Journal of Minimally Invasive Gynecology (2007) 14, 407– 418

Development of hysteroscopy: From a dream to a reality,

and its linkage to the present and future
Rafael F. Valle, MD

From the Department of Obstetrics and Gynecology, Northwestern University Medical School, Chicago, Illinois.

KEYWORDS: Abstract. Hysteroscopy today represents 200 years of salient innovations in instrumentation, new clinical
Development; applications for existing instruments, and continual modification of techniques, all aiming at observing,
Gynecologic diagnosing, and treating pathologic conditions of the uterine cavity. Pioneers established the fundamental
endoscopy; principles of intrauterine observation that steady technological advances would simplify and refine, all the
History; way to the instrumentation and ancillary equipment now in use. Homage should be given and tribute paid
Hysteroscopy; to predecessors who made instrumentation, intrauterine distention, and illumination safe and practical for
Innovators; diagnostic and therapeutic hysteroscopy. Their accomplishments are remembered as we look with optimism
Pioneers to the many advances that undoubtedly will mark the future of hysteroscopy.
© 2007 AAGL. All rights reserved.

New techniques are no more based on just one idea than
a building’s foundation is on just one stone; and rather, they
evolve in many steps. Because hysteroscopy is commonly
used today by gynecologists in diagnosis and therapy,1– 6 a
review of the multiple observations and innovations that
arose over the years to bring forth the relatively simple,
practical techniques in use today is warranted.
While the history of hysteroscopy will be traced over 2
centuries, some facets of this history will be highlighted,
particularly the various approaches taken to make the visu-
alization of the uterine cavity feasible (Table 1).
First hysteroscopic attempts
For a long time, attempts at hysteroscopy consisted of
testing the usefulness of instruments that could be inserted
in the uterus and reflect external light for visualization.
The author has no commercial, proprietary, or financial interest in the
products or companies described in this article.
Corresponding author: Rafael F. Valle, MD, 880 N. Lake Shore Drive,
Suite 20-C, Chicago, IL 60611-5715.
E-mail: r-valle@northwestern.edu
Submitted January 12, 2007. Accepted for publication March 10, 2007.
Bozzini7 (1773–1809), a German, was the first to invent
such an instrument. His Lichtleiter, or light conductor, as he
named it, was a hollow tube divided by a vertical septum
fitted with a concave mirror that, by transmitting the light of
a candle, permitted the visualization of body cavities. He
conceived the instrument to explore externally accessible
body cavities such as the mouth, nose, ears, vagina, cervix
and uterus, urethra and urinary bladder, and rectum. Al-
though he personally did not use it for hysteroscopy, it is
clear that most of the experiments conducted with the light
conductor aimed at visualizing the rectum and the uterus
(Figures 1–3).
Although Bozzini published a brief description of his
instrument in 1804 in a Frankfurt newspaper, it was not until
1805 that he announced, again in a newspaper, that he had
created a device that made it possible to inspect the inner
cavities of the human body. A formal and extensive descrip-
tion of the instrument was published in 1807.
Although the invention suffered from bureaucracy and
professional jealousy, Bozzini is rightly considered today as
the father of endoscopy. His epitaph, inscribed in Latin on
a marble slab attached to an outside wall of the Frankfurt
cathedral, reads: In memory of the devout, deceased soul of
Philip Bozzini, medical doctor. He, German born, was the

1553-4650/$ -see front matter © 2007 AAGL. All rights reserved.

doi:10.1016/j.jmig.2007.03.002
408 Journal of Minimally Invasive Gynecology, Vol 14, No 4, July/August 2007

