Human life starts when a fertilised egg has successfully implanted in the inner layer of the cavity of the womb. It is believed that abnormalities originating from this site, such as polyps, fibroids, septa or adhesions, may disturb this important event. The removal of these abnormalities by doing a so-called hysteroscopy using a very small diameter inspecting device might therefore increase the chance of becoming pregnant either spontaneously or after specialised fertility treatment, such as intrauterine insemination or in vitro fertilisation. This review identified no studies reporting live birth as an outcome. We found one study on the removal of fibroids in women with unexplained infertility. It suggests that there might be a higher chance of conceiving after surgery compared to regular sexual intercourse for 12 months. Due to the low number of women (94) and the low number of pregnancies (30) the differences are not statistically significant. The quality of the study is very low. Therefore uncertainty remains about the real value of removal of fibroids in raising the chance of conception in women having difficulty becoming pregnant. We found only one study on hysteroscopy in 215 women with polyps who were to be treated with insemination for various fertility problems. The findings support an important increase in the pregnancy rates after the hysteroscopic removal of polyps. Although the quality of this study is high, further studies are needed to confirm this result. Neither of the two studies reported data on the surgical complications of hysteroscopy.
More studies are needed before hysteroscopy can be proposed as a fertility-enhancing procedure in the general population of women having difficulty becoming pregnant.

https://biblio.ugent.be/publication/7007716/file/7007727.pdf

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

background: Although hysteroscopy is frequently used in the management of subfertile women, a systematic review of the evidence
on this subject is lacking.
methods: We summarized and appraised the evidence for the benefit yielded by this procedure. Our systematic search was limited to
randomized and controlled studies. The QUOROM and MOOSE guidelines were followed. Language restrictions were not applied.
results: We identified 30 relevant publications. Hysteroscopic removal of endometrial polyps with a mean diameter of 16 mm detected
by ultrasound doubles the pregnancy rate when compared with diagnostic hysteroscopy and polyp biopsy in patients undergoing intrauterine
insemination, starting 3 months after the surgical intervention [relative risk (RR) ¼ 2.3; 95% confidence interval (CI): 1.6–3.2]. In patients
with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant
management (RR ¼ 1.9; 95% CI: 1.0–3.7). Hysteroscopic metroplasty for septate uterus resulted in fewer pregnancies in patients with subfertility
when compared with those with recurrent pregnancy loss (RR ¼ 0.7; 95% CI: 0.5–0.9). Randomized controlled studies on hysteroscopic treatment of intrauterine adhesions are lacking. Hysteroscopy in the cycle preceding a subsequent IVF attempt nearly doubles
the pregnancy rate in patients with at least two failed IVF attempts compared with starting IVF immediately (RR ¼ 1.7; 95% CI: 1.5–2.0).
conclusions: Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps, fibroids, septate uterus
or intrauterine adhesions indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic
surgery in the general subfertile population can be justified.

https://biblio.ugent.be/publication/818743/file/1134345.pdf

The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review

the quality of visualization of the uterine cavity (0‐3) and the complications were recorded. The examination was considered successful when the pain score was 1 and no complication occurred. RESULTS: Less pain, better visualization and higher success rates were observed with mini-hysteroscopy ( P< 0.0001, P< 0.0001 and P< 0.0001, respectively), in patients with vaginal deliveries ( P< 0.0001, P< 0.0001 and P< 0.0001, respectively) and in procedures performed by experienced surgeons (P 5 0.02, P 5 NS and P 5 NS, respectively). The effects of patient parity and surgeon experience were no longer important when minihysteroscopy was used. CONCLUSIONS: Our data demonstrate the advantages of mini-hysteroscopy and the importance of patient parity and surgeon experience, suggesting that mini-hysteroscopy should always be used, especially for inexperienced surgeons and when difficult access to the uterine cavity is anticipated. They indicate that mini-hysteroscopy can be offered as a first line office diagnostic procedure.

Prospective multicentre randomized controlled trial to evaluate factors influencing the success rate of office diagnostic hysteroscopy

Objective To compare the effects of different types of local anaesthetic for pain control during outpatient hysteroscopy. Design Systematic review and meta-analysis of randomised controlled trials. Setting Outpatient hysteroscopy clinics. Participants Women undergoing diagnostic or operative hysteroscopy as outpatients—that is, without general anaesthesia. Study selection criteria Medline, Embase, CINAHL, the Cochrane library, and reference lists of relevant studies. Two reviewers independently selected trials. Data were abstracted on quality, characteristics, and results. Results There were 20 trials (2851 participants). Data from 15 of these were meta-analysed in subgroups defined by type of intervention and study quality. Intracervical (standardised mean difference −0.36, 95% confidence interval −0.61 to −0.10, I 2 =0%) and paracervical (−1.28, −2.22 to −0.35, I 2 =97%) injections of local anaesthetic significantly reduced the pain in women undergoing hysteroscopy as outpatients, whereas transcervical (−0.11, −0.31 to 0.10, I 2 =27%) and topical application (−0.32, −0.97 to 0.33, I 2 = 90%) did not. Meta-regression showed that paracervical injection was superior to the other anaesthetic methods (P=0.04), a finding that was supported by the high quality subgroup of studies. Use of local anaesthetic did not have a significant effect on the incidence of vasovagal episodes (P=0.09). Conclusions Paracervical local anaesthetic injection is the best method of pain control for women undergoing hysteroscopy as outpatients.

https://www.bmj.com/content/bmj/340/bmj.c1130.full.pdf

Local anaesthesia for pain control during outpatient hysteroscopy: systematic review and meta-analysis

Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies

https://www.rima.org/web/medline_pdf/BJOG_57.pdf

Meena Shankar

Papers

Randomised comparison of distension media for outpatient hysteroscopy.

The long-term effectiveness of endometrial laser ablation: a survival analysis.