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Effect of hysteroscopy performed in the cycle preceding controlled ovarian hyperstimulation on the outcome of in vitro fertilization

2003; Elsevier BV; Volume: 79; Issue: 3 Linguagem: Inglês

10.1016/s0015-0282(02)04758-1

1556-5653

Stephen Mooney, Amin A. Milki,

Uterine Myomas and Treatments

Hysteroscopy (HS) has not been widely adopted as a routine procedure before IVF. It is often performed when indicated by abnormal findings on hysterosalpingogram or saline-contrast sonohysterogram. Although these imaging modalities are easy to perform, hysteroscopy allows more accurate visual assessment of the endometrial cavity, and affords the possibility of performing therapy in the same setting. Several investigators (1Frydman R. Eibschitz I. Fernandez H. Hamon J. Uterine evaluation by microhysteroscopy in IVF candidates.Hum Reprod. 1987; 2: 481-485PubMed Google Scholar, 2Seinera P. Maccario S. Visentin L. DiGregorio A. Hysteroscopy in an IVF-ET program clinical experience with 360 infertile patients.Acta Obstet Gynecol Scand. 1988; 67: 135-137Crossref PubMed Scopus (32) Google Scholar, 3Dicker D. Ashkenazi J. Feldberg D. Farhi J. Shalev J. Ben-Rafael Z. The value of repeat hysteroscopic evaluation in patients with failed in vitro fertilization transfer cycles.Fertil Steril. 1992; 58: 833-835Abstract Full Text PDF PubMed Scopus (49) Google Scholar, 4Shamma F.N. Lee G. Gutmann J.N. Lavy G. The role of office hysteroscopy in in vitro fertilization.Fertil Steril. 1992; 58: 1237-1239Abstract Full Text PDF PubMed Google Scholar, 5La-Sala G.B. Montanari R. Dessanti L. Cigarini C. Sartori F. The role of diagnostic hysteroscopy and endometrial biopsy in assisted reproductive technologies.Fertil Steril. 1998; 70: 378-380Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar) have described the value of hysteroscopy before IVF. Ideally, HS should be performed in the immediate postmenstrual phase of the cycle. Placing the patient on oral contraceptive (OC) pills not only maintains an optimally thin endometrial lining, but also lengthens the scheduling window for HS from days to weeks. Because it is common practice to use OC pills in IVF protocols, it is reasonable to perform HS while the patient is still in the OC pill phase of the IVF cycle. It would be helpful to assess the impact of the timing of HS, especially if operative in nature, on the outcome of the cycle. In this study, we compared the viable pregnancy (VP) rate in two similar, good prognosis, patient groups with regard to whether or not HS was performed in the cycle before controlled ovarian hyperstimulation (COH) start. In the senior author's practice, patients under the age of 40 years, who had more than three 8-cell embryos on day 3 routinely underwent blastocyst transfer. Ninety-four consecutive cycles performed during a 2-year period met these criteria, and were studied in relation to the timing of HS before IVF. Patients were placed on OC pills on the third day of the previous menstrual cycle. The IVF stimulation protocol consisted of GnRH agonist down-regulation, overlapping with the last 5 days of OC pills, followed by COH using FSH/hMG. Hysteroscopy performed during the OC pill phase before COH start was classified as a recent HS. Patients who underwent hysteroscopy at a previous time were assigned to the remote HS group. All recent hysteroscopies were performed in the office using a rigid 5-mm hysteroscope with an operative channel for the use of hysteroscopic grasping forceps or scissors. Distention of the uterine cavity was accomplished with a normal saline solution. Oral premedication with diazepam, intramuscular analgesia with meperidine, and a paracervical block were used. No complications occurred and patients were typically discharged within 1 hour of the HS procedure. A mock ET, performed during a separate office visit before the recent HS, and the actual ET using a Tefcath (Cook Ob/Gyn, Spencer, IN) were both performed by the same physician (A.A.M.). The mock ET and actual ET were classified as easy, moderately difficult, or difficult. A moderately difficult ET was defined as one that required the use of a cervical introducer (6El-Danasouri Milki A.A. A new cervical introducer for embryo transfer with soft open-end catheters.Fertil Steril. 1992; 57: 939-941PubMed Google Scholar) or the application of a tenaculum. Classification as a difficult ET meant that multiple passes were necessary or significant cramping occurred. Mock ET and actual ET classifications and VP rates were compared in the two groups. Statistical analysis was performed using χ2 and t tests. Each couple signed the appropriate informed consent for the treatment received. Institutional review board approval was obtained for review of patient charts and laboratory records for this retrospective study. Of the 94 IVF cycles examined, there were 48 cycles with a recent HS and 46 cycles with remote HS. The mean time lapse between the remote HS and the IVF cycle was 13 months. The VP rate in the recent HS group was 71% (34/48) and was significantly higher than the 39% (18 of 46) VP rate noted when a remote HS was performed (P<.01). No differences were found between the recent and the remote group with regard to patient age (34.5 ± 3.5 vs. 35.2 ± 3.3 years, P = .32), number of blastocysts transferred (2.2 ± 0.5 vs. 2.2 ± 0.6, P = .9), or number of failed previous IVF cycles (0.80 ± 1.4 vs. 0.85 ± 1.05, P = .41). The distribution of infertility diagnoses was similar in the two groups. Furthermore, within the recent HS group, 20 of the VP resulted from 27 IVF cycles (74.1%) where a recent operative HS was performed (typically polypectomy or lysis of filmy adhesions). This VP rate was not significantly different from the 14 VP seen in the 21 IVF cycles (66.7%) in which only recent diagnostic HS was performed (P = .57). In the recent HS group, 5 of 48 patients were judged to have a moderately difficult ET compared to 6 of 46 patients in the remote HS group. Clearly, these values were not significantly different (P = .94). No patient in either group was classified as having a difficult mock ET or actual ET. Previous work has shown that abnormalities, detectable by HS, are present in up to 45% of patients undergoing IVF (2Seinera P. Maccario S. Visentin L. DiGregorio A. Hysteroscopy in an IVF-ET program clinical experience with 360 infertile patients.Acta Obstet Gynecol Scand. 