10

Diagnostic and Therapeutic Hysteroscopy in the Office

David A. Grainger, Bruce L. Tjaden, and Arjav Shah

The clinical presentation of gynecologic patients often mandates evaluation of the uterine cavity. Symptoms requiring evaluation include menorrhagia, intermenstrual bleeding, postmenopausal bleeding, and infertility, particularly those preparing for in vitro fertilization (IVF). Techniques for uterine evaluation include endometrial biopsy, vaginal ultrasonography, sonohysterography, hysterosalpingography, and hysteroscopy. Dating back to its introduction by Bazzini during the early 1800s, hysteroscopic evaluation has added to the elucidation of uterine factors for infertility, which may account for 1015% of cases.1,2 Infertility is defined as 1 year of unprotected intercourse without conception. It is estimated that 1015% of couples at reproductive age are infertile (Table 101).3 Uterine factors, which include structural and developmental defects (mllerian anomalies) account for 10% of infertility cases (Table 102).4,5 Hysterosalpingography (HSG) has been the time-honored modality for uterine evaluation. The procedure has diagnostic limitations, however, and is not useful as a treatment modality. Nonetheless, HSG remains a useful tool with relatively high sensitivity and specificity. Indeed, recent publications have confirmed the continuing value of HSG. Sonohysterography (sonoHG, sometimes termed hysterosonography) has been developed and may play a significant role in the evaluation of the uterine cavity.6 Hysteroscopy does not necessarily replace HSG or sonoHG but, rather, augments these modalities. The major advantage of hysteroscopy is direct visualization of the uterine cavity. Most importantly, hysteroscopyand with advances in equipment, office hysteroscopycan be utilized to diagnose and treat intrauterine lesions at a single session.
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Traditionally, hysteroscopy has been a hospital or outpatient surgery center procedure, usually necessitating a major anesthetic (general anesthesia or regional block). With the advent of better optics smaller instrumentation became available, reducing the need for major anesthesia; officebased hysteroscopy became a reality. Publications have confirmed the safety, efficacy, and utility of office-based hysteroscopy.7,8 This chapter focuses on the use of in-office hysteroscopy for diagnostic and therapeutic purposes in the management of infertility patients. Indications for office hysteroscopy are reviewed, as are techniques for performing this procedure. We review also some emerging technology that will provide new options for the clinician in his or her office. Lastly, economic considerations for the clinician regarding the cost of equipment (capitalization) versus potential economic benefit are explored.

Indications
The indications for hysteroscopy are listed in Table 103. Endometrial curettage has been the standard procedure for evaluating the endometrial cavity

TABLE 101. Causes of Infertility

Cause of Infertility Male Female Ovulatory dysfunction Tubal Uterine Cervical Unexplained % 4045 4050 4045 4045 1020 12 510

10. Diagnostic and Therapeutic Hysteroscopy in the Office TABLE 102. Uterine Factors as a Cause of Infertility
Study Rock DeCherney Diamond Source: Li and Cook4 and Rock and Murphy.5 % 5 7 4

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(specifically, endometrial histology) for many years. Several studies have demonstrated the inadequacies of dilatation and curettage (D&C), including inadequate sampling, missed lesions (including large polyps), and, most concerning, missed diagnosis of endometrial carcinoma.9,10 Hysteroscopy offers the distinct advantage of direct visualization and directed sampling (biopsy). Loeffer has demonstrated the value of negative hysteroscopic results in women with abnormal bleeding. With a normal hysteroscopic evaluation, he (and others) have shown that histologic evaluation is abnormal in fewer than 3% of patients.10,11

Intrauterine Masses
Endometrial polyps are occasionally suspected on sonography and can usually be confirmed by HSG or sonoHG. The diagnosis can be confirmed and a definitive diagnosis established with hysteroscopy. (This is just one example of the complementary nature of HSG or sonoHG and hysteroscopy.) Pathophysiologic characteristics of these polyps include their origination as a focal hyperplastic process of the basalis, which develops into a benign overgrowth of endometrial tissue containing glands, stroma, and vasculature. The estimated prevalence of endometrial polyps in the general population is 24%.12 For some patients polyps are a source of infertility, presumably acting as an intrauterine device (IUD). Many of these patients present with abnormal uterine bleeding in addition to infertility.