Table 1 Milestones in the development of hysteroscopy

Year Investigator Contribution

1807 Bozzini First endoscope (the “Light Conductor”)
1869 Pantaleoni First hysteroscopic examination in a living patient
1879 Nitze Cystoscope with distal illumination
1907 David First contact hysteroscope
1914 Heineberg System for irrigating the uterine cavity
1925 Rubin CO2 for uterine distension
1926 Seymour Hysteroscope with in-flow and out-flow channels
1927 Mikulicz-Radecki and Freund Biopsy-taking capability; cornual electrocoagulation
1928 Gauss Intrauterine photography
1934 Schroeder Measurement of intrauterine pressures
1934–1943 Segond Irrigating system and biopsies
1936 Schack Identified applications
1942–1970 Norment Rubber balloon; practical irrigating system; cutting loop; fiberoptics
1953–1978 Mohri and Mohri Fiberhysteroscope for intrauterine visualization; tubaloscopy
1957 Englund et al Evaluation of abnormal uterine bleeding, comparing hysterography
and dilatation and curettage with hysteroscopy
1962 Silander Studied endometrial carcinoma using a distal silastic balloon
1968 Menken Tubal cannulation; polyvinylpyrrolidone
1970 Edstrom and Fernstrom Dextran 32%
1972 Quinones et al Tubal catheterization: applications
1974 Edstrom Therapeutic applications
1974 Parent et al Contact hysteroscopy
1978 Neuwirth Use of resectoscope
1980 Hamou Microhysteroscope
1981 Goldrath et al Laser endometrial ablation
2001 Valle et al First practical hysteroscopic sterilization method

