Hysteroscopy is a procedure that allows Gynaecologist to see inside the womb by means of a fine telescope (Hysteroscope) that can be introduced through the (cervix) neck of the womb. Hysteroscopy can be painless and can be done in an outpatient basis. More often it is done in an operation theatre under anaesthesia. Hysteroscopy usually follows investigations such as Hysterosalpingography or transvaginal ultrasound.
A small telescope, the hysteroscope, is passed through the cervix and the inside of the uterine cavity can be seen. A small camera is attached to the telescope and the view is projected on a video monitor. This magnifies the picture and also allows the physician to perform the surgery while sitting in a comfortable position.
If I have difficulty in conceiving do I need to undergo hysteroscopy as a routine investigation?
No. We at Ankoor clinic do not advise hysteroscopy for all infertility patients as hysteroscopy is not recommended as a routine investigation for infertility.
What are the indications for a Hysteroscopy?
You may need to undergo hysteroscopy if you have any of the following:
Abnormal hysterosalpingography (HSG) (Screening test for tubal patency wherein a dye is) injected in the uterus and visualized under X-ray control).
Abnormal bleeding pattern
Uterine abnormalities or pathology suspected on ultrasonography
Unexplained infertility.(Inability to conceive despite all routine investigation being normal)
Hysteroscopy enables the gynaecologist to inspect the lining of the womb and to detect possible causes for the above problems like polyps or fibroids. Many experts in radiology and imaging feel that high resolution ultrasound can pick up intrauterine pathology accurately, in which case hysteroscopy is more often considered as a see and treat procedure.
How will a Hysteroscopy help in unexplained infertility?
Review of literature shows that positive hysteroscopic findings were found in as many as 15 % cases despite having normal HSG and no history suggestive of intra uterine lesions.
If I am undergoing laparoscopy for infertility should hysteroscopy be done at the same time?
There are certain indications when both hysteroscopy and laparoscopy are done at the same time. However it is not done in all cases. It depends on the individual patient.
For eg. In a woman coming with large intrauterine polyp, if the patency of fallopian tubes is not known then it is better to do a laparoscopy along with polyp removal by hysteroscopy. This will help us to check for the fallopian tubes as well as the uterus and ovaries.
There is no harm in doing hysteroscopy at the same time as laparoscopy. It does not take extra time or exhorbitant cost, is safe and has low complication rate.
How many days do I have to take off from work?
Hysteroscopy can be done as a day care procedure i.e. you will be able to go home in few hours after the operation. However to be on safer side or if there are any potential difficulties, the gynaecologist may advice an overnight stay. You will not need more than a couple of days off at work. Recovery period is very short as there are no scars.
How do I prepare for a hysteroscopy?
You may have to do a few blood investigations before your operation. Do not eat or drink (even water) after midnight on the night before your operation. You can bathe in the morning before surgery.
Your doctor may also have additional instructions for you. Some surgeons recommend use of vaginal misoprostol (a vaginally introduced tablet) 2-4 hrs prior to hysteroscopy to reduce cervical resistance and thereby cervical trauma due to dilatation.
Can I know how is the operation performed?
The operation is done from the vagina (Birth passage) and leaves no scar.
After giving anaesthesia the cervix (neck of the womb) is dilated to pass the hysteroscope into the womb. The cavity of your womb is then distended with fluid. All four walls as well as the fundus and the lining of the womb (endometrium) are examined systematically.
If any abnormality is found, it can be tackled at the same time (Operative hysteroscopy) or at a later date as per the woman’s wish. Many a times curetting (scraping of lining of uterus i.e. endometrium) of the uterine wall is carried out after hysteroscopy. This endometrial material can be sent for histopathology and other investigations to diagnose hormonal problems or infections like tuberculosis etc.
Which other procedures may be usually performed during Hysteroscopy?
Curettage and polypectomy are commonly performed procedures during hysteroscopy.
Curettage includes gentle scraping of lining of the womb by a slender instrument. The sample is sent for histopathology. Polyps are harmless fleshy growths that are attached to lining of the womb by stalks. Polyps are removed by using a forceps or by using cautery to cut them. They are also sent to laboratory for histopathology. The reports are generally available in a week’s time.
What type of anaesthesia is used?
Hysteroscopy is usually performed under a general anaesthesia, although sometimes a local anaesthesia is used instead. You will be always seen by an anaesthetist before you come in for your operation.
What are the complications?
Hysteroscopy is considered safe however it carries some risks that a patient should be aware of.
Occasionally there might be failure to visualize the uterine cavity if the neck of the womb is too tight.
Uterine perforation wherein scope or an instrument may pass through and through the uterine wall occurs in less than 1 % of cases.
Pelvic infection is not common as we now-a-days give peri-operative antibiotics, but may manifest with lower abdominal pain, fever and offensive vaginal discharge and can be easily treated.
Hemorrhage and need for blood transfusion is very rarely necessary.
Although rare the gas or fluid used to distend the uterine cavity could spill into your bloodstream and cause serious problems.
Anaesthesia may carry a small risk. Side-effects may arise with the medications given
Level of complication is almost negligible in expert surgeon hands. Most of the time the injury may heal by itself and there are no further future implications. However there may be a need of prolong hospital stay or sometimes further intervention. A laparoscopy (insertion of telescope through your umbilicus) may be performed to investigate any possible internal injury. Very rarely, a laparotomy (An operation through a larger incision) is necessary to repair an injury.
