Hysteroscopy

Definition of hysteroscopy

Hysteroscopy is one of the diagnostic and therapeutic means in the field of gynecology and infertility, which depends on the introduction of a medical endoscope in the cervix through the vagina to the uterus

Types of hysteroscopy in terms of function or purpose of the endoscopy

* Diagnostic hysteroscopy

* Therapeutic (surgical) hysteroscopy

Diagnostic hysteroscopy

The uterus is seen with a camera and high-resolution lenses that allow the doctor to examine the internal surface of the cavity of the vagina, cervix and uterus

Diagnostic hysteroscopy

Indications for diagnostic hysteroscopy

To ensure the diagnosis of uterine deformity, such as the uterine septum and bicornuate uterus, for example, after they appear in the sonar and then HSG

Important notes about the diagnostic hysteroscopy

It is not possible to ascertain the patency of the fallopian tubes through the hysteroscopy as it only sees the inner opening of the channel at the point of contact with the uterine cavity, and does not see the entire channel

The status of the ovaries cannot be confirmed through hysteroscopy as it only sees the inner cavity of the uterus

Therapeutic or surgical hysteroscopy

A hysteroscopy with a camera, high-resolution lenses and special equipment is used to allow the doctor to perform simple surgical interventions in the uterine cavity

Surgical hysteroscopy

Indications for surgical hysteroscopy

To Take a sample of the endometrium to diagnose the causes of uterine bleeding when it is not possible to know the cause by other means, especially after the failure of the curettage sample to diagnose the cause as the curettage sample is random,(in curettage it is possible to take samples from healthy areas while the affected areas did not luck to be within the specimen), the specimen is taken from the hysteroscopy is taken from specific areas where the nature of the lining of the uterus is changed under a clear vision of the hysteroscopy camera and therefore less likely not to take a sample from infected areas.

Excision of endometrial polyp that causes continuous bleeding after the failure of D & C, and  not necessarily that the patient has a hysteroscopy from the beginning

Myomectomy, for myoma within the uterine cavity and not implanted in the muscles of the uterus or located outside the uterus, where the hysteroscopy cannot remove fibroids implanted within the uterine muscle or outside the uterus

Endometrial resection through cauterization in cases of uterine bleeding after menopause (menopause) due to benign endometrial hyperplasia unresponsive to hormone therapy

Removal of the uterine septum as in cases of infertility or repeated abortions

Removal of adhesions within the uterine cavity, as in Asherman’s syndrome (which is caused by an abnormal D & C of the endometrium)

Removal of adhesions that cause blockage of the internal openings of the fallopian tubes at the point of contact with the uterine cavity, and this procedure is done with a diagnostic laparoscopy at the same time to ensure the integrity of the channels after the completion of the process of removing the adhesions by surgical hysteroscopy, and this is through the injection of dye intrauterine and make sure they exit the two tubes

Closing the fallopian tubes with adiana or essure ,a material which is implanted into the slot of the fallopian tubes at the point of contact with the uterine cavity as in:

  • The closure of the fallopian tubes as a contraceptive alternative to the process of tubal ligation
  • Closure of fallopian tubes in cases of hydrosalpinx (when the tubes contain fluid due to severe inflammation of the tubes), this procedure is done before ICSI to prevent the entry of this fluid to the embryos

Removal of a foreign object inside the uterus such as missed IUD, after the failure of all attempts to pick up the IUD, especially in cases where the IUD has been implanted in the muscles of the uterus and is difficult to be extracted blindly

Timing of hysteroscopy

The hysteroscopy can be performed at any time except menstruation, but preferably after the end of the menses

Where hysteroscopy can be done?

Diagnostic hysteroscopy can be performed at the doctor’s office, outpatient clinic or in the operating room, depending on the patient’s symptoms.

For the surgical hysteroscopy, surgical procedures must be performed inside the operating room

Does hysteroscopy needs anesthesia?

The diagnostic hysteroscopy can be performed without anesthesia, as the diameter of the endoscope lens is very small and can enter the cervix without causing pain, but can also be performed under the influence of general anesthesia or local anesthesia of the cervix as desired by the patient.

Surgical hysteroscopy should be performed under general anesthesia

Position of the patient

You will be lying on the back with spacing of the legs

Lithotomy position for hysteroscopy

How hysteroscopy is done?