first who tried to look into the hollow cavities of the human
body by ingeniously conducted light. During the rage of a
malignant fever which he bravely kept away from others
and from which he cured many by his art and devotion,
death took his life in his 36th year on the night of April 4th
to 5th, 1809. Himself a victor, he became defeated. His
faithful friends8 (Figure 4).
The French physician Desormeaux9 presented a model of
the first truly workable cystoscope to the French Academy
of Medicine in 1853. A central perforation allowed direct
view, and light from an alcohol and turpentine lamp traveled
through one half of the tube before it was reflected by a
concave mirror inserted in a viewing tube. The instrument
allowed the bladder to be filled with fluid and observed
through a glass window cemented to the end of the endo-
scope. It also allowed instrumentation through a lateral
canal (Figures 5 and 6).
Twelve years after the Desormeaux invention, Cruise,10
from Dublin, made some improvements to this endoscope,
replacing the alcohol and turpentine by petroleum and a
little dissolved camphor and adding a small glass chimney
to contain the vapors (Figure 7). In 1869, Pantaleoni,11 who
had spent some time in Dublin and learned from Cruise how
to use the endoscope, performed a hysteroscopic examina-
tion in a postmenopausal woman with abnormal uterine
bleeding. He then graciously acknowledged in a communi-
cation that he had found a polypoid growth in the uterus and
cauterized it with silver nitrate under hysteroscopic view.
Figure 1 Self-Portrait by Bozzini (1805). Three years earlier, he had tried to use the same endoscope
Valle Development of hysteroscopy
Figure 2 Diagram of the Light Conductor (1807).
to observe the nasal passages and treat some polyps in a
similar way. To other physicians who claimed that the same
evaluations could be done with a finger palpation of the
uterus, he cleverly responded that while this was true in an
Figure 3 Bozzini’s endoscope displayed at the American Col-
lege of Surgeons headquarters in Chicago.
409
Figure 4 Bozzini’s epitaph restored in 1954.
overdilated cervix after delivery, it was extremely difficult,
if not impossible, in an undilated cervix. Moreover, when
dilatation of the cervix was required for finger palpation, it
had to be at least twice that required for his instrument. He
added that, even granting that the finger could diagnose
abnormal lesions, it certainly could not offer direct
treatment.
Other physicians followed suit after Pantaleoni’s first
known hysteroscopic diagnosis and treatment; still, inade-
Figure 5 Desormeaux’s endoscope (1853).
410 Journal of Minimally Invasive Gynecology, Vol 14, No 4, July/August 2007
Figure 6 Diagram of Desormeaux’s endoscope. (A) Endoscope.
(B) Sagittal view showing flame and reflecting lens.
quate light transmission, bleeding inside the uterus, and the
inability to distend the organ properly slowed the develop-
ment and applications of hysteroscopy.
Following the introduction of Nitze’s cystoscope in
1879,12 in which distal illumination was provided by an
incandescent platinum loop cooled with fluid circulating
around the endoscope, cystoscopy was made practical. The
thin-walled urinary bladder could be distended by gravity
pressures and, unlike the uterus, did not bleed on contact;
hysteroscopy, however, remained cumbersome (Figures 8
and 9).
The long list of investigators who tried their hand at
similar techniques includes Blondel,13 Morris,14 Bumm,15
Duplay, Clado,16 and others.2
Figure 7 Schematic representation of Cruise’s endoscope
(1865). (A) Light reflected by a plano-convex lens. (B) Sagittal
view of the endoscope. (C) Endoscope in position for use.
Figure 8 Nitze’s early endoscope with a platinum loop for
illumination (1879).
The beginning of contact hysteroscopy
As examinations with a uterine distension medium raised
the specter of infection, a hysteroscope providing a view
from direct contact with the surface of the endometrium
would be an important advance for the observation of the
postpartum or postabortal uterus. In 1907, David17 devel-
oped the first contact hysteroscope (Figure 10).
The various modifications to David’s contact hystero-
scope brought by Palmer18 (1942), Norment19 (1947), Mar-
leschki20,21 (1966), Parent et al22 (1974), and Hamou23
(1980) added magnification and produced the microcolpo-
hysteroscope. But if the contact instrument had the advan-
tage of greater simplicity, it did not permit a complete and
accurate evaluation of the uterine cavity. Its applications
were eventually relegated to the endocervix and to specific
areas of the endometrium found suspicious for disease on
panoramic hysteroscopy. At present, it is used only to eval-
uate endometrial vascularization.
Liquid rinsing methods (original continuous-
