease the pain. If you have a fever, chills, or heavy bleeding, call your health care professional right away.
What are the risks of hysteroscopy? Hysteroscopy is a very safe procedure.