The hysteroscope is inserted from the vagina until it reaches the outer opening of the cervix, then the doctor waits until the cervix expands due to the expanding material and then when the cervix expands, the doctor can enter the hysteroscope into the uterine cavity through the cervix

Important Note

* If the doctor did not wait until the cervix expands and try to enter before widening it will lead to cervical injury

* If the doctor has no experience in hysteroscopy and cannot gently enter the cervix may lead to injury to the anterior wall of the vagina and enter the urinary bladder or injury to the posterior wall of the vaginal and injury to the rectum

Expanding material:

Because the uterine cavity is an extremely small potential space and difficult to examine accurately, an amounts of gas or fluid are pumped into the uterus to allow its expansion and detailed examination

*CO2:

Because of its inability to ignite, and easy solubility in the blood stream and thus easier for the body to get rid of it after the end of the hysteroscopy, as it allows a clear view of the doctor

* Solutions:

The use of solutions has many advantages over gases. The use of solutions works to clean the uterus from the inside and get rid of any bleeding blood or damaged tissue. Normal saline and Lactated Ringer’s solution are among the most commonly used solutions.

Instructions for hysteroscopy

  • The doctor prescribes some antibiotics for the patient before and after the procedure
  • Fasting: The patient should be fasting for 6-8 hours before the procedure.
  • You should tell her specialist doctor if you have any type of allergies or taking any medications, especially drugs that cause increased blood flow.
  • The doctor will examine the site of the uterus using his hands (bimanual examination) before starting the hysteroscopy procedure.
  • The patient takes off her clothes and lies on the examination table on her back, spacing her legs. The area around the vagina is sterilized and the doctor enters the hysteroscope through it and begins to examine the cervix and endometrium through the camera
  • In the case of the need for intervention the hysteroscope is changed to have a cover allows the introduction of surgical instruments (like resectoscope) and then re-enter the hysteroscope again and since the cover is thicker than the diagnostic hysteroscope, the doctor tries to expand the cervix again before entering by cervical dilators

Instructions after the operation

  • The patient do not need to stay in the hospital after the hysteroscopy procedure, and can return home after an hour or two
  • The patient is prescribed analgesic and antibiotic as a prevention of any infections

Contraindications to hysteroscopy

Hysteroscopy is prohibited in a few medical conditions, including:

  • Inexperience of the doctor
  • At the time of menstruation where the doctor will not be able to see clearly
  • The presence of intrauterine pregnancy
  • Cervical inflammation
  • Acute reproductive tract infection in order to avoid the risk of infection spreading which may cause infertility resulting from inflammation and adhesions of the fallopian tube, or may lead to septicemia and death.
  • The presence of cancerous of the cervix, vagina or endometrium, in order to avoid the risk of cancer cells spread and into new places of the reproductive system.
  • Severe myocardial dysfunction, as the introduction of fluid used during the hysteroscopy into the circulatory system can lead to increased effort on the heart muscle

Trauma that may occur during a hysteroscopy

Hysteroscopy is a safe medical procedure that rarely results in complications, but some problems can occur in rare cases where the doctor is not able and not well trained to deal with hysteroscopy, and these errors are very rare and may occur up to 0.28% of the total number of cases of hysteroscopy, including:

  • Perforation of the uterus: It is the least complication in terms of the incidence as the doctor conducts the operation in clear vision conditions through the camera and screen display, there is no room for error as not closed eyes
  • Cervical rupture: If the doctor does not give the opportunity to the cervix to expand by the effect of pumping gas or saline
  • Injury of one of the internal organs: These are also rare errors that occur in the case of uterine perforation and the doctor does not realize that he punctured the uterus will continue to enter resulting in injury to the urinary bladder or ureter or injury to the colon or intestines or one of the main blood vessels in the pelvis, which is the most serious mistakes
  • Bleeding due to myomectomy, especially if implanted in the muscles of the uterus, which is not suitable for hysteroscopic resection

Complications that can occur with a hysteroscopy

  • Simple bleeding due to fibroid resection
  • Arrhythmia, especially in cases of cardiac patients
  • Pulmonary embolism, especially in cases of cardiac patients, and this occur if some gas bubbles used to expand the uterus leak into the blood stream, causing air embolism