flow systems)
It was clear that a practical method of viewing the uterine
cavity should provide a panoramic view similar to that
obtained in cystoscopy, and therefore required intrauterine
Figure 9 Nitze’s later instrument (1882).
Valle Development of hysteroscopy
Figure 10 Contact endoscope designed by David (1907).
distension. Many ingenious modifications of the early en-
doscopes were introduced to overcome cumbersome uterine
bleeding and maintain adequate uterine distension for pan-
oramic viewing. In- and out-flow channels for uterine irri-
gation were independently introduced by Heineberg24 in
1914 and Seymour25 in 1926. The endoscope used by Hei-
neberg had an internal channel for illumination and con-
tained a system of irrigation with low-viscosity fluids to
wash any blood and permit uterine distension (Figure 11).
This method was the beginning of continuous-flow hyster-
oscopy and the basis for all such methods introduced later
on.
In 1926, using a bronchoscope 6 mm in diameter fitted
with a distal arm and a suction tube, Seymour25 was able to
obtain an excellent view of the endometrial cavity—as the
suction kept it from being impaired—and to perform surgi-
cal interventions such as the removal of submucous
leiomyomas and other lesions. And by using a 9-mm bron-
choscope, he was able to pass a forceps for biopsies or
removal of tissue. Later on, he designed a smaller instru-
ment, 6 mm in diameter, which could be used for the same
purposes. Although this instrument seemed practical, it fell
into oblivion (Figure 12).
Carbon dioxide gas and low-viscosity fluids
for uterine distension
Carbon dioxide gas had been used extensively to assess
tubal patency, and Rubin was among the method’s pioneers.
In 1925, Rubin26 reported on his experience and excellent
results using CO2 to distend the uterine cavity for hyster-
oscopy. Nonetheless, the use of this gas remained rare as
most physicians preferred working with low-viscosity flu-
ids, especially German physicians. In 1927, Mikulicz-
Radecki27,28 wrote extensively about their method of irri-
gation for diagnostic and therapeutic hysteroscopy, which
he developed with his Kuretoscope, as he called his instru-
ment, with which he was able to obtain biopsies and remove
abnormal tissues. He commented about the use of hyster-
411
oscopy for electrocoagulation of the intramural portion of
the fallopian tubes as a method of sterilization.
Gauss29,30 wrote about his experience of hysteroscopy
using low-viscosity fluids and in 1928 published excellent
diagrams of normal and abnormal hysteroscopic views. He
also transmitted his enthusiasm to disciples, as Schroeder31
pursued his teaching and investigations. Schroeder noted
that intrauterine pressure varied with the height at which the
fluid container was placed; that a pressure of 25 to 30 mm
Hg was sufficient for good intrauterine visualization; and
that fluid may spill into the peritoneal cavity when the
pressure exceeded 55 mm Hg.
Although Schroeder expanded his investigations to tubal
sterilization by electrocoagulation, he availed himself of his
extensive experience of hysteroscopy to shed light on its
value in the diagnosis of intrauterine diseases. Yet while
also attempting to establish indications for hysteroscopy,
Shack32 commented in 1936 on the extreme difficulty of
obtaining adequate visualization.
Simultaneously, in France, Segond33–36 attempted to cal-
ibrate in- and out-flow to achieve adequate uterine disten-
sion and decrease the amount of fluid lost in the peritoneal
cavity. He designed an operative hysteroscope with a fluid
irrigation system and a fixed optical instrument, the first of
its kind, the one that modern instrumentation would im-
prove on for operative hysteroscopy (Figure 13). The endo-
scope’s outer diameter was 10 mm, like that of a size 10
Hegar dilator, which permitted passage of electrodes
through the tubal openings for tubal electrocoagulation.
Although the most useful feature of the hysteroscope was
the possibility of in- and out-flow, the telescope’s foreob-
lique direction permitted a better assessment of the utero-
tubal cones; and according to Douay, the discussant of a
paper by Segond, bleeding was not excessive with this
instrument and thus did not impair visualization.36
Zakrojczyk37 reported in 1937 and Palmer38 in 1957 on
their experience of Segond’s hysteroscope with an irrigation
system. They used 2 versions with different outer diameters,
an 8-mm version for diagnosis and an 11-mm version for
Figure 11 Diagram of Heineberg’s hysteroscope (bottom) with
obturator (top) (1914). A ⫽ endoscopic tube; B ⫽ irrigating
attachment (B1 ⫽ inlet; B2 ⫽ outlet); C ⫽ obturator; D ⫽ lighting
attachment.
412 Journal of Minimally Invasive Gynecology, Vol 14, No 4, July/August 2007