TABLE 103. Indications for Hysteroscopy

Abnormal uterine bleeding Menorrhagia Intracycle bleeding Postmenopausal bleeding Intrauterine mass(es) Asherman syndrome Lost intrauterine device (IUD) Foreign object Abnormal hysterosalpingography (HSG) or sonohysterography (sonoHG) Before artificial reproductive therapy (pre-ART)

The occurrence of carcinoma in seemingly benign polyps is reported to be less than 0.5%.13 Even though some polyps can be removed with blind curettage, many are missed during the process because of their mobility. Polyps are often morphologically described as broad-based and sessile, pedunculated, or attached to endometrium by a slender stalk. Clinical implications lie with categorization of polyps into one of three broad areas: hyperplastic, atrophic, or functional. Hyperplastic polyps often populate the endometrial cavity diffusely. Malignant tumors are more likely to develop from these polyps secondary to their source (the baseline), which is much less responsive to progesterone than estrogen. Atrophic polyps are found in postmenopausal patients and may represent the process of regressive changes in a hyperplastic or functional polyp. Functional polyps resemble the surrounding endometrium in that they respond to hormonal changes during the menstrual cycle. Virtually any size polyp can be removed in the office.14 Scissors or cautery are utilized to incise the attachment of the polyp from the uterine wall. Large broad-based sessile polyps may require follow-up treatment in the operating room with the resectoscope. The polyps are excised under direct visualization. Functional polyps are identified as those with a lining identical to the surrounding endometrium. Nonfunctional polyps are noted to be white protuberances that are covered with branching surface vessels. All removed polyps should be sent to the pathology laboratory for histologic evaluation. Approximately 20% of uteri removed for endometrial carcinoma have additional pathology, including benign polyps.14 Leiomyomas of the uterus are the most common uterine neoplasms. In hysterectomy specimens, 75% of uteri have histologic evidence of leiomyoma.15 They are more common in black women than white women. Myomas arise often during the third and fourth decade, thus affecting reproductive performance. Myomas arise from the myometrium and are thought to be a clonal tumor. Indeed, approximately 60% of uterine fibroids are karyotypically abnormal.16,17 These tumors shrink with gonadotropin-releasing hormone (GnRH) analogue treatment but generally return to their pretreatment size within 3 months of discontinuing the therapy.18 Submucous fibroids tend to cause problems with abnormal bleeding or early pregnancy loss(es); large myomas may cause pressure symptoms or obstruction of labor, or they may inhibit palpation of adnexal structures.19 Myomas are classified by their location: subserosal, intramural, submucosal, or pedunculated (into the uterine or peritoneal cav-

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ities). Treatment for leiomyomas is indicated if they are symptomatic, interfere with fertility, enlarge rapidly, or pose diagnostic problems. The definitive diagnosis of submucosal leiomyoma is made by hysteroscopy and excisional biopsy. They appear as white spherical masses covered with a fragile, thin-walled vasculature. Myomas can be sessile or pedunculated. Hysteroscopic resection of myomas is often relatively simple when the tumor diameter is less than 2 cm.14 For larger submucous fibroids, pretreatment with GnRH analogues should be considered. Maximal shrinkage occurs after 3 months of therapy.18 This therapy results in a decrease in size and may also decrease the bleeding by reducing the vasculature of the tumor.

Mllerian Anomalies
Congenital abnormalities of the uterus are uncommon and appear to be transmitted by a polygenic or multifactorial pattern of inheritance. Based on retrospective studies, the incidence of these abnormalities appears to be 23%. Uterine anomalies are found in 4% of infertile women and in 1015% of women with recurrent abortion.20 Spontaneous abortion and obstetric complications such as premature labor and abnormal fetal presentation are the most common reproductive symptoms in patients with uterine anomalies.21 Uterine defects are not a proven primary cause of infertility, and most authors agree that mllerian anomalies are more commonly associated with pregnancy wastage (Table 104). The septate uterus is the most common uterine abnormality (30%) associated with recurrent early spontaneous abortion.22 The septum is a product of the persistence of the fused mllerian ducts with failure of resorption of the intervening wall. Hysteroscopic metroplasty has been the mainstay of therapy for the uterine septum. Though originally described as a procedure necessitating laparotomy, metroplasty is now most commonly done via hysteroscopy. Hysteroscopic metroplasty has traditionally been performed in a minor surgery set-

ting, often with laparoscopic visualization to establish the diagnosis (septate uterus versus bicornuate uterus). Using imaging techniques such as magnetic resonance imaging, laparoscopy may not be required to confirm the diagnosis. Furthermore, many hysteroscopic surgeons are comfortable treating the known uterine septum without laparoscopic visualization. Thus the procedure is amenable to use in an office setting with proper instrumentation. Pregnancy outcomes appear to be quite good for patients with recurrent pregnancy loss secondary to a uterine septum after metroplasty (85% pregnant with a 75% delivery rate). It is less clear what relation a uterine septum may have with infertility.23 Treatment with estrogens after resection of the septum may help with reepithelialization of the raw surfaces of the endometrial cavity. Additionally, an intrauterine balloon or IUD may be left in the uterine cavity to help reduce the chance of intrauterine adhesions. The transcervical approach, whether in the operating room or the office, is less invasive and avoids the risk of pelvic adhesions associated with abdominal procedures.

