HYSTEROSCOPIC FINDINGS AMONG FEMALE PARTNERS PRESENTING IN A GOVERNMENT-FUNDED IVF CENTRE OF NATIONAL HOSPITAL ABUJA, NORTH CENTRAL NIGERIA. Mahmoud R, Rais-Ibraheem S M, Ladipo O P, Efetie E R, Oladepo S O, Abubakar S J and Katagum D A IVF Centre National Hospital Abuja  

INTRODUCTION Hysteroscopy-- first performed in 1890 First IVF Birth– Louise Brown in 1978 Exponential development of ART in the last 30 years Endometrium is a major factor for successful implantation and pregnancy Many things within it can adversely affect implantation

Hysteroscopy Hysteroscopy which is the direct visualization and assessment of the endometrial cavity is a relatively new procedure made more popular by the pioneering work of Jacques Hamou( the father of modern hysteroscopy.) Very useful procedure to assess the endocervical canal and the endometrium It can be use for diagnosis- polyps, adhesions, synaechiae, abnormalities, fibroid, infections, etc It can also be used for treatment An office/ outpatient procedure with few side effects in experienced hands

Other methods of assessing endometrium Transvaginal ultrasonography Sono-hysterosalpingography Hysterosalpingography ?Endometrial curettage

Contraindications to hysteroscopy viable intrauterine pregnancy, active pelvic infection, known cervical or uterine cancer, inexperienced surgeon.  

Hysteroscopy Procedure It involves the use of the use 4mm 300 telescope and 4.5mm examination sheath for diagnostic hysteroscopy, though smaller telescopes of various sizes – 2mm, 3mm; are now available which make the procedure less traumatic. distending medium to provide a global view of the endometrial cavity. The most commonly used distending media are low viscosity fluids and carbon dioxide.

Complications of hysteroscopy Cervical injury Uterine perforation hemorrhage Embolism Infection Hydrosalpinx 9

OBJECTIVES To describe our experience with hysteroscopy in the National Hospital, Abuja Nigeria

MATERIALS AND METHODS  Retrospective review of all cases of hysteroscopy done between January 2016 to December 2016 at the National Hospital, Abuja, Nigeria was carried out. Relevant information was extracted from the patient’s case notes. A 4mm 00 rigid hysteroscope was used. Normal saline was used as a distention medium. Therapeutic procedures were performed with hysteroscopic grasping forceps/ scissors.

A total of 92 hysteroscopy were done. RESULTS A total of 92 hysteroscopy were done.

Age and parity of the patients TABLE 1; AGE DISTRIBUTION OF PATIENTS Age and parity of the patients AGE NUMBER PERCENTAGE(%) 30-34 15 16.3 35-39 27 29.3 40-44 21 22.8 45-50 25 27.2 >50 4 4.4 PARITY NUMBER PERCENTAGE(%) 74 80.4 1 7 7.6 2-4 8 8.7 >5 3 3.3

Indications for Hysteroscopy NUMBER PERCENTAGE(%) Primary 18 19.6 Secondary 71 77.2 Irregular bleeding 3 3.2

Findings at the Procedure NUMBER PERCENTAGE(%) Cervico-uterine adhesions 32 34.8 Cervical adhesions 18 19.6 Normal Lush endometrium 14 15.2 Polyp 10 10.7 Submucous fibroid 8 8.7 Cervical stenosis 5 5.5 Small sized uterus

Procedure done at the hysteroscopy PROCUDURES NUMBER PERCENTAGE(%) Adhesiolysis 40 43.5 Hysteroscopy alone 33 35.8 Polypectomy 8 8.7 Myomectomy 6 6.5 Curettage 3 3.3 Cervical dilatation 2 2.2

Discussion The age distribution of the patients showed that the peak age to be among women in their early or mid thirties. This is because it is at this age bracket that affected women seek for medical intervention and is in agreement with findings of other workers. Among the patient population, a previous pregnancy was observed to be associated with an abnormal hysteroscopy which is irrespective of the outcome. This may not be unconnected with risks associated with termination of unwanted pregnancy which may not be safely done in our environment where the abortion laws are restrictive in nature 14, and the availability and use of contraception is poor

Only 15 % of the patients had normal endometrium The use of routine hysteroscopy had been advocated by many other workers 22, 23 prior to commencing ovulation induction for IVF, whereas other authorities especially in the US, belief that hysteroscopy should only be performed in women that have two or three IVF failures 24. The former stand is a very sensible approach as against the later because it is best to optimize the chances of a successful IVF/ET than wait for two or three failures better acting.