Figure 12 Seymour’s continuous-flow hysteroscope (1926).

operative procedures. Zakrojczyk suggested using laminaria In 1957, Norment et al described his latest invention, a
tents to obtain cervical dilatation. In 1942, Palmer18 had cutting loop to resect polyps and submucous leiomyomas.47
reported on direct visualization of the endocervical canal, He experimented for more than 18 years before he finalized
recommended routine inspection of the endocervical canal the design of this hysteroscope, which could be fitted with
during hysteroscopy, and commented on the disregard of the resecting loop when needed. Although he did not report
most hysteroscopists for the endocervical canal, as they on his experience with the loop, it is clear that he used it in
confined their observations to the uterine cavity. For contact some cases for the removal of polyps and myomas.
cervicoscopy, Palmer used an endoscope consisting of a Describing their experience with the Norment hystero-
simple glass tube, 21 cm long and 8 mm in outer diameter, scope with continuous water irrigation, Gribb49 in 1960 and
with the distal end shaped as a cone for easier introduction. Burnett50 in 1964 mentioned removing intrauterine polyps
Norment,39 – 48 from North Carolina, devoted almost 30 and leiomyomas with the resecting loop and described new
years of his professional life to the simplification and en-
applications for the hysteroscope.
hancement of hysteroscopy, reporting extensively between
1942 and 1970 on his observations and instrument modifi-
cations. First, he described the hysteroscope he used to
evaluate the cervical canal and uterine cavity. The distal end
of the instrument was fitted with a thin rubber bag that, once
in the uterine cavity, could be inflated with air or water for
intrauterine observations, thereby avoiding direct intrauter-
ine distension and, when filled with air, precluding spillage
of fluid into the peritoneal cavity. In 1947, he described
another innovation, a contact hysteroscope made of a plastic
sheath whose light was located at the open proximal end.
Rather than being reflected, the light was transmitted along
the walls of the sheath to a forward-vision optical instru-
ment located in the distal end. Nonetheless, after many
trials, Norment went back for good to the fluid system that
he had also used since 1950 (Figure 14).46 From 1956 on, he
used an instrument with an in- and out-flow similar to those
of Gauss, Schroeder, and Segond, which allowed fluid
egress for continuous flow. He also followed Schroeder’s
method of elevating the fluid container to increase fluid
pressure in the uterus as a way to distend it. Modern con-
tinuous flow for hysteroscopy and resectoscopy is based on
the continuous-flow system for low-viscosity fluids as mod-
ified by Norment.