Asherman Syndrome
Intrauterine synechiae (Asherman syndrome) most commonly develop after curettage is performed during the postpartum or postabortal period. The concurrent presence of an intrauterine infection raises the probability of synechia formation. The clinical presentation may consist of hypomenorrhea or amenorrhea and infertility. The diagnosis is made by HSG or hysteroscopy. Hysteroscopic examination reveals bands of fibrous tissue or smooth muscle, without significant inflammation, that traverse the endometrial cavity. The treatment lies in identifying the adhesions and dividing them with scissors or cautery. The office setting often is utilized for dividing central synechiae, which do not need to be excised, just divided.14 Lateral and diffuse adhesions are probably best lysed in the operating room with concomitant laparoscopic guidance. Upon restoration of normal intrauterine anatomy, or IUD or a pediatric Foley catheter is generally placed in the uterine cavity. The catheter is removed in 710 days; the IUD may be left in for 13 months. Patients are placed on conjugated estrogen (1.25 mg per day) for 1 month. Hysterography or office hysteroscopy can be done for follow-up within 13 months of surgery. Reproductive outcomes are related to the extent of preoperative endometrial damage and are summarized in Table 105.2429

TABLE 104. Mllerian Anomalies Associated with Poor Reproductive Performance

Septate uterus Unicoruate uterus Bicornuate uterus Uterine didelphys

10. Diagnostic and Therapeutic Hysteroscopy in the Office TABLE 105. Reproductive Outcomes Following Treatment of Intrauterine Adhesions
No. of pregnancies/study population Study March24 Valle25 Lancet26 Caspi27 Oelsner28 Total Pretreatment 14/84 8/266 189/484 40/122 9/57 260/1013 (25.7%) Posttreatment 33/38 85/95 77/113 28/33 14/20 237/299 (79.3%)

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Other Indications
Retrieval of an IUD often can be attempted using the office hysteroscope prior to obtaining radiographic imaging. Transvaginal ultrasonography can be utilized to identify the location of the device in the endometrial cavity that is not readily found on palpation with a uterine sound. If the IUD has partially perforated the abdominal cavity, hysteroscopic removal with concurrent laparoscopy may provide the safest means.30 Postpartum or postabortal bleeding may be a result of retained products of conception. Such persistent bleeding can be evaluated and treated by hysteroscopy-guided removal of the retained products. After completion of the procedure, antibiotic therapy is generally recommended.

Hysteroscopy Prior to In Vitro Fertilization

Detectable uterine abnormalities have been noted in up to 45% of the patients undergoing IVF.31 These abnormalities include endometrial polyps, submucous leiomyomas, uterine malformations, and cervical stenosis. Shamma et al. studied patients who underwent office hysteroscopy under paracervical block prior to IVF.32 Twenty-eight

patients were studied, all having had normal HSGs prior to enrollment. Twelve patients (43%) had abnormal hysteroscopic findings, including small uterine septa, small submucous fibroids, uterine hypoplasia, and cervical ridges. Significant differences in the clinical pregnancy rates were found in patients with abnormal and normal findings by hysteroscopy (8.3% vs. 37.5%). The above indications for office hysteroscopy deal with correcting abnormalities of the cavity in an attempt to improve pregnancy outcomes. Indications for office hysteroscopy for patients attempting conception who have a normal cavity include transcervical transfer of gametes or embryos. One review summarized the experience with hysteroscopic replacement of gametes and embryos.31 Overall, the pregnancy rates from these procedures do not appear to offer any advantage to ultrasoundguided transfers and are comparable to the pregnancy rates after transcervical intrauterine embryo transfer (see Table 106).

Contraindications
In concordance with the relative safety and ease of office hysteroscopy, absolute contraindications are cervical carcinoma, acute pelvic infection, and pregnancy. If pelvic infection occurs with an unretrievable IUD, office hysteroscopy may be per-

TABLE 106. Outcome of Transcervical GIFT Using Hysteroscopy or Ultrasonography

Outcome Procedure Ultrasound-guided Hysteroscopy SART; IVF in 1994 Cycles (no.) 173 131 31,000 Pregnancy 36 (20.1%) 25 (19%) 21% Ectopic 2 (6%) NR 4%

GIFT, gamete intrafollopian transfer; SART, Society for Assisted Reproductive Technology; IVF, in vitro fertilization.

