On the journey towards having a child, every couple's story is unique, and sometimes small obstacles appear along the way. In the treatment of infertility — especially when advanced techniques such as IVF are involved — the health of the inner structure of the uterus is of great importance. This is exactly where hysteroscopy comes in: a minimally invasive method that allows us to look directly inside the uterus and both to diagnose and to treat potential problems. This detailed intrauterine assessment can play a critical role in increasing the chance of pregnancy and paving the way for a successful one.
Hysteroscopy is an important diagnostic and therapeutic tool in women's health. It is a method frequently used to identify and correct problems inside the uterus, particularly in infertility treatment, recurrent pregnancy loss and failed IVF attempts. As Prof. Dr. Mehmet Çınar, at our Ankara IVF Center we adopt modern, science-based approaches so that our patients achieve the best possible results. In this article we will look in detail at the hysteroscopy procedure, when and why it is needed, and above all at the importance of hysteroscopy before IVF.
How is hysteroscopy performed?
Hysteroscopy is the procedure in which a thin, illuminated telescope (a hysteroscope) is passed through the cervix to view the inner cavity of the uterus (the endometrial cavity) and the cervical canal directly. The procedure is usually planned for the first week after menstrual bleeding has ended — that is, the period when the uterine lining (endometrium) is at its thinnest. During this window the inside of the uterus can be seen more clearly and possible pathologies are easier to detect.
The procedure can generally be carried out under light anaesthesia (sedation) or local anaesthesia, so that the patient feels no pain or discomfort. The hysteroscope is advanced gently through the cervix until it reaches the uterine cavity. At the same time, a special fluid (usually saline) or gas (carbon dioxide) is used to expand the inside of the uterus and provide a clearer view. In this way the walls of the uterus are separated from one another so that a detailed examination can be carried out.
The camera at the tip of the hysteroscope transmits images from inside the uterus to a high-resolution monitor. This allows the doctor to assess the uterine lining, the shape of the uterine cavity, the areas where the fallopian tubes join the uterus (the ostia) and any possible abnormalities (such as polyps, fibroids, adhesions or a septum) in real time. The duration of the procedure varies depending on whether it is diagnostic or operative, but it generally takes between 15 and 45 minutes.
Diagnostic and operative hysteroscopy
Hysteroscopy is divided into two main categories according to its purpose:
Diagnostic Hysteroscopy
As the name suggests, the main purpose of diagnostic hysteroscopy is to diagnose potential problems inside the uterus. This kind of intrauterine assessment is generally performed in the following situations:
- To evaluate intrauterine factors in cases of unexplained infertility.
- To investigate the cause of recurrent pregnancy loss.
- To determine the cause of abnormal uterine bleeding (bleeding between periods, heavy bleeding).
- To confirm intrauterine lesions (polyps, fibroids, adhesions) suspected on other imaging methods such as ultrasound or HSG (hysterosalpingography).
- To examine the inside of the uterus in detail before IVF treatment and to provide an environment suitable for pregnancy.
- To confirm the presence of intrauterine adhesions (Asherman's syndrome).
During a diagnostic hysteroscopy, the doctor can directly observe any abnormality inside the uterus. If necessary, a biopsy can be taken from suspicious tissue and sent for pathological examination. This is of vital importance particularly where there is a suspicion of uterine cancer.
Operative Hysteroscopy
Operative hysteroscopy is performed in order to treat, in the same session, intrauterine pathologies that are detected during the diagnostic procedure or that are already known. In this case a wider hysteroscope and special surgical instruments are used. The conditions that can be treated with operative hysteroscopy include:
- Removal of intrauterine polyps (polypectomy): these are benign growths arising from the uterine lining; they can prevent pregnancy or cause bleeding.
- Removal of small submucosal fibroids (myomectomy): fibroids that arise from the muscle layer of the uterus but grow towards the uterine cavity can make it harder for the embryo to implant.
- Division of intrauterine adhesions (adhesiolysis): adhesions that may form after previous surgery, infections or a curettage narrow the inner cavity of the uterus and can prevent pregnancy or cause recurrent miscarriage.
- Correction of a uterine septum (septoplasty): this is a congenital uterine anomaly consisting of a wall that divides the uterus in two, and it can lead to recurrent pregnancy loss or premature birth.
- Removal of lost intrauterine devices (coils).
Operative hysteroscopy is far less invasive than open surgery, offers a shorter recovery time and generally allows discharge from hospital on the same day. Thanks to this, our patients are able to return to their daily lives more quickly.
