Guideline No. 446: Hysteroscopic Surgery in Fertility Therapy

Abstract

Objective

To evaluate the indications, benefits, and risks of hysteroscopy in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.

Target Population

Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.

Benefits, Harms, and Costs

Hysteroscopic surgery can be used to diagnose the etiology of infertility and improve fertility treatment outcomes. All surgery has risks and associated complications. Hysteroscopic surgery may not always improve fertility outcomes. All procedures have costs, which are borne either by the patient or their health insurance provider.

Evidence

We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix B for MeSH search terms).

Validation Methods

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).

Intended Audience

Gynaecologists who manage common conditions in patients with infertility.

Tweetable Abstract

When offering hysteroscopic surgery to patients with infertility, ensure it improves the live birth rate.

SUMMARY STATEMENTS

• 1.Hysteroscopy, sonohysterography, and 3-D sonohysterography are comparable for diagnosing intracavitary pathology in patients with unexplained infertility (high).
• 2.The beneficial effects of hysteroscopy on conception and live birth rates in patients with unexplained infertility remains uncertain as numerous studies report contradictory results (low).
• 3.Improvements in imaging modalities means that the majority of müllerian anomalies can be diagnosed non-invasively, with hysteroscopy and laparoscopy being reserved for cases where imaging is inconclusive (high).
• 4.There is no evidence of improved reproductive outcomes following the correction of most müllerian anomalies (low).
• 5.Published literature supports resection or correction of a uterine septum or a T-shaped uterus to improve reproductive and obstetrical outcomes; however, a small, randomized controlled trial did not show a benefit (moderate).
• 6.FIGO types 0–2 (submucosal) fibroids are associated with lower pregnancy and higher miscarriage rates (moderate).
• 7.Hysteroscopic myomectomy appears to be associated with improved unassisted and assisted pregnancy rates (low).
• 8.Fertility outcomes are similar between the various hysteroscopic myomectomy techniques (low).
• 9.Hysteroscopy can reliably diagnose intrauterine adhesions in patients with a normal transvaginal ultrasound and hysterosalpingogram (moderate).
• 10.Hysteroscopic correction of intrauterine adhesions increases conception rates in patients with infertility or recurrent pregnancy loss (high).
• 11.Although hysteroscopy improves the live birth rate in patients known to have intrauterine adhesions, the effect on live birth rates in patients with infertility or recurrent pregnancy loss is uncertain (low).
• 12.In patients with infertility, hysteroscopy can diagnose previously unrecognized polyps in patients with normal investigations (high).
• 13.Hysteroscopic polypectomy improves unassisted and intrauterine insemination conception and live birth rates in asymptomatic patients with infertility (moderate).
• 14.Hysteroscopic polypectomy has limited evidence of benefit for pregnancy or live birth rates in asymptomatic infertility patients undergoing IVF (low).
• 15.Although limited fertility data exist, intrauterine barriers may reduce intrauterine adhesions following hysteroscopic surgery (low).
• 16.There are no data to support the use of medications to improve uterine blood flow or antibiotics in hysteroscopic surgery (low).
• 17.The use of steroid hormones, estrogen with or without progestin, may reduce intrauterine adhesions following hysteroscopic surgery (low).

RECOMMENDATIONS

• 1.Patients with unexplained infertility may benefit from uterine cavity evaluation by either hysteroscopy, sonohysterography, or 3-D sonohysterography (conditional, low).
• 2.In patients with unexplained infertility, correction of intracavitary pathology may improve live birth rates (conditional, low).
• 3.Diagnostic imaging (sonohysterography, 3-D sonohysterography, and MRI) should be the first-line investigation of müllerian anomalies, reserving invasive surgical procedures for cases where imaging studies are inconclusive (strong, high).
• 4.Hysteroscopic correction of müllerian anomalies should be limited to septate and T-shaped uteri, unless functional or pain concerns are present (e.g., cervical agenesis, obstructed uterine horn) (conditional, low).
• 5.Hysteroscopic myomectomy may be considered in patients attempting conception whether unassisted or with assisted reproductive technology (conditional, low).
• 6.Patients with infertility or recurrent pregnancy loss diagnosed with intrauterine adhesions on routine investigation should have hysteroscopic adhesiolysis to increase the likelihood of conception (strong, high).
• 7.Patients planning to conceive and known to have intrauterine adhesions should have hysteroscopic adhesiolysis to improve the likelihood of a live birth (conditional, moderate).
• 8.Hysteroscopic polypectomy to improve reproductive outcomes is recommended in patients attempting unassisted conception, ovulation induction, or mild ovarian stimulation (conditional, moderate).
• 9.Hysteroscopic polypectomy is recommended to improve fertility outcomes in patients planning intrauterine insemination (conditional, moderate).