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formed to remove the device. The patient would then undergo an antibiotic regimen to complete the treatment for pelvic infection. Relative contraindications include extensive intrauterine adhesions, leiomyomas larger than 2 cm, severe medical disorders (diabetes, asthma, blood dyscrasias), and excessive uterine bleeding (restricting the hysteroscopic view).14 Gestations with an IUD in place can be managed by hysteroscopic removal of the device.

Equipment
The uterine cavity is a potential space and must be distended to allow complete visualization for adequate diagnosis and treatment. Optical systems must provide adequate light and resolution, and there must be a means of delivering energy to the areas requiring therapy (mechanical energy, thermal energy, laser energy). We discuss each of these three areas separately as they apply to office hysteroscopy.

Distension of the Cavity

Carbon dioxide gas has been used most commonly to distend the uterine cavity in an office setting. The insufflators are relatively inexpensive, use low rates of flow, and are easy to maintain. Visualization using CO2 is excellent and for strictly diagnostic purposes provides an adequate means of distending the cavity. CO2 is rapidly absorbed into the bloodstream and cleared by the lungs. There are several disadvantages. The CO2 often leaks around the hysteroscope, making distension of the cavity difficult. Furthermore, it is inadequate for operative procedures as it tends to form bubbles when mixed with blood. Care must be taken to use only insufflators specifically designed for hysteroscopy for CO2 delivery. Laparoscopic insufflators are designed for high flow rates, and deaths have been reported using laparoscopic insufflators for hysteroscopy (high flow, leading to CO2 embolism). Fluid distension media include high-molecularweight dextran (Hyskon), electrolyte solutions, and non-ionic solutions (sorbitol, mannitol, glycine). Hyskon is used relatively infrequently for several reasons. It is messy, with a consistency of syrup, and if not cleaned from instruments quickly results in immobilization of moving parts. It provides excellent visualization, particularly if there is any bleeding present. We have found the easiest delivery system to be a 50 cc syringe, intravenous extension tubing, and a strong nurse or medical student. Generally, the amount of Hyskon used should not

exceed 500 ml as there is significant risk of pulmonary edema. Furthermore, rare adverse reactions including anaphylaxis and disseminated intravascular coagulation have been reported. Overall, this medium is unlikely to find a useful place in office hysteroscopy. Low viscosity fluids are easier to use in an office setting. They include ionic fluids (electrolytecontaining, such as normal saline or lactated Ringers) and non-ionic fluids (such as sorbitol, mannitol, or glycine). The electrolyte-containing solutions are advantageous in that their absorption, even in relatively large amounts, poses little risk to the patient. However, they cannot be used with traditional monopolar electrosurgery. The non-ionic solutions may be used with monopolar electrosurgery but carry the risk of water intoxication if absorbed in large amounts. Therefore, it is critical that accurate measurements of fluid absorption be maintained throughout the procedure. In the office setting, this is less likely to pose significant problems, as the more difficult and extensive hysteroscopic procedures should be performed in an ambulatory surgery center or in the hospital. Visualization of the endometrial cavity is best accomplished using continuous flow of distension medium. Office hysteroscopes with dual channels for inflow and outflow are readily available and are preferred for both diagnostic and therapeutic use.

Light and Optics: Flexible, Micro, or Rigid Hysteroscopes?

Although advances in fiberoptics, light sources, and delivery systems have occurred, it is the authors opinion that the visual clarity of rigid hysteroscopic systems remains superior at the present time. Additionally, rigid systems are more adaptable to therapeutic usage. We profile some of the more common systems, including one flexible hysteroscope (Olympus), one microhysteroscope (Imagyn), and one rigid system (Wolf). Many other products are available and are adequate or perhaps superior, but these systems give the reader an idea of what is available currently.

Flexible Hysteroscopy
The advantages of a flexible hysterocope is its small size, resulting in improved tolerance by the patient. Most patients do not require anesthesia or cervical dilation. The Olympus hysterofiberscope (Fig. 101) provides an ergonomic design and singlehanded control. Minor surgical procedures may be

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Rigid Hysteroscopy
Rigid hysteroscopes range from 3 to 5 mm outside diameter and can be configured for continuous flow and operative procedures (Fig. 103). The optical resolution with these systems is excellent and approaches or exceeds that of the large resectoscopes utilized in the operating room. The hysteroscopes are generally inserted with no dilation of the cervix; if dilation is required, a paracervical block is used. Operating channels allow introduction of semirigid instruments or bipolar electrodes (Versapoint). The resolution obtained with these instruments, combined with the increased firepower obtained by using bipolar technology in physiologic distension media, should add greatly to the therapeutic benefits of office hysteroscopy.

