Hysteroscopy is a minor surgical procedure utilizing a thin fiberoptic tube or hysteroscope to see the inside of the uterus (endometrial cavity). Hysteroscopy allows the doctor to diagnose and treat a variety of uterine abnormalities which may cause infertility, recurrent miscarriages, abnormal bleeding and pain.
Hysteroscopy is an outpatient procedure which can be performed in the operating room of a hospital, surgical center or at a doctor’s office. Before the surgery, you will be given a hospital gown and asked to empty your bladder. You will be given medicine to help you relax and then local or general anesthesia depending on the type of hysteroscopy (diagnostic or operative) planned for you.
The hysteroscopy (fig.1) is performed with you lying on your back while your feet are supported by footrests (stirrups).
A speculum will be inserted into the vagina so your doctor can see the cervix. The vagina is cleansed with a special antiseptic solution and the hysteroscope is gently inserted through the cervix and advanced into the uterus. A liquid will be injected through the hysteroscope into your uterus to help your doctor see the uterine cavity clearly. High definition camera attached to the hysteroscope will project an image of the uterine cavity on a screen (fig.2 and 3). Your doctor will be able to see if there is any abnormality in the uterine cavity. The hysteroscopy takes only 10-15 minutes to complete unless other procedures are also planned to remove fibroids, polyps, uterine adhesions or unblock your tubes.
Preparing for Hysteroscopy
- Hysteroscopy is best performed during the first week after your period (day 5-12 of cycle).
- If you are scheduled to have a fibroid removed, you may be treated with Lupron for several weeks before surgery, to shrink the size of the fibroid
- Tell the doctor if you are or might be pregnant, if you are allergic to any medicines or if you take blood-thinning medications, such as aspirin or Coumadin.
- Talk with your doctor about the risks of hysteroscopy. Have the doctor explain how the procedure is performed and what the results will mean.
- You will be asked to sign a consent form giving the doctor permission to perform the surgery.
- You should not eat or drink after midnight the day before your scheduled surgery.
The “normal” Hysteroscopy
The uterine cavity has smooth walls and is free of fibroids, scar tissue, congenital malformation or polyps (fig.4). The right (fig.5) and left (fig.6) openings of the fallopian tubes are marked by white arrows.
When to consider hysteroscopy?
Indications for hysteroscopic surgery include:
- Uterine Polyps
- Uterine Fibroids
- Uterine scar tissue
- Tubal Blockage
- Congenital Uterine Abnormalities
- Recurrent miscarriages
- Recurrent Implantation Failures (RIF) with IVF
- Abnormal uterine bleeding
Polyps (fig. 7) can grow within the uterine cavity, where they may interfere with embryo implantation and cause infertility or abnormal bleeding. They can be diagnosed by HSG (tubal x-rays), ultrasound or MRI. A special cutting loop tool (fig. 8) called the resectoscope is often used to remove the polyps.
When growing within the uterine cavity (fig.9) or in close proximity to the cavity, fibroids can cause infertility, recurrent miscarriage, abnormal bleeding and severe menstrual cramps. Such fibroids are called intracavitary or submucosal. Their presence can be confirmed by Saline Infusion Sonography (SIS), MRI, and HSG or by direct visualization with a hysteroscope. The fibroids can be resected into small fragments utilizing a specialized cutting loop (fig. 10). The tissue fragments are removed from the uterine cavity and sent to the pathology lab for diagnosis. The uterine cavity has normal appearance after the surgery (fig. 11), greatly improving the likelihood of successful pregnancy.
Asherman’s Syndrome – uterine scar tissue (adhesions)
Scar tissue within the uterine cavity (fig. 12 and 13) may occur after D&C, uterine surgery or as a result of an infection. The scar tissue has poor blood supply and is hostile to embryo implantation. When severe uterine scarring is present (Asherman’s syndrome), it may cause a woman to stop having periods altogether.
During surgery, long scissors, inserted through the hysteroscope operating channel, are used to cut through the scar tissue and restore the uterine cavity (fig. 14). After surgery, a small balloon may be inserted into the uterine cavity to prevent the walls of the uterus from getting stuck to each other all over again. Estrogen therapy may also be utilized in severe cases to speed up the healing of the uterine lining.
The fallopian tube may be blocked at its narrowest part (fig. 15), at the point where it is closest to the uterus. This type of tubal blockage is called Proximal Tubal Occlusion or PTO and is most commonly diagnosed during tubal X-ray procedure or HSG. Viewed from within the uterine cavity, the opening of the tube can be easily seen (fig.16). The blockage is most often caused by thin scar tissue or a mucus “plug” within the tubal opening. Using the hysteroscope, the opening of the tube is visualized and a thin soft catheter (fig. 17) is guided into the tube, clearing away the mucus plug. Blue dye is injected into the tubes via the catheter (fig. 18, 19). Laparoscopy is simultaneously performed to visualize the blue dye as it flows out of the other end of the tube indicating that the tube is open (fig. 20).
The Uterine Septum
A uterine septum is a congenital malformation of the uterus. The uterine cavity is divided into 2 compartments or horns by an elongated ridge of fibrous tissue or septum (fig. 21). It lacks adequate blood supply, and is hostile to implantation of the fertilized egg. This abnormality can cause recurrent pregnancy loss, infertility and various obstetrical complications. To repair the uterus, scissors are introduced through the hysteroscope to cut the septum along the dotted line (fig. 22), unifying the divided uterus into a single cavity (fig. 23).
The Bicornuate Uterus
During hysteroscopy the uterine cavity of a bicornuate uterus resembles a uterine septum. The bicornuate uterus, when viewed through the laparoscope, is extremely wide with a central depression almost dividing the uterus into two uteri (fig. 24). In contrast, the uterus with a septum is externally indistinguishable from the normal uterus (fig. 25). The bicornuate uterus does not require surgical correction unless the woman experiences recurrent miscarriages or preterm deliveries. A wedge resection of the uterus is then performed to unify the two compartments.
How safe is Hysteroscopy?
Hysteroscopy is a very safe procedure. The most common complications are:
- Uterine bleeding, occurring in 3% of patients.
- Puncture of the cervix or uterus by the hysteroscope occurs in less than 1% of patients.
- In rare cases, puncture of the bowel or bladder can occur. If this happen surgical repair of the complication will be necessary.
- During hysteroscopy, fluid is injected to distend the uterus. This helps the surgeon see the lining of the uterus more clearly. In very rare cases, excess fluid can be absorbed by your system, lowering the sodium level. Low sodium level requires treatment to prevent more serious complications.
- There is a small risk of complications from anesthesia.
- Infection can occur, but it is an uncommon complication of hysteroscopy.
Recovering from Hysteroscopy
- You will be taken to a recovery room immediately after surgery. The Recovery Room nurses will care for and observe you for 1 to 3 hours or until the anesthesia wear o
- Cramping can occur after surgery and you may be given appropriate medication to help you feel better.
- When you are ready for discharge, you will be given a paper with care instructions and who to call if there is any problem.
- It is normal to have a bloody discharge for a few days after your surgery.
- You should use sanitary napkins rather than tampons and avoid sexual intercourse or strenuous physical exercise for two weeks after surgery.
- You may resume normal activities within 24 hours after surgery.
When to call your doctor
- Heavy bleeding
- Fever or chills
- Severe abdominal pain
- Problem urinating
- Shortness of breath