Hysteroscopic findings in patients with secondary infertility

INTRODUCTION

Secondary infertility is defined as the incapability to conceive a fetus or has a gestation to full-term thereafter formerly giving delivery. This condition cause recurrent pregnancy with ability to conceive but disability carry to term. The preceding delivery should have happened with no assistance from fertility drugs or treatment, like in vitro fertilizations. Secondary infertility characteristically detected afterward unsuccessful conceive for 6-mths to a 1-yr. ¹

Globally approximately 10-15% of the couples are infertile and the primary and secondary infertility rates are 67.3% & 32.6% from total number of infertile subjects. Prevalence of secondary infertility elevated abruptly with age, from 2.60% (2.30%, 3.00%) in women aging between 20&24 yrs to 27.10% (24.70%, 29.90%) in women aging between 40&44 yrs.²

Most endometrial pathologies concerned in infertility cause both structural and functional damages.³ Consequently, endometrial space evaluation must be comprised in the assessment of non-fertile couples. This may be performed through TVS, hystero-salpingography (HSG), sono-hysterography and hysteroscopy.⁴

However, the WHO recommends HSG alone, for managements of non-fertile females may be owing to its capability to deliver information concerning tubal patency.⁵ Never the less, hysteroscopy is a more precise tool owing to the elevated false-positive and false negative rates of intra-uterine abnormalities with HSG.⁶

Furthermore, anomalous hysteroscope results are significantly elevated in cases with preceding ART failures and hysteroscopy can be realized as a positive prognostical factor for accomplished in gestation in following IVF procedures in females with a history of recurrent implantation failures (RIF).⁷

Aim of the work was to assess the advantage of hysteroscopy in diagnosing the abnormalities of the uterine-space among females having secondary infertility 12-mths or more of steady un-protected intercourses and having normal uterine-space by 2DUS and normal H.S.G.

PATIENTS AND METHODS

The present study was conducted on 138 patients having secondary infertility with no suspected uterine defect, aged between 20 and40 years attending the gynecological outpatient clinic in Al-Hussein and Sayed-Galal University Hospital, Al-Azhar University.

Patient selection and inclusion criteria: Women aged 20-40, women with secondary infertility (12 months or more after last pregnancy with regular sexual intercourse without lactation), Females with a ordinary uterine space by 2 DUSandwomen with a normal uterine-space by hysterosalpingography following last pregnancy

Exclusion criteria: Women with untreated cervicitis, women with undiagnosed AUB, women with cardiac disease and other diseases contraindicating hysteroscopy or pregnancy, women who refuse to join our study and women with any uterine abnormality in 2 DUS or HSG.

Interventions: A written signed agreement was attained from the cases who fulfilled the inclusion criteria and was not excluded.

All patients was subjected to

History taking, general examinations: BMI, vital signs, abdominal and pelvic examination, base line 2D transvaginal ultrasound and review of the recent HSG ( less than 1 year ) and documentation

Technique of hysteroscopy: Diagnostic hysteroscopy has been achieved throughout the proliferative stage of the menstrual cycle. A rigid 0.29-cm hystroscope has been utilized with a 30º forward oblique lens and an outer sheath diameter of 0.5cm (Karl Storz GmbH, Tuttlingen, Germany) in this study.⁸ Distilled water solution has been utilized to distend the uterine-space. The pressures of the swelling media kept from 60 to 100-mmHg. Hysteroscopy has been achieved using no touch method (vaginoscopy method) as presented by Bettocchi and Selvaggi, ⁹. The uterine-space was systematically inspected preliminary by its frontal and backward walls, the fundus, and the boundaries. The size and equality of the tubal orifices was observed and any pathology found at the tubal orifices (adhesions, polyps or hyperemia or inflammatory changes) was reported. Passages of any air bubbles in the irrigation fluid to tubal ostea has been stated. If no bubbles of air are detected at all, two ml of air will be injected into the rubber end of the sterilized infusions set to be realized by the hysteroscope operator. Hysteroscopic bubble suctions examination was measured positive if air bubble suctions by the ostium is realized on the patent side within one minute. Throughout this retro, neither injections of air nor elevated pressures was accomplished. If no suctions of bubbles occur, the operator will pause for 1 minute more. Once more, if no suctions occurs, the examination was measured negative.¹⁰ The pathologies, time of procedure (from insertion of the hysteroscope through the vagina till complete removal), subjective ease of procedure was determined by the observer.

Study outcome: Intrauterine hysteroscopic findings (whether normal or pathologic) and the type and degree of pathology present

Ethical considerations: Study protocol was submitted for approval by the Ethical Committee of Faculty of Medicine - AL Azhar University – Ethical committee of the Obstetrics and Gynecology Department. Informed verbal and written agreement was attained from all participants sharing in the work after explanation of the purpose and procedures of the study.

Statistical Analysis: Collected data was statistically analyzed via the windows-based SPSS-20 (IBM, USA). In accordance to the kind of data qualitative introduces as numbers and percentages, quantitative continues group introduced as mean ± SD, the next examinations have been utilized to test variances for significance; comparison among frequencies and percentages in groups were done using Chi-square testing. comparison among parametric quantitative non-dependent groups by student testing P-value was significant at

RESULTS

Table 1: Demographic characteristics among studied patients

This table shows that patients’ age ranged 20 – 40 years with mean BMI 27.54 kg/m². Majority of the patients were rural.

Table 2: Hysteroscopy indications among studied patients

Majority of the patients underwent hysteroscopy as per infertility workup (77.5%)

Table 3: Hysteroscopy findings among studied patients

Majority of the patients were normal hysteroscopy (60.9%).

Table 4: Association between Pre-hysteroscopic diagnosis and Hysteroscopy findings among the studied patients

Table 5:  shows that between 76 females who had ordinary hysteron-graphy and US; 18 females had anomalous results from hysteroscope, for a NPV 86.8% for both ultrasound and hysterography.