FIGURE 101. Microhysteroscope.

performed through this hysteroscope, including directed biopsy or excisional biopsy of small polyps.

Energy Sources
Microhysteroscopy
Imagyn Medical (Laguna Niguel, CA) has introduced the MicoSpan hysteroscopy system (Fig. 102), which has as an integral component a 1.6 mm offset microhysteroscope with enhanced microoptics. The outside diameter, when used with the sheath, is approximately the size of a Pipelle, yet the fused image fiber and the microoptics provides 150% of the illumination and up to three times the resolution of similar-size hysteroscopes. This system is used in combination with the MicroSpan Sheath, which has an expandable working channel that accepts 2 mm semirigid instruments for biopsy or excision. The sheath also allows continuous flow or distension medium, with controls for inflow and outflow optimizing visualization of the cavity.

Mechanical Energy
Mechanical energy in the form of biopsy instruments is the most common application of energy in the office. These instruments are small (2 mm)

FIGURE 102. Flexible hysteroscope appropriate for performing minor surgical procedures including directed biopsy or excisional biopsy of small polyps.

B FIGURE 103. A, B. Rigid hysteroscope.

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and semirigid, allowing them to pass down the operating channels of most office hysteroscopes. These instruments can be used to obtain directed biopsies, transect the base of polyps, or cut uterine septa.

Unipolar Energy
Generators producing unipolar energy use the patient as a conductor, with the source of energy being the active electrode, and the ground plate being the receiver of the electrons. Thus conductive distension solutions may not be used, as the energy is dissipated in the medium, extinguishing any meaningful tissue interaction. These forms of energy are commonly conducted via electrodes designed to be used for endometrial ablation, resection of large fibroids or polyps, or metroplasty. Non-ionic solutions are used (glycine, sorbitol, mannitol); it is incumbent on the surgeon to maintain accurate measurements of fluid absorption (infused minus recovered). Several devices have been designed to aid in the accurate measurement of fluid absorption. The experienced hysteroscopist recognizes situations in which fluid absorption is likely (bleeding from ablation or resection of fibroids). However, one must always be alert to the problem of excessive fluid absorption, even with seemingly benign cases, as fluid overload with these solutions can have serious sequelae.

FIGURE 104. Bipolar electrosurgery system (Versapoint). (Courtesy of Gynecare)

one of the emerging thermal therapies such as ThermaChoice, shown in Figure 105 (Gynecare).

Procedure
Timing the Examination
Especially for the novice, hysteroscopy is best performed during the early to mid-proliferative phase of the cycle. Bleeding has stopped, but the endometrium has not grown to the point that it obscures the view. With insertion of the hysteroscope, strips of late proliferative or secretory endometrium can be elevated and easily confused with polyps. If therapeutic procedures such as ablations are performed in the office, endometrial preparation with either danazol (Danocrine) or GnRH analogues can provide thinning of the endometrium, allowing excel-

Bipolar Energy
A new hysteroscopic energy delivery system has been introduced. Traditionally, unipolar energy is utilized through loops, bars, or other types of ablative electrode, which requires the use of non-ionic solutions with the attendant risks of water intoxication and hyponatremia. Versapoint (Gynecare, Menlo Park, CA) is a bipolar electrosurgery system that employs at least three distinct advantages: (1) normal saline may be used as a distension medium; (2) the electrodes are small and pass easily through a 5 mm hysteroscope; and (3) instantaneous tissue vaporization eliminates resection chips (Fig. 104). The generator delivers energy to the active electrode, creating a vapor pocket, which causes instantaneous cellular rupture upon contact with tissue. This bipolar energy source also provides excellent hemostasis and is useful for treating submucus leiomyoma or endometrial polyps. Versapoint may also be used as an adjunct to endometrial ablation, either traditional rollerball or using

FIGURE 105. ThermaChoice system. (Courtesy of Gynecare)

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lent visualization and perhaps more efficacious treatment.