1988; 67: 135-137Crossref PubMed Scopus (32) Google Scholar, 4Shamma F.N. Lee G. Gutmann J.N. Lavy G. The role of office hysteroscopy in in vitro fertilization.Fertil Steril. 1992; 58: 1237-1239Abstract Full Text PDF PubMed Google Scholar). Furthermore, HS revealed that the false-negative rate for hysterosalpingography (HSG) performed in IVF candidates was 37% (1Frydman R. Eibschitz I. Fernandez H. Hamon J. Uterine evaluation by microhysteroscopy in IVF candidates.Hum Reprod. 1987; 2: 481-485PubMed Google Scholar, 2Seinera P. Maccario S. Visentin L. DiGregorio A. Hysteroscopy in an IVF-ET program clinical experience with 360 infertile patients.Acta Obstet Gynecol Scand. 1988; 67: 135-137Crossref PubMed Scopus (32) Google Scholar). Shamma et al. (4Shamma F.N. Lee G. Gutmann J.N. Lavy G. The role of office hysteroscopy in in vitro fertilization.Fertil Steril. 1992; 58: 1237-1239Abstract Full Text PDF PubMed Google Scholar) reported significantly lower clinical pregnancy rates with IVF-ET when uterine cavity abnormalities were present (8.3% vs. 37.5%). More recently, La-Sala et al. (5La-Sala G.B. Montanari R. Dessanti L. Cigarini C. Sartori F. The role of diagnostic hysteroscopy and endometrial biopsy in assisted reproductive technologies.Fertil Steril. 1998; 70: 378-380Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar) reported unsuspected pathology revealed at HS in 18% of patients who had failed two IVF cycles and had a normal HSG. The present study addresses the impact of HS timing on the success of the cycle. The two groups examined consisted of similar good prognosis IVF patients, in whom embryo quality is unlikely to be a significant variable. Office-based HS performed immediately before COH for IVF, even when it included an operative component, had no detrimental effect on cycle outcome. In fact, our data suggest that there may be a benefit to timing the HS close to the initiation of COH. Used in this manner, HS provides a way to avoid missing endometrial pathology, such as polyps or polypoid changes, which could have developed over the course of a few months, especially if the intervening period included COH with the associated increase in estrogen (E) levels. The relatively high incidence of operative HS in our study (27/48) may reflect our low threshold for targeting polyps of any size and adhesions of any magnitude. This ratio, however, is not significantly different from the incidence of pathology found by other investigators, 148 of 332 patients reported by Seinera et al. (2Seinera P. Maccario S. Visentin L. DiGregorio A. Hysteroscopy in an IVF-ET program clinical experience with 360 infertile patients.Acta Obstet Gynecol Scand. 1988; 67: 135-137Crossref PubMed Scopus (32) Google Scholar) and 12 of 28 women reported by Shamma et al. (4Shamma F.N. Lee G. Gutmann J.N. Lavy G. The role of office hysteroscopy in in vitro fertilization.Fertil Steril. 1992; 58: 1237-1239Abstract Full Text PDF PubMed Google Scholar). Regarding other possible reasons for the increased VP rate seen in the recent HS as compared with the remote HS group, some investigators have suggested that the differences in IVF success seen here are attributable to cervical dilatation and not to the HS itself. McManus et al. (7McManus J. McClure N. Traub A.I. The effect of cervical dilatation in patients with previous difficult embryo transfer.Fertil Steril. 2000; 74: S159Abstract Full Text Full Text PDF Google Scholar) reported that cervical dilation (31 ± 2 days before ET), led to significantly more ETs, previously classified as difficult being reclassified as very easy or easy. Overall, the pregnancy rate was significantly higher when cervical dilation was later associated with an easier ET (46.2% vs. 11.8%). In our study, a comparable number of patients in each group were classified as having a moderately difficult transfer at the time of the actual ET. Furthermore, in the recent HS group, three patients with an easy mock ET were later judged to have a moderately difficult actual ET and three patients with a moderately difficult mock ET experienced an easy actual ET. Although cervical dilatation may be an added benefit of a recent HS, these findings argue against that specific variable as being the major factor responsible for the improvement noted in the VP rate. It is also possible that irrigation of the uterine cavity with saline at the time of the recent HS may have a beneficial effect on implantation as suggested by a study reported by Takahashi et al. (8Takahashi K. Mukaida T. Tomiyama T. Oka C. High pregnancy rate after hysteroscopy with irrigation of the uterine cavity prior to blastocyst transfer in patients who have failed to conceive after blastocyst transfer.Fertil Steril. 2000; 74: S206Abstract Full Text Full Text PDF Google Scholar). In conclusion, the information presented in this study suggests that it may be beneficial to time a hysteroscopic evaluation as close as possible to the IVF cycle, and to consider repeating the HS on patients who experience multiple COH failures after a previously normal HS.