IVF treatment is often a costly and challenging process for patients. Therefore, to increase the chances of treatment success, it is essential to carry out the necessary preliminary assessments and preparations. Proper preparation of the patient for IVF treatment is one of the elements that can improve treatment success.
Even in cases where IVF is chosen as a priority treatment, without the need to try classical treatment methods, the doctor will need to explain to the patient the reasons for this clearly. Therefore, it will be imperative to conduct examinations and evaluations before treatment.
Since IVF is beginning to be considered the first treatment option in many cases today, the circumstances in which hysteroscopy and laparoscopy are being applied are decreasing. But this naturally shows changes from center to center and from case to case. In some centers, the presence of a condition in the uterine cavity that will prevent pregnancy is routinely investigated before starting IVF treatment using the hysteroscopy method. Although it is less, in some centers, the condition of the pelvic region is examined in detail by diagnostic laparoscopy. Some patients may prefer to start IVF treatment directly rather than performing these procedures.
It should be remembered that each patient’s condition is different, and whether hysteroscopy/laparoscopy should be performed is a decision that should be made by evaluating it individually. Naturally, no single truth can be applied in all cases. Still, examining the research done will shed light on the subject.
HYSTEROSCOPY
Diagnostic Hysteroscopy
This process has become a practice that is primarily performed in practice.
The importance of diagnostic hysteroscopy in the study of the intrauterine cavity is indisputable. Fairly straightforward information about the volume and shape of the cavity (intrauterine cavity) can be obtained with hysteroscopy. This method also gives an idea of the thickness and surface of the endometrium. Alternatives to this method are HSG (Hysterosalpingography) and ultrasound, preferably performed in 3D. However, many studies comparing the effectiveness of hysteroscopy with HSG show that hysteroscopy is superior.
In fact, the questions that need to be answered regarding the examination of the intrauterine cavity are much more than which method to choose:
- Is it always necessary to examine the intrauterine cavity before IVF treatment?
- In what cases is it beneficial to do it if it is not routinely performed?
- Does the treatment of intrauterine anomalies with hysteroscopy increase the pregnancy success of assisted reproductive techniques?
Undoubtedly, congenital, or later acquired pathologies of the intrauterine cavity significantly reduce the success of assisted reproductive techniques. The incidence of endometrial and intrauterine cavity anomalies can be up to 38%, especially in recurrent IVF failures.
Hysteroscopy for Therapeutic Purposes
On the treatment side, there is research that hysteroscopic surgery for intrauterine abnormalities has a significant positive effect on fertility. Although these findings, combined with the fact that hysteroscopy is a simple procedure performed in an office setting, make us think intrauterine abnormalities should be treated routinely before IVF, this is not always the case. Many IVF centers agree that the incidence of intrauterine anomalies depends on personal risk factors, and most of these anomalies are not necessarily enough to prevent implantation (attachment to the uterus). In addition, in most cases where intrauterine abnormalities are suspected, HSG or ultrasound is considered sufficient as initial examinations.
Due to the lack of randomized controlled trials on this issue, no single method should be recommended in each case, and a personalized approach should be followed.
Indications for Hysteroscopy Before IVF
- Examination of the intrauterine cavity should be routinely included in the examinations to be performed for an infertile couple. The method of examining the uterine cavity (ultrasound, HSG, or hysteroscopy) in patients with regular menstrual bleeding, no complaints of abnormal bleeding, and a normal uterus during examination is a matter of the doctor to decide on their personal experience. Exceptional cases that do not require the examination of the intrauterine cavity are to know for sure that infertility originates from the male, there is no family history of a uterine anomaly, and the patient is under the age of 35.
- If the woman is over the age of 35, has abnormal vaginal bleeding, and has abnormal/suspicious findings on examination, hysteroscopy is considered the gold standard for investigating and, if necessary, treating potential intrauterine abnormalities.