Medications
The patient should be given nonsteroidal antiinflammatory drugs (NSAIDs) approximately 3060 minutes prior to the procedure. Some of these medications are available as rectal suppositories and are effective within 1530 minutes of administration. The procedure is generally well tolerated with no further medications being given. The occasional patient benefits from a mild sedative or tranquilizer (e.g., the patient who does not tolerate an endometrial biopsy). These medications should also be administered 3060 minutes prior to the procedure. Most of these procedures are performed without intravenous access; therefore, if any narcotic medications are required, they are usually administered intramuscularly. This situation arises only in rare patients in our experience.

perception scores by the patients.33 This study evaluated 177 women undergoing outpatient hysteroscopy. Paracervical block consisted of 10 cc of 1% mepivacaine hydrochloride solution (87 patients) or no block (90 patients). The pain scores for the treated group were 4.2 2.0 and for the untreated group 5.2 2.1, which were not significantly different. It is probably more important to pretreat patients with nonsteroidal medications 3060 minutes prior to the procedure. Occasional patients do not tolerate office hysteroscopy (e.g., those who do poorly with an endometrial biopsy may tolerate diagnostic hysteroscopy but probably not do well with therapeutic procedures). Several techniques may be used for a paracervical or intracervical block. We prefer to inject 0.25% bupivicaine into the cervix through a 20-gauge spinal needle, using 5 cc at the 4 and 8 oclock positions. Bupivicaine has a little longer onset of action but provides longer relief after the procedure.

Patient Position
The patient is placed in the dorsal lithotomy position, and a bimanual examination is performed to make certain no adnexal tenderness is present and to determine uterine size and position. Ideally, an adjustable electric bed with leg rests is available for patient comfort. As the examinations are brief, it has been our experience that the procedure is well tolerated even with a normal examination table. If video equipment is available, the patient is positioned such that she can view the screen. Involvement of the patient with the ongoing procedure is beneficial for both educational purposes and patient comfort (distraction).

Insertion of the Hysteroscope

The hysteroscope is gently inserted through the external cervical os, and the endocervical canal is inspected. Insufflation medium (CO2 or liquid) is injected, allowing visualization of the cavity, which appears as a dark spot (the location of this dark spot depends on the angle of scope and the position of the uterus). The hysteroscope is directed toward this dark spot until the cavity is entered. The flow of medium is adjusted so the cavity is adequately distended. Systematic inspection of the cavity is performed and should include examination of the fundus, anterior and posterior walls, lateral walls, both tubal ostia, and the lower uterine segment. The findings should be recorded on hard copy, which is kept with the patients record.

Cervical Preparation
After placing a bivalved speculum, the cervix is cleansed with povidone-iodine solution. The bivalved speculum allows for its easy removal after the uterine cavity has been entered with the hysteroscope. Removing the speculum allows more range of motion with the hysteroscope and thus more complete inspection of the cavity.

Complications
Inadequate Visualization
Inadequate visualization is the most common complication of hysteroscopy, and the most common cause of inadequate visualization is lack of flow of the distension medium. Increasing the flow rate by raising the bag of medium, increasing pressure on the syringe, or increasing the flow rate on the CO2 insufflator may resolve the problem. If the cervical canal is narrow, it may be gently dilated prior to inserting the hysteroscope. Blood in the cavity, obscuring the view, generally responds to increasing flow rate. If blood continues to obscure the field, high-molecular-weight dextran may be

Paracervical Block
The use of a paracervical block is controversial. In general, with small hysteroscopes (3.55.0 mm) no cervical dilation is necessary to introduce the instrument. A prospective randomized comparison of paracervical blocks with anesthetic versus no injection revealed no significant difference in pain

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used. This medium is immiscible with blood but has the potential complications listed above. If CO2 is used and leakage is occurring at the external cervical os, the tenaculum may be adjusted to narrow the canal. Downward traction on the tenaculum is often useful for the anteverted or retroverted uterus.

Perforation of the Uterus

If the hysteroscope advances easily, and the cavity is not visualized, uterine perforation should be suspected and the procedure terminated. Likewise, insufflation of large amounts of distension medium with little return indicates perforation. These perforations are generally midline and require no further therapy. Exceptions include perforation of the uterus with a monopolar or bipolar device, or if there is any suspicion of bowel injury. These patients should undergo a laparoscopic evaluation of the pelvis, with possible laparotomy if indicated.

the procedure. The discussion in this chapter has focused on an office-based system. One should recognize that a state of the art system is expensive ($15,000$20,000) as it includes light sources, hysteroscopes, video equipment, and hysteroscopic instruments. Additional costs may include bipolar instrumentation, the modality that allows true therapeutic efficacy in the office. It becomes clear that so long as physician reimbursement is unaffected by the site of the procedure (i.e., a traditional feefor-service system), there is no incentive for the capitalization costs. However, in a managed care environment (capitated or global fee), the hospital portion of the expense falls to the physician. This may run $1000$2000 per procedure. It therefore requires few procedures to justify the expenditure for the equipment. This, combined with the overall patient satisfaction and improvements in technology, may result in more of these procedures being performed in-office.

