Journal of Reproductive Health and Contraception

Opinion

The diagnosis of unexplained infertility is one of exclusion and is made only after evaluation has failed to reveal abnormalities, it's incidence has decreased as diagnostic techniques have improved and investigations became more intensive. Evaluation of the uterine cavity is a basic step in the investigation of infertile women. Both the condition of endometrium as well as uterine cavity are thought to be important factors in determining receptivity for embryo implantation. It has been suggested that intrauterine abnormalities such as fibroid, synechia, or polyps, may have a negative impact on uterine receptivity and thereby the likelihood of achieving an ongoing pregnancy. Hence, it is recommended to diagnose and treat these abnormalities, in order to optimize the uterine conditions and subsequent in vitro fertilization success rates. Hysteroscopy can diagnose small uterine lesions that might not be readily diagnosed by conventional means such as transvaginal sonography with or without the use of saline or gel as contrast media, followed by hysterosalpingography. Hysteroscopy allows direct visualization of the endometrial lining and evaluation of the potential implantation site which is an important step in the management of women with infertility. 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.

In our study, published in the Asian Pacific Journal of Reproduction, December 2014, the incidence of uterine abnormalities was 33% which was similar to the incidence reported by previous studies. Also, the incidence of uterine abnormalities was greater in women aged ≥ 30 years(40%) and women with secondary infertility (44.3%). It has been reported that 34% of women with primary infertility and 40% of women with secondary infertility had tubal obstruction and endometrial pathology detected by hysteroscopy. In addition, the rates of abnormal findings ranged from 30% at 30 years to more than 60% after 42 years, therefore, our study and others have additional argument toward the use of hysteroscopy as part of first-line infertility work up regardless of age. In our study, all women were infertile for more than 3 years and all other factors that might contribute to infertility (other than the subtle uterine defects) had been excluded. Despite the debate concerning the relationship between such defects and infertility following correction of these defects, the overall pregnancy rate was 46% within one year of treatment. Several studies have reported the success of treatment of subtle uterine abnormalities on the chance of natural conception as well as after IVF cycles. It has been established that sub mucosal myomas negatively impact fertility and pregnancy rate as the endometrial receptivity is impaired throughout the uterine cavity, and surgical removal of such myomas leads to improved pregnancy rate. Also it has been demonstrated that small endometrial polyps are common findings on hysteroscopic assessment of infertility women with increase in pregnancy rate after removal of such lesions. In an infertile population, the prevalence of adhesions lies between 0.3%-14%. It has been reported that mild intrauterine adhesions can cause infertility due to changes in the functional aspects of the endometrium and hysteroscopic adhesiolysis is a safe and effective method of choice for restoring menstrual function and fertility. Moreover, there is accumulated evidence that hysteroscopy is beneficial for women experiencing implantation failures after IVF cycles. Not only the correction of hysteroscopic findings improves the pregnancy rate, at least when compared to controls not having a hysteroscopy, but also the procedure itself may have a positive prognostic value for achieving a subsequent pregnancy. To conclude, our findings suggest that correction of any uterine abnormalities even if small and minor improves the chance of conception in infertile women who have no other causes for infertility. In addition, women who do not conceive will get the benefit of improved results of assisted reproductive techniques.