1. 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

2. 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

3. 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

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

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

7. 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.

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

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

10. 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.

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

12. 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

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

14. 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

15. 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

16. 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

17. 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.

18. 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

19. 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

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

21. 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 participants were included comparing hysteroscopy with no intervention in the cycle preceding the first IVF cycle.

22. There was a significantly higher clinical pregnancy rate (relative risk, RR, 1.44, 95% CI , P=0.01) and LBR (RR 1.30, 95% CI , 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.

23. 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).

24. 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.

25. 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

26. acknowledgements
NHA
AFRH
MY FAMILY

27. REFERENCES
1.Dicter D,et al : J In Vitro Fert Embryo Transf Octo;7(5):
2.Goldenberg M. et al: J in Vitro Fert Embryo Transf Dec; 8(6):336-8.
3. Gola A., et al : Hum Reprod (10):
4.Feghali J., et al : Gynecol Obstet (31) :
5 Morales A.; et al : International Congress Series, iffs 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
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 Feb;28(2): doi: /j.rbmo Epub 2013 Oct 5. Review. PubMed PMID:

28. Thank you very much