Infection
Infection following hysteroscopy is rare. Careful selection of patients by bimanual examination and careful inspection of the cervical discharge prior to the procedure prevents infectious sequelae. Prophylactic antibiotics should be administered to patients with mitral valve prolapse per recommendations of the American Heart Association.

Summary
Assessing the endometrial cavity is an integral part of the infertility evaluation. Traditionally, it was accomplished using HSG. Although HSG continues to be utilized, along with sonoHG, it appears that hysteroscopy is the most sensitive method for examining the endometrial cavity. Whether the small lesions identified at hysteroscopy that are missed with other evaluations are clinically significant is not known. The advances in optics has allowed much smaller hysteroscopes to be utilized; and combined with advances in energy delivery this has made other diagnostic and therapeutic hysteroscopy feasible. The cost of the equipment (and reimbursement constraints) remains a barrier to more widespread use of this effective therapy. Furthermore, many clinicians are easily frustrated when beginning to use hysteroscopy and abandon the procedure, to the detriment of their patients. Educational efforts directed at both clinicians and third-party payers may increase utilization of this extremely beneficial, cost-effective procedure.

Bleeding
Bleeding following office hysteroscopy is rare. As more therapeutic procedures are performed in an office setting, the risk of bleeding increases. Bleeding can occur from the cervix (laceration from the tenaculum). The cervix should be carefully inspected at the end of the procedure, and if a laceration is present it should be repaired using a figure-of-eight suture. Intracavitary bleeding due to resection of polyps or fibroids, the septum, or after ablation may be controlled by placing a Foley catheter with a 30 cc balloon in the uterus and inflating with 1030 cc of saline. The catheter acts as both a tamponade and a drain and is left in place for 24 hours. Antibiotic prophylaxis should be provided for patients in whom a catheter is left in the uterus.

Economic Considerations
After recognizing the benefits of hysteroscopy from both a diagnostic and therapeutic viewpoint, the clinician must then decide in which setting to perform

Options for the Next Step in the Treatment Algorithm

Evaluation of the uterine cavity is an important step in the evaluation of the infertile couple. Office hysteroscopy is a valuable technique that is probably

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more sensitive than HSG or sonoHG in detecting small lesions (for some of which the clinical significance is not well established). The next steps include evaluation of tubal patency and function (HSG or falloposcopy).

References
1. Russell JR. History and development of hysteroscopy. Obstet Gynecol Clin North Am 1988;15: 111. 2. Pellicer A. Hysteroscopy in the infertile women. Obstet Gynecol Clin North Am 1988;15:99105. 3. Mosher WB, Pratt WF. Fecundity and infertility in the United States: incidence and trends. Fertil Steril 1991;56:192193. 4. Li TC, Cooke ID. Uterine factors in infertility. Curr Opin Obstet Gynecol 1992;4:212219. 5. Rock JA, Murphy AA. Anatomic abnormalities. Clin Obstet Gynecol 1986;29:886911. 6. Parsons AK, Lense JJ. Sonohysterography for endometrial abnormalities: preliminary results. J Clin Ultrasound 1993;21:8795. 7. Valle RF. Future growth and development of hysteroscopy. Obstet Gynecol Clin North Am 1988;15: 111126. 8. Chambers JT, Chambers SK. Endometrial sampling: When? Where? Why? With What? Clin Obstet Gynecol 1992;35:2839. 9. Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage: a review of 276 cases. Am J Obstet Gynecol 1988;158:489492. 10. Loeffer FD. Hysteroscopy with selective endometrial sampling compared with D & C for abnormal uterine bleeding: the value of a negative hysteroscopic view. Obstet Gynecol 1989;73:1620. 11. Fraser IS. Hysteroscopy and laparoscopy in women with menorrhagia. Am J Obstet Gynecol 1990;162: 12641269. 12. Van Bogaert LJ. Clinicopathologic findings in endometrial polyps. Obstet Gynecol 1988;71:771773. 13. Pettersson B, Adami HO, Lindgren A. Endometrial polyps and hyperplasia as risk factors for endometrial carcinoma. Acta Obstet Gynecol Scand 1985; 64:653659. 14. Gimpleson RJ. Office hysteroscopy. Clin Obstet Gynecol 1992;35:270281. 15. Cramer SF, Patel D. The frequency of uterine leiomyomas. Am J Clin Pathol 1990;94:435438. 16. Fletcher AJ, Morton CC, Pavelka K, Lage JM. Chromosome aberrations in uterine smooth muscle tumors: potential diagnostic relevance of cytogenetic instability. Cancer Res 1990;50:40924097. 17. Meloni AM, Surti U, Contento AM, Davare J. Uterine leiomyomas: cytogenetic and histologic profile. Obstet Gynecol 1992;80:209217. 18. Stewart EA, Friedman AJ. Steroidal treatment of myomas: preoperative and long-term medical therapy. Semin Reprod Endocrinol 1992;10:344350.

19. Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology and management. Fertil Steril 1981;36:433445. 20. Valle RF. Hysteroscopy in the evaluation of female infertility. Am J Obstet Gynecol 1980;137:425431. 21. Rock JA, Schlaff WD. The obstetrical consequences of utero-vaginal anomalies. Fertil Steril 1985;43: 681692. 22. Heinonen PK, Saarikoski S, Pystynen P. Reproductive performance of women with uterine anomalies. Acta Obstet Gynecol Scand 1982;61:157162. 23. Hassiakos DK, Zourlas PA. Transcervical division of uterine septa. Obstet Gynecol Surv 1990;45:165 173. 24. March CM, Israel R. Gestational outcome following hysteroscopic lysis of adhesions. Fertil Steril 1981; 36:455459. 25. Valle RF, Sciarra JJ. Intrauterine adhesions: classification, treatment and reproductive outcome. Am J Obstet Gynecol 1988;158:14591470. 26. Lancet M, Kessler I. A review of Ashermans syndrome, and results of modern treatment. Int J Fertil 1988;33:1424. 27. Caspi E, Peripinal S. Reproductive performance after treatment of intrauterine adhesions. Int J Fertil 1975; 20:249252. 28. Oelsner G, David A, Insler V, et al. Outcome of pregnancy after treatment of intrauterine adhesions. Obstet Gynecol 1974;44:341344. 29. Schlaff WD, Hurst BS. Preoperative sonographic measurement of endometrial pattern predicts outcome of surgical repair in patients with severe Ashermans syndrome. Fertil Steril 1995;63:410413. 30. Thompson JD, Rock JA. Te Lindes Operative Gynecology. Philadelphia: Lippincott, 1992, pp 385409. 31. Balmaceda JP, Ciuffardi I. Hysteroscopy and assisted reproductive technology. Obstet Gynecol Clin North Am 1995;22:507518. 32. Shamma FN, et al. The role of office hysteroscope in in vitro fertilization. Fertil Steril 1992;58:1237 1239. 33. Vercillini P, Colombo A, Mauro A, et al. Paracervical anesthesia for outpatient hysteroscopy. Fertil Steril 1994;62:10831085.

Suggested Readings
Lindheim SR, Kavic S, Shulman SV, et al. Operative hysteroscopy in the office setting. J Am Assoc Gynecol Laparosc 2000;7:6569. Zullo F, Pellicano M, Stigliano CM, DiCarlo C, Fabrizio A, Nappi C. Topical anesthesia for office hysteroscopy. A prospective randomized study comparing two modalities. J Reprod Med 1999;6:3316. Pal L, Lapensee L, Toth TL, Isaacson KB. Comparison of office hysteroscopy, transvaginal ultrasonography, and endometrial biopsy in evaluation of abnormal uterine bleeding. J Soc Laparaoendosc Surg 1997;1:125 30. Valli E, Zupi E, Marconi D, Solima E, Nagar G,

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D.A. Grainger, B.L. Tjaden, and A. Shah Ross JW. Numerous indications for office flexible minihysteroscopy. J Am Assoc Gynecol Laparosc 2000;7: 221226. Marrello F, Bettochi S, Greco P, Ceci O, Vimercati A, Di Venere R, Loverro G. Hysteroscopic evaluation of menopausal patients with sonographically atrophic endometrium. J Am Assoc Gynecol Laparosc 2000;7:197200.

Romanini C. Outpatient diagnostic hysteroscopy. J Am Assoc Gynecol Laparosc 1998;5:397402. Saidi MH, Sadler RK, Theis VD, Akright BD, Farhart SA, Villanueva GR. Comparison of sonography, sonohysterography, and hysteroscopy for evaluation of abnormal uterine bleeding. J Ultrasound Med 1997; 16:587591.