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Published byDenis Shelton Modified over 7 years ago
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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
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Outline Introduction Routine hysteroscopy before 1st IVF
Evidence from poor quality studies Evidence from good quality studies Routine hysteroscopy for RIF Conclusions
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Its sole purpose is to enable implantation of an embryo during a relatively short window of opportunity in the menstrual cycle.
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Normal SIS
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The most common finding detected by office hysteroscopy is an intrauterine polyp.
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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.
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Structural anomaly
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Routine hysteroscopy before 1st IVF
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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.
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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.
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Routine hysteroscopy for RIF
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Published Systematic Review
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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)
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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
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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
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8 European Centres GSTT, London Barts, London BWH, Birmingham
LIFE, Leuven GIFT, Genk SISMER, Bologna Univ of Turin, Torino Sanatorium Pronatal, Prague
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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?
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IVF Outcome ITT Analysis: all randomised women
Protocol Analysis: completed treatment
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IVF Outcome: ITT
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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
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IVF Outcome: Protocol P = 0.5
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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
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