Who is it recommended for before IVF?
The success of IVF treatment is not limited to obtaining good-quality embryos; the uterine environment in which the embryo will implant must also be healthy and receptive. For this reason, the intrauterine assessment carried out before the IVF process or after unsuccessful attempts is of great importance. Hysteroscopy before IVF is recommended particularly for patients who carry certain risk factors or who have previously experienced failure.
The situations in which hysteroscopy before IVF may be considered are as follows:
- Repeated IVF failures: if pregnancy has not been achieved despite the transfer of good-quality embryos on one or more previous occasions, there may be an overlooked problem inside the uterus. Hysteroscopy in IVF is an effective method for detecting and correcting intrauterine problems in such cases and thereby improving success.
- Recurrent pregnancy loss: in women who have had more than one miscarriage, structural abnormalities such as intrauterine adhesions, a septum, polyps or fibroids may be the cause. Correcting these problems with hysteroscopy increases the chance of a subsequent pregnancy.
- Suspicious findings on ultrasound or HSG: if a polyp, fibroid, septum or adhesion is suspected inside the uterus during routine gynaecological ultrasound examinations or on hysterosalpingography (HSG), hysteroscopy is the gold-standard method for confirming and treating these findings.
- Abnormal uterine bleeding: menstrual irregularities, bleeding between periods or heavy bleeding may be a sign of lesions such as polyps or fibroids inside the uterus. Such conditions can adversely affect implantation of the embryo.
- Unexplained infertility: where pregnancy cannot be achieved even though all other causes of infertility have been excluded, a detailed examination of the intrauterine environment may be useful. Sometimes even very small polyps that cannot be seen on ultrasound, or mild adhesions, can prevent pregnancy.
- Endometrial preparation: in some cases, in order to make the uterine lining (endometrium) more receptive to embryo transfer, a light intrauterine scratching procedure known as "endometrial scratching" may also be performed during a diagnostic hysteroscopy. Some studies suggest that this procedure may increase pregnancy rates.
Because every patient's situation is different, the decision on hysteroscopy before IVF should be made individually, taking into account the patient's history, previous treatment cycles and the results of other tests. At our Ankara IVF Center, Prof. Dr. Mehmet Çınar and his team carry out a comprehensive assessment in order to determine the most appropriate treatment plan for each of our patients. Our aim is to ensure that the uterus offers the most favourable conditions possible for a healthy pregnancy to take place.
Recovery after the procedure
Because hysteroscopy is a minimally invasive procedure, recovery is generally quick and uneventful. Most patients can return home a few hours after the procedure and go back to their normal activities within a short time.
The following are to be expected after the procedure:
- Mild cramping and pain: after the procedure, cramps similar to mild period pain may be felt as the uterus contracts. This can usually be controlled easily with painkillers.
- Light spotting or bleeding: light vaginal spotting or a very small amount of bleeding lasting a few days after the procedure is normal. This bleeding is generally mild and stops on its own.
- Gas or bloating: because of the gas or fluid used during the procedure, mild bloating in the abdomen or shoulder pain may be felt. This is temporary and resolves within a short time.
- Sexual intercourse and tampon use: in order to reduce the risk of infection and allow the cervix to heal, it is generally recommended to avoid sexual intercourse and the use of tampons for 1–2 weeks after the procedure. Using sanitary pads is more suitable during this period.
Your doctor will give you detailed information about what to pay attention to during recovery and about possible complications. Although rare, if symptoms such as heavy bleeding, severe abdominal pain, fever or foul-smelling vaginal discharge occur, it is important to contact your doctor immediately.
After operative hysteroscopy, additional measures may be taken by your doctor to prevent intrauterine adhesions from forming again, such as placing a temporary balloon inside the uterus or using special gels. In such cases, following your doctor's instructions meticulously is of critical importance for the success of the treatment.
Hysteroscopy is an important step in infertility treatment, and especially on the IVF journey. The early diagnosis and treatment of problems inside the uterus can significantly increase the chance of pregnancy and open the way to a healthy one. As Ankara IVF Center, we are proud to stand by you during this sensitive process and to offer the most up-to-date treatment approaches. If you too would like more information about hysteroscopy in IVF or about laparoscopy and hysteroscopy in general, or would like your situation assessed, you can contact us for a free preliminary consultation with our expert team. We are here to help you take a step towards a healthy future.