Figure 14 Diagram of Norment’s water-irrigating hysteroscope

Figure 13 Segond’s hysteroscope (1934). in use (1950).
Valle Development of hysteroscopy
Figure 15 Silander’s hysteroscope with distal silastic balloon
(1962).
Hysteroscopy with distal balloons
The first of Norment’s pioneering ideas, attaching trans-
parent balloons to the distal end of the hysteroscope, was
reintroduced with several modifications. The rubber balloon
was replaced by a thinner, more transparent, and more
resistant plastic or silastic balloon.
Despite Norment’s work, and initial trials of this type of
hysteroscope published by Wulfsohn51 in 1958 and Bank52
in 1960, it was Silander53–55 who popularized this method
of uterine evaluation in the early 1960s. He used a hystero-
scope 7 mm in outer diameter with a saline-filled silastic
balloon attached to its distal tip, mainly to evaluate and map
endometrial carcinoma (Figure 15). While visualization was
adequate and the spilling of any distending medium in the
peritoneal cavity avoided, the balloon compressed the en-
dometrium and distorted its topography. Additionally, it
was not possible to perform biopsies and resection of tissue.
The method was used by several investigators, but while
they enthusiastically endorsed it, they recognized its limi-
tations. Lyon56 described in detail the clinical use of this
instrument in 1964, and Schmidt-Mathiesen,57 Esposito and
Accinelli,58 Leidenheimer,59 Quinones-Guerrero et al,60 and
others, including Gutenberg,61 also used the balloon method
for intrauterine evaluation into the early 1970s. The method
was abandoned when hysteroscopy with uterine distension
was re-introduced.
Introduction of fiberoptics and flexible
hysteroscopes; intrauterine visualization of
early pregnancy
T. Mohri62 describes his 25 years’ experience with en-
doscopes in a magnificent book published in 1975. Through
a process of trial and error, modifications, and adaptations,
he designed his own rigid hysteroscope based on Norment’s
endoscope for low-viscosity irrigation. He evaluated the
possibility of hysteroscopy-guided electrocoagulation of the
tubal-cornual regions as early as 1954; and pioneering the
use of movie cameras to evaluate his observations dynam-
413
ically, he paved the way for extraordinary film recordings
by Norment45,48 and Muller and Keller63,64 from the mid-
1950s to the mid-1970s.
Mohri’s main interest was the hysteroscopic observation
of embryos in early pregnancy, and in 1956 he documented
early movements in the embryonal stages by means of rigid
endoscopes. Teaming up with his wife, Chie, a photogra-
pher and embryologist, he pioneered in 1964 the use of the
flexible fiberhysteroscope to observe the fetus through the
cervix when needed in early or late pregnancy.65,66
The use of Hirschowitz’s fibroscope,67 with which the
gastroenterologist had been working since 1954, was now
extended to hysteroscopy. In 1966, Aguero et al68 reported
using a rigid 24F McCarthy’s panendoscope for early- and
late-pregnancy hysteroscopy, as an extended amnioscopy.
Later, in 1968, the fibroscope was fitted with a distal plastic
balloon to permit better extra-amniotic visualization of the
embryo or fetus without the need for a distension medium.
In 1970, Mohri et al69 published in English the results of
his intratubal observations, performed with a glassfiber en-
doscope miniaturized for tubaloscopy. The latter instrument
was a modification of the spinaloscope he had previously
designed.
Mohri published mainly in Japanese, and despite the
immense progress he had brought about in hysteroscopic
instrumentation, both rigid and flexible, his work long re-
mained practically unknown in the West. And yet his few
reports in English, as well as his frequent participation in
international meetings, secured for Mohri his rightful place
among the all-time pioneers of hysteroscopy.
Hayashi70 also developed flexible mini-endoscopes for
intratubal observation in the early 1970s, and produced
excellent films capturing the intratubal milieu and early
embryo transtubal transfer sequences.
High-viscosity fluids for uterine distension
In 1968, Menken71 published his pioneering experience
with a 4% solution of Luviskol K 90 (BASF Chemical
Company, Ludwigshafen, Germany). Compared with low-
viscosity fluids, a lesser quantity of this high-density poly-
vinylpyrrolidone (a mixture of linear polymers of different
lengths and molecular weights) was needed for uterine dis-
tension, which meant a lesser chance of peritoneal spillage
during hysteroscopy. However, because this medium is not
Figure 16 Menken’s hysteroscope for tubal cannulation
(1970).
414 Journal of Minimally Invasive Gynecology, Vol 14, No 4, July/August 2007
biodegradable and has a yellowish tinge in solution, it was
not widely adopted for hysteroscopy.
Menken designed several hysteroscopes, most of them
geared for tubal cannulation and evaluation as well as cor-
nual electrocoagulation. He was the first to propose a com-
plete evaluation of the female genital tract by endoscopy,
from the vagina through the cervix and uterus to the fallo-
pian tubes and other pelvic organs, a process that he called
colpoendocerviscopy, hysterotubaloscopy, and laparohys-
tero-tubaloscopy (Figure 16).72–74
In 1970, Edstrom and Fernstrom75 combined efforts to
evaluate another high-viscosity fluid for hysteroscopy, a
dextran with a molecular weight of 70 000. First using this