- In the event that the patient has already had two unsuccessful attempts at IVF, hysteroscopy must necessarily be performed.
- Indications for hysteroscopy for therapeutic purposes before IVF are no different from indications after infertility examinations. Intrauterine polyps need to be removed. Submucous fibroids, which significantly protrude into the uterine cavity and do not exceed 4 cm in diameter, must also be removed. It is necessary to cut the intrauterine septums (curtains), which markedly divide the uterine cavity into two parts. Mucosal synechia (adhesions) should be treated if it is expected to correct the shape of the intrauterine cavity. If antibiotic treatment was performed after the diagnosis of endometritis, it is recommended to check the results with hysteroscopy. All these pathologies should be treated before starting IVF, especially if there have been unsuccessful IVF attempts before.
LAPAROSCOPY
Diagnostic Laparoscopy
Laparoscopy is a procedure performed in the hospital, often requiring general anesthesia and hospitalization. Complications can be seen in 2-3% of the patients, and although rare, they can be fatal. Therefore, diagnostic laparoscopy should not be used as the first choice in infertility examinations. Laparoscopy should be used in cases of pelvic region infections, infertility caused by tubes, and in case of abnormal/suspicious findings (anomaly detected in ultrasound or HSG, positive chlamydia) in other examinations.
In cases of unexplained infertility, the situation is more uncertain. Endometriotic lesions are seen in 40% of the cases considered as unexplained infertility, and pelvic infection or adhesions in the tubes are seen in 10%. However, the important thing is not their diagnosis but what can be done if they are diagnosed — in most cases, trying to correct these before IVF is a waste of time and does not significantly improve the results.
Therapeutic Laparoscopy
There are some indications for therapeutic laparoscopy to increase the success before IVF. One of them is hydrosalpinx (fluid in the tubes). Depending on the type of hydrosalpinx and some other factors, salpingectomy may be performed before IVF.
Endometriosis indications are somewhat more complicated. The improvement of IVF results after surgery depends on the type of lesions and the severity of the disease.
On the subject of fibroids, many studies show that success does not increase after myomectomy. Indications for surgery for fibroids should be decided independently of IVF treatment.
In order to diagnose these conditions, routine laparoscopy is not required before IVF. They are diagnosed mainly by clinical signs or abnormal ultrasonography/HSG results. Sometimes they occur during laparoscopy due to the patient’s risk factors. The indications for laparoscopic treatment are independent of whether or not IVF treatment will be applied afterward.
Pre-IVF Laparoscopy Indications
- Laparoscopy is not applied in patients with no suspicious clinical signs, standard pelvic view, and infertility cases whose cause is known with certainty (primarily male infertility).
- Laparoscopy may be performed if the patient has suspected pelvic region inflammation because of risk factors, medical history, pelvic examination, or abnormal imaging findings.
- Laparoscopy is indicated in the presence of pathological pelvic region (such as hydrosalpinx, severe endometriosis, endometriotic cyst). This indication is even stronger if the patient has had previous IVF failures.
CONCLUSION
Hysteroscopy and laparoscopy are part of the global treatment of infertile patients and are used only when necessary. None of these methods are routine examinations. However, the performance of these methods is very high, both in terms of diagnosis and treatment, so it cannot be considered that they should be ignored entirely for patients who will be included in assisted reproductive treatments.
The doctor should establish a personalized approach by carefully examining the clinical findings. With such an approach, it may be possible to increase both the success rate of each cycle and the cumulative pregnancy probability of the patient.
You can visit our IVF Turkey page to get detailed information about IVF treatment and how the processes work in Turkey.
You can visit our IVF Turkey page to get detailed information about IVF treatment and how the processes work in Turkey.
REFERENCES:
https://pubmed.ncbi.nlm.nih.gov/25769434/
https://pubmed.ncbi.nlm.nih.gov/23768623/
https://pubmed.ncbi.nlm.nih.gov/26986742/
