1. Role of Hysteroscopy in Assisted Reproductive Technology
Yacoub Khalaf MD, FRCOG
Director of Assisted Conception Unit & Centre for
Pre-implantation Genetic Diagnosis
Guy’s & St Thomas’ Hospital and King’s College, London
London, UK

2. Outline Introduction Routine hysteroscopy before 1st IVF
Evidence from poor quality studies
Evidence from good quality studies
Routine hysteroscopy for RIF
Conclusions

3. Its sole purpose is to enable implantation of an embryo during a relatively short window of opportunity in the menstrual cycle.

12. Normal SIS

14. The most common finding detected by office hysteroscopy is an intrauterine polyp.

17. The only RCT on pregnancy rate after IUI demonstrated significant improvement in pregnancy rate in women who underwent hysteroscopic polypectomy.
Perez Medina et al., Hum Reprod 2005;20:1632–5.
The practice guidelines of the AAGL recommend removing polyps in infertile women to improve fertility outcomes. J Minim Invasive Gynecol 2012;19:3–10.

28. Structural anomaly

32. Routine hysteroscopy before 1st IVF

34. In conclusion, this systematic review and meta-analysis of published studies suggests that hysteroscopy in asymptomatic women prior to their first IVF cycle could be associated with improved treatment outcome when performed just before commencing the IVF cycle.
Robust and high-quality randomized trials to confirm this finding are needed to further guide clinical practice.

38. Routine hysteroscopy does not improve live birth rates in infertile women with a normal trans-vaginal ultrasound of the uterine cavity scheduled for a first IVF treatment.
Women with a normal trans-vaginal ultrasound should not be offered routine hysteroscopy.

39. Routine hysteroscopy for RIF

40. Published Systematic Review

41. Published Systematic Review
Pooling the results of five studies showed benefit from outpatient hysteroscopy in improving pregnancy rate in the subsequent IVF cycle
(RR = 1.75, 95% CI 1.51–2.03)

42. How good is this evidence?
Small number of randomised trials available
Methodological limitations (no blinding, no allocation concealment)
Limited live birth data in RIF patients

43. Trophy Trial Collaborators Group
A multi-centre randomised study of pre-IVF outpatient hysteroscopy in women with recurrent IVF-ET failure: The Trophy Study
T El-Toukhy, Y Khalaf, A Coomarasamy, C Tabanelli, SS Gordts, S Gordts, G Mestdagh, T Mardesic, G L Marchino, T Al-Shawaf, M Gergolet, R Campo
Trophy Trial Collaborators Group

44. 8 European Centres GSTT, London Barts, London BWH, Birmingham
LIFE, Leuven
GIFT, Genk
SISMER, Bologna
Univ of Turin, Torino
Sanatorium Pronatal, Prague

45. Hypothesis
Does performing an OPH prior to starting an IVF cycle improve the live birth rate in women who have experienced 2-4 failed IVF cycles?

46. IVF Outcome ITT Analysis: all randomised women
Protocol Analysis: completed treatment

47. IVF Outcome: ITT

48. IVF Outcome: Protocol
10 patients in the control group had uterine cavity intervention after randomisation:
Hysteroscopy
Saline hysterosonography
8 patients in the hysteroscopy group declined hysteroscopy after randomisation

49. IVF Outcome: Protocol
P = 0.5

50. Conclusions Hysteroscopy is valuable in assessing the uterine cavity
OPH prior to IVF or after repeat IVF-ET failure does not significantly improve subsequent IVF cycle outcome
OPH can not be routinely recommended before IVF or after recurrent IVF failure