Hysteroscopy: Common Findings

So whether it is your OBGYN, a minimally invasive GYN surgeon, or even a subspecialist like myself, reproductive endocrinologist, or potentially some other sub specialists, a hysteroscopy may be a procedure you have on your infertility journey. For REIs like me, this is this is our surgery. The inside of the uterus and optimization of the uterine cavity for implantation falls in our wheelhouse, so suggest strongly that I do the surgery more than anything else. REIs tend to be the ones that do very complex uterine surgery. Now that also said, there are some MIGS, which is minimally invasive gynecologic surgeons, and there are some of them who do extensive, amazing jobs at uterine surgery, and some who focus more on robotic or laparoscopic approaches. So it's not a one size fits all, and that can sometimes be hard if you fall into the position of needing hysteroscopic surgery. Hysteroscopy is a camera that goes in to your uterus. It does this by going through the cervix and into the uterine cavity. So it's a vaginal based approach, and that means there's no incisions. You're not paralyzed throughout the surgery. It is a much less risky surgery than what you may think of as surgery. One reason for hysteroscopy is diagnostic purposes. It is the absolute gold standard best way to evaluate the inside of the cavity. Evaluating the inside of the cavity is a part of the normal fertility evaluation, and it's also a part of the evaluation for pregnancy loss or preparation for embryo transfer. This is a step that often can reveal different things. So diagnostic means I don't have a known reason that something is wrong. I'm not going in preparing for something to be wrong, but I'm just going to look. This might be done preemptively as a part of the diagnostic evaluation. It also might be done because something's not going right. Other reasons for hysteroscopy can include abnormal bleeding, which usually is tied into abnormal findings on an ultrasound, so things that can cause abnormal bleeding.

Uterine Polyp

A polyp is a projection of endometrial tissue that's inside the uterus. Typically, a polyp is benign, but not always. Polyps project into the uterine cavity. Polyp cells can cause inflammation inside that uterine cavity and can decrease implantation. Not every polyp, it depends where and the size, but specifically, if you're going through IVF and you're taking all this time and money, we 100% want to optimize that uterine cavity before we go put an embryo inside. Polyps can cause some spotting. Intermenstrual spotting is one clue. So in that case we would do a hysteroscopy to see if that is what is causing the abnormal spotting.

Fibroids

Fibroids are a little bit different than a polyp. A fibroid is a tumor, so it's a ball of cells, but it's of the muscular cell component of the uterus. In the uterine cavity, there's the innermost layer that is the endometrium. There is the myometrial layer, the muscle, which is the bulk or the majority of the uterus, and then there's the serosa, or the outside layer. Fibroids can be in all the different places. The ones I'm specifically talking about that you can operate on with hysteroscopy are the ones that are inside the uterine cavity. These are called submucous fibroids, which are in the innermost portion of the uterus, or they are projecting into it. Sometimes fibroids that are partial submucous and invading into that myometrial layer can also be operated on hysteroscopically, but a lot of fibroids are just deep in the myometrium or even on the outside of the cavity, and not always can these be accessed from the inside of the uterus. Also, not all fibroids need to be removed. So we are removing most polyps, but for a fibroid, especially if it is not in or invading that inside of the uterine cavity, that endometrial layer, if they're not sub mucus or have a sub mucus component, we're often leaving them in place, which has been a change in the field. The exceptions here are if they are very large or if they're causing other symptoms. If you have really heavy bleeding, if you're needing blood transfusions, if you're having pain, if you're having bulk symptoms, where those fibroids are so big you look pregnant, it can cause a lot of discomfort. Those are definitely reasons why you might want fibroids removed separately. If we're focusing on hysteroscopy and what we need to do for fertility or to help you get pregnant, then definitely the things that are inside the cavity need to be fixed, and that's what hysteroscopy is doing.

Scar Tissue

Scar tissue can come from a variety of different reasons the uterus has if we think about that endometrium as the layer that regenerates and regrows and sheds, this is your menstrual blood. So this endometrial layer that you see is constantly regrowing and regenerating, and that layer actually has some stem cells coming from a basal layer right above it. The reason why that is important is that basal layer can get damaged, and when it does, it loses the ability to regenerate the endometrium, and this is what facilitates the development of scar tissue. Scar tissue inside the uterus can be so damaging, and it can range from mild or thin to dense, thick scar tissue, when the scar tissue takes over the majority of the cavity to the point where there really is no endometrium. You've now developed asherman’s syndrome. Asherman’s syndrome is an amenorrhea and a complete destruction of the uterine cavity. Then there's partial versions where there's a large portion of the uterine cavity which has been taken over by scar tissue. You may have some bleeding, maybe it's light, depending on where the scar is and where there is still endometrium. I've even had a patient who has endometrium trapped above where that scar tissue is. You can go and you can resect or cut out the scar. The big question here is, how do you prevent it from coming back? If that basal layer is damaged, it's just going to come back over and over. I will tell you, everybody who does hysteroscopy, or most people, especially if they deal with Asherman’s, have an approach, and my approach is going to be different than somebody else's. It doesn't mean that it's one isolated approach. In general, I have an extensive post operative protocol, so putting a balloon inside the uterus that is there for a week, trying to distant the cavity so those basal layers don't touch antibiotics, high dose estrogen, and a month of hormone replacement, trying to encourage that endometrial layer to grow over that area where the scar has been. I'm always a big believer in an ultrasound afterward, a saline sonogram or repeat hysteroscopy to make sure that the scar is really gone, depending on the severity.

Uterine Septum

Hysteroscopy alone is only telling you about the inside of the cavity. So there are certain mullerian anomalies, which are birth defects of the uterus, where hysteroscopy is not going to give you the full picture. The most common type of birth defect that we are actually operating on nowadays is a uterine septum. A uterine septum is the most common type of uterine birth defect. This is where you had complete development of those mullerian buds. They fused together completely, but you had failure of complete reabsorption of that midline connecting structure, leaving you with an avascular septum. This septum now dangles into the midline portion of the uterus, for lack of better word, but that can prevent an embryo from coming in and being able to attach correctly, and so what we see is higher rates of miscarriage, specifically in the presence of a septum that corrects itself when aseptum is removed. Now, septums are removed, and then, depending on how broad and deep it is, sometimes that also requires post operative management, like scar tissue does, and mainly with the idea that we don't want that area that you just resected to then develop a scar because it's the same problem. If I cut it out, and now I've replaced it with a vascular scar tissue, I haven't really helped. I have seen people had a septum removed and develop terrible asherman’s afterward. So that is certainly not the most common scenario, but a potential scenario.

So all of these things potentially could be possibilities, depending on what you're leading into the hysteroscopy knowing. If your doctor is doing it as a part of your diagnostic evaluation for infertility, you might actually have some of these other procedures done if they are found at the same time. So there's a situation where you're signing a consent form saying, yes, you could do X, Y or Z because I'll be asleep, and I can't consent at that time. There's also the circumstance where some people do in office hysteroscopy, and they don't have the operative capability of doing all of these things, but they're taking a look and getting a better idea. Then you might have to go to a full fledged surgery if something is found.