Literature search in support 1. Dicter, D.;et al- hysteroscopy should be done in all before IVF as many abnormalities were found and corrected with improved pregnancy rates 1 2. Goldenberg, M.; et al- the overall abnormal findings was 21% on hysteroscopy with need for operative intervention.2 3.Golan, R.; et al- out of a total of 324 patients with suspicious HSG, 50% had abnormal hysteroscopic findings, implying that HSG although very sensitive had a low specificity(23%), a false positive rate of 44% and false negative rate of 10%.3 4.Feghalli, J.; et al- 45% pathological findings at hysteroscopy in a group of 145 patients, with enhanced pregnancy rates in these patients compared to those with normal cavities.4 5. Morales, A; et al- in a prospective observational study found that 22.5% of patients had abnormalities missed by HSG.5

6.Doldi,N.; et al- found 40% of patients had abnormal hysteroscopic finding, with a statistically significant difference in pregnancy rates between women who had hysteroscopy and those that did not have it prior to IVF/ICSI-ET.6 7.Shamma, F.N.;et al- patients with normal HSG but abnormal hysteroscopy have a significantly lower clinical pregnancy rates, thus need for routine hysteroscopy prior to IVF.7

Hysteroscopy prior to the first IVF cycle: a systematic review and meta-analysis. Pundir J1, Pundir V2, Omanwa K3, Khalaf Y4, El-Toukhy T4

This systematic review and meta-analysis investigated the use of routine hysteroscopy prior to starting the first IVF cycle on treatment outcome in asymptomatic women.. Searches were conducted on MEDLINE, EMBASE, Cochrane Library, National Research Register and ISI Conference Proceedings. The main outcome measures were clinical pregnancy and live birth rates achieved in the index IVF cycle. One randomized and five non-randomized controlled studies including a total of 3179 participants were included comparing hysteroscopy with no intervention in the cycle preceding the first IVF cycle.

There was a significantly higher clinical pregnancy rate (relative risk, RR, 1.44, 95% CI 1.08-1.92, P=0.01) and LBR (RR 1.30, 95% CI 1.00-1.67, P=0.05) in the subsequent IVF cycle in the hysteroscopy group. The number needed to treat after hysteroscopy to achieve one additional clinical pregnancy was 10 (95% CI 7-14) and live birth was 11 (95% CI 7-16). Hysteroscopy in asymptomatic woman prior to their first IVF cycle could improve treatment outcome when performed just before commencing the IVF cycle.

Robust and high-quality randomized trials to confirm this finding are warranted. Currently, there is evidence that performing hysteroscopy (camera examination of the womb cavity) before starting IVF treatment could increase the chance of pregnancy in the subsequent IVF cycle in women who had one or more failed IVF cycles. However, recommendations regarding the efficacy of routine use of hysteroscopy prior to starting the first IVF treatment cycle are lacking. We reviewed systematically the trials related to the impact of hysteroscopy prior to starting the first IVF cycle on treatment outcomes of pregnancy rate and live birth rate in asymptomatic women. Literature searches were conducted in all major database and all randomized and non-randomized controlled trials were included in our study (up to March 2013).

The main outcome measures were the clinical pregnancy rate and live birth rate. The secondary outcome measure was the procedure related complication rate. A total of 3179 women, of which 1277 had hysteroscopy and 1902 did not have a hysteroscopy prior to first IVF treatment, were included in six controlled studies. Hysteroscopy in asymptomatic woman prior to their first IVF cycle was found to be associated with improved chance of achieving a pregnancy and live birth when performed just before commencing the IVF cycle. The procedure was safe. Larger studies are still required to confirm our findings.

conclusion More than ¾ of the patients had abnormal hysteroscopic findings which could adversely affect ivf treatment outcome There is significant evidence suggesting improved outcome of treatment if patients have routine diagnostic hysteroscopy prior to commencement of COH, IVF/ICSI-ET. In the well trained hand, hysteroscopy is a very safe and eassy to perform procedure

acknowledgements NHA AFRH MY FAMILY

REFERENCES 1.Dicter D,et al : J In Vitro Fert Embryo Transf. 1990 Octo;7(5): 267-70. 2.Goldenberg M. et al: J in Vitro Fert Embryo Transf. 1991 Dec; 8(6):336-8. 3. Gola A., et al : Hum Reprod 1992 7 (10): 1433-4. 4.Feghali J., et al : Gynecol Obstet 2003 2 (31) : 127-131. 5 Morales A.; et al : International Congress Series, iffs 2004 Sept 2004; 1271:263-5. 6. Doldi N. ;et al : Gynecol Endocrinol. Oct 2005; 21(4):235-7. 7. Shamma FN, et al: Fertil Steril 1992:58:1237-9 8. Ragni G.; et al : Gynecol Obstet Invest 2005;59:184-8 9. Demirol A, et al : Clin Exp Obstet Gynecol 2007; 34: 61-2 10. 10.Pundir J, Pundir V, Omanwa K, Khalaf Y, El-Toukhy T. Hysteroscopy prior to the first IVF cycle: a systematic review and meta-analysis. Reprod Biomed Online. 2014 Feb;28(2):151-61. doi: 10.1016/j.rbmo.2013.09.025. Epub 2013 Oct 5. Review. PubMed PMID: 2436502

Thank you very much