Are there any side effects?
It is usual to have some bleeding after hysteroscopy, which is bright red at first and should gradually reduce to a brownish discharge. This can last for up to 2 weeks. Some degree of pain is to be expected but this is not severe and relieved by painkillers like paracetamol or ibuprofen. Submucous Or Intramural Fibroid
Which fibroids can be treated hysteroscopically? As already explained in link of fibroids, they can either be subserosal (on the outer surface of uterus), submucous fibroids (inside the uterine cavity) or intramural (within the wall of uterus). It is the submucous fibroids which can mainly be treated with hysteroscopic resection. Also intramural fibroids may require hysteroscopic management if they protrude within the uterine cavity. Other intramural and subserosal fibroids need laparoscopic removal.
Hysteroscopic classification of fibroids: European Society for Gynaecological Endoscopy (ESGE) Classification of submucous myomas (Adapted from Wamsteker’s classification):
Type 0 – Entirely within endometrial cavity
No myometrial extension (pedunculated)
Type I – < 50% myometrial extension (sessile)
< 90 degree angle of myoma surface to uterine wall
Type II – > or = 50% myometrial extension (sessile)
>or = 90 degree angle of myoma surface to uterine wall
Type 0 and type I can be removed hysteroscopically, while type II is to be removed laparoscopically. What does hysteroscopic resection of fibroid mean?
Video of hysteroscopc resection of fibroid
A resectoscope (thin long telescope like instrument) is a special operative instrument that is attached to a normal hysteroscope. To this resectoscope a special loop is loaded which can conduct electricity. It is this electricity that is used to cut the fibroid into pieces and then remove it through the cervix / vagina.
This procedure is performed as outpatient surgery without any incisions and virtually no postoperative discomfort. Anesthesia is needed because the surgery may take one to two hours. A small telescope, the hysteroscope, is passed through the cervix and the inside of the uterine cavity can be seen. A small camera is attached to the telescope and the view is projected on a video monitor. This magnifies the picture and also allows the physician to perform the surgery while sitting in a comfortable position.
Electricity passes through the thin wire (resectoscope) attachment at the end of the hysteroscope, allowing the instrument to cut through the fibroid like a hot knife cutting through butter. As the fibroid is shaved out, the heat from the instrument blocks blood vessels and the blood loss is usually minimal. Women go home the same day, and recovery is remarkably fast, with most patients able to go back to normal activity, work and exercise in one or two days.
Is it necessary to remove submucous fibroids? Many studies have found that submucous fibroids that change the shape of the uterine cavity decreased pregnancy rates by as much as 70%. Not only is the pregnancy rate reduced but also there is an increased chance of abortion. When these fibroids were removed there was an increase in the pregnancy rates.
The reason submucous fibroids leads to infertility is not clear, but current theories are that the fibroids change blood supply to a the developing embryo, or block passage of the embryo through the fallopian tube, or cause inflammation in the uterine lining, or interfere with attachment of embryo to the uterine lining or hamper embryo development. Only a few years ago, treatment for fibroids in the cavity of the uterus involved major surgery-an abdominal incision and either cutting open the entire uterus to remove the fibroid or performing a hysterectomy. Such a major surgery did not significantly improve pregnancy outcomes. Also an incision on uterus increased rate of complications in pregnancy. Hysteroscopic myomectomy has been a major advance in the treatment of women who have submucous fibroids.
Hysteroscopic removal definitely improves pregnancy rates. Also there is no increased incidence of complications in pregnancy.
Can these fibroids be managed with medicines? No, there is no definitive medical management for fibroids. Surgical removal is the only way to get rid of the fibroid and obtain optimal result. It is just like a mole on the skin, it needs to be removed no medicines can treat it.
How long does the surgery take? Since the fibroid has to be cut and removed chip by chip, it may take 30 min to 2 hours to remove a submucous myoma depending upon the size and extent. One can remove as large as 6-7 cm fibroid at a time. Sometimes if the fibroid is very large the entire procedure may need to be done in two sittings with a gap of 3-4 weeks. This ensures complete removal and lesser complication rates.
Once removed do fibroid come back again? If completely removed the fibroid does not come back again, however new fibroids can appear. The location and size of fibroids may vary and you may or may not require further surgery.
What anaesthesia is used? General anaesthesia is used for this surgery. It means you will be put to complete sleep and won’t feel any pain or discomfort during surgery.
How do I prepare prior to surgery? Preparation for the surgery is similar to any other hysteroscopic surgery. Some medicines may be prescribed to you prior to surgery and a fasting of 6 hours is sufficient. A vaginal tablet (Misoprostol) may be inserted 2 hours prior to surgery to reduce cervical resistance and thereby cervical trauma.
How many day will I be hospitalized? How many days do I need to take rest after surgery? You may be discharged on the same day evening. In cases of larger fibroids where surgery went on for a longer time you may be kept overnight for observation. You will be mobilized after 4 hours of surgery and can go home walking. You may go back to work after 2 days of rest.
What are the complications? Minor discomfort in the pelvic region and few cramps are normal. There might be slight bleeding which will subside in 3-4 days. Major complications like uterine perforation, trauma to bladder or rectum, severe hemorrhage and fluid overload are rare.