substance for hysterosalpingograms, they appreciated its
viscous consistency and crystal-clear transparency; and be-
cause only a small quantity was needed for an image, there
was a lesser chance of peritoneal spillage. Furthermore, the
high-viscosity dextran not mixing readily with blood, its use
not only enhanced visualization but also kept the uterine
cavity distended without bleeding. By then, fiberoptics tech-
nology was permitting excellent visualization without risk-
ing thermal injuries to tissues or the breakage of distal light
bulbs—problems that had occurred with the previous meth-
ods of illumination. The results that Edstrom and Fernstrom
obtained were highly satisfactory, and their original report
established the routine use of high-viscosity dextrans for
hysteroscopy.75,76 Thus, a truly practical method already at
hand enhanced diagnostic hysteroscopy; and because it per-
mitted a visualization of the uterine cavity as clear as if the
uterus had been extirpated and opened, the method was
adopted for operative hysteroscopy.77–79
Clinical reviews
At first, most investigators focused on instrumentation
and techniques, and Norment, Mohri, and Palmer were
among the very few who published clinical studies on their
uses of hysteroscopy. Similarly, few general reviews were
published with detailed clinical histories besides those by
Ahumada and Herrera80 in 1935 and Hamani and Durand81
in 1936.
The study most firmly establishing the advisability of
performing a hysteroscopic evaluation before dilatation and
curettage for abnormal uterine bleeding may be that pub-
lished in 1957 by Englund, Ingelman-Sundberg, and Wes-
tin.82 The authors reported on women who had a hystero-
scopic or a hysterographic evaluation before undergoing the
procedure. The hysteroscopic diagnosis proved to be correct
in 101 (93%) of 109 cases analyzed, and hysteroscopy
proved to be diagnostically superior to hysterography.
Moreover, the uterine cavity was satisfactorily emptied in
only 44 (35%) of 124 women followed up after being
treated by curettage by experienced gynecologists. In the 80
other women, large portions of polyps, submucous myomas,
and endometrium remained. Hysteroscopy was performed
after a second curettage in 46 of these women, and the result
of the operation was still unsatisfactory in 5 of them.
Reintroduction of carbon dioxide gas as a
medium for uterine distension
In 1971, Lindemann83 reported that the virtual cavity of
the uterus could be safely converted into an actual cavity by
insufflating 40 to 100 mL of CO2 per minute at a pressure
as low as 200 mm Hg. Because of the clear view and
high-quality pictures of the uterine cavity that this gas
permitted, and its cleanness of use compared with the then-
cumbersome low- and high-viscosity fluids, Lindemann
proposed this method of distending the uterus as the best for
hysteroscopy.84 – 86
At the same time, but separately, Porto87,88 was using
CO2 to insufflate the uterus during hysteroscopy, and he
published excellent-quality pictures of normal and abnormal
uteri.89,90 It seemed that, finally, the best distending medium
for diagnostic hysteroscopy had been found and would be
adopted by most hysteroscopists. Nonetheless, Porto made
beginners aware that excessive delivery of gas, and too high
a pressure exerted in the uterus, had resulted in several
fatalities, and he called for further developments in the
control of gas flow and intrauterine pressure.89,90 The in-
dustry took on the challenge of manufacturing electronically
calibrated insufflators, which today are routinely used for
the intrauterine delivery of this gas.
Low-viscosity fluids for uterine distension:
modern use
In those times of transition, while investigators were
struggling to decide whether to use high-viscosity fluids or
carbon dioxide gas for uterine distension, others were opting
for a return to low-viscosity fluids. In their 1972 publica-
tions of the results of their investigations regarding tubal
sterilization by electrocoagulation of the cornual regions of
the fallopian tubes, Quinones-Guerrero and collabora-
tors91,92 reported delivering to the uterus a 5% water solu-
tion of dextrose and modernizing with special tourniquets
and pumps Norment’s method of increasing intrauterine
pressures.46,49 That same year, Sugimoto93,94 reported opt-
ing for low-viscosity fluids, particularly a normal saline
solution, and combining gravity pressures with positive
pressures provided by a 3-way connection and an attached
syringe to increase intrauterine distension selectively.
Still, the problem remained of obtaining a continuous-
irrigation system that permitted a clear view while avoiding
excessive vascular intravasation of the fluid used. The fluid
could mix easily with blood and cloud the view, and many
physicians pointed out the difficulty of performing intra-
uterine washings to improve visualization. Different inno-
vations were brought about, including those by Quinones-
Valle Development of hysteroscopy
Guerrero and collaborators91,92 and Valle,95 in which
polyethylene catheters were used as siphons to convert the
original unidirectional hysteroscopes into continuous flow
systems.
With the demand for minimally invasive operative ap-
proaches in the 1980s, physicians began to use hysteroscopy
to treat a variety of intrauterine diseases. However, some
lacked familiarity with the interaction of electrolytes and the
handling of fluids. Infusing the uterine cavity sufficiently to
obtain uterine distention could lead to problems such as
excessive fluid absorption, particularly when procedures
were lengthy and required significant intrauterine dissec-
tion. To understand why complications, particularly those
caused by fluid overload, accompanied or not by hypona-
tremia, were occurring, physicians had to review the anat-
omy, physiology, and pathology of the uterus. As physi-
cians educated themselves, and learned all the details on
which to focus, problems became less severe, and the num-
ber of occurrences dwindled.
The resistance of the uterine vasculature should not be
overcome by the pressure of the infused intrauterine fluid.
Fluid under pressure can easily find its way into the vascular
system when fluid overload is allowed. To prevent this
occurrence, new equipment was introduced. Electronic
pumps were specially designed to calibrate the inflow rate
and pressure exerted in the uterine cavity, and the anesthe-
siologists’ monitoring systems were improved for early de-
tection of fluid overload. More important, most of these
pump systems weighed the difference between input and
output fluid in real time so as to give early warning of
impending fluid overload. To further ensure the safe perfor-
mance of operative hysteroscopic procedures, and prevent
most of the complications of fluid intravasation, the need to
limit procedure duration was emphasized.
Paying utmost attention to detail during the procedure,
controlling the intrauterine pressure of the fluids used, min-
imizing the endometrial/myometrial vascular damage, and
limiting the operative time are major safety factors. None-
theless, to avoid complications, common sense and sound
medical judgment remain paramount.96 A meticulous tech-
nique, genuine indications, and a lack of contraindications
may not absolutely prevent surgical complications, but they
will certainly limit their occurrence.
Contact hysteroscopy: modern use
In 1974, when many physicians were ambivalent about
which method was best for hysteroscopy, Parent and col-
laborators22 reported on a new method that would revive
intrauterine examination by contact of the endoscope with
the tissue surface. They modified in different ways the
techniques proposed by David17 and Marleschki,20,21 as
external light was now delivered by means of a glass rod
encased in a metallic sheath, and the endoscopes were
manufactured with outer diameters of 4-, 6-, or 8 mm to
415
serve various needs. In theory, hysteroscopic examination
seemed simple and straightforward with this instrument; in
practice, it was soon realized that segmental examination
may not be as complete and accurate as that provided by
panoramic hysteroscopy, when the uterus is distended. Be-
sides, no intrauterine interventions were possible, and the
method would have to remain diagnostic only.
Thus contact hysteroscopy lost its appeal as the tech-
niques of panoramic hysteroscopy were perfected, and it
became relegated to the evaluation of the endocervical canal
as an extension to the colposcopic examination. Even with
the introduction of new small-caliber hysteroscopes, contact
hysteroscopy seemed to be less practical and effective.
Contact hysteroscopy was revived once more, however,
with the introduction of Hamou’s microcolpohysteroscope
in 1980.23,97 This instrument permitted both contact and
panoramic hysteroscopy, and in the contact mode was ca-
pable of magnifying images up to 150 times. Panoramic
hysteroscopy revealed areas of the endometrium that re-
quired further examination; and after the uterus was de-
flated, contact hysteroscopy provided images of the selected
areas magnified 80- or 150 times, all with the same instru-
ment. At present, although this method is used for investi-
gation of endometrial vascularization or vascularization of
lesions suspicious for malignancy, it is not used routinely
for intrauterine evaluation.
Later innovations
In 1978, Neuwirth98 reported on the use of a urologic
resectoscope fitted with a cutting loop electrode for the
removal of submucous leiomyomas. Although the original
resectoscope lacked continuous flow, its ability to morcel-
late greatly facilitated the work. The resectoscope was pro-
vided with a round configuration, and the continuous-flow
system proposed for urology by Iglesias and collaborators99
was adapted for gynecology, with superb results as the
viewing clarity made cleansing the field much easier.
In 1981, Goldrath et al100 reported on the use of the
neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with
a bare fiber to perform endometrial ablation in patients with
abnormal uterine bleeding unresponsive to hormonal treat-
ment. This approach seemed excellent, particularly in
women at high risk for major surgery, including hysterec-
tomy. It was, however, just a matter of time until electro-
surgery replaced laser surgery for endometrial ablation. The
U.S. Food and Drug Administration (FDA) approved the
Nd:YAG laser for that purpose in 1986101 and the resecto-
scope for gynecologic procedures in 1989.
Fostered throughout the 1980s by the new approaches to
hysteroscopy, innovation in instrumentation brought forth:
(1) continuous-flow systems for operative and diagnostic
hysteroscopes; (2) vaporizing bipolar electrodes; and (3) the
miniaturization of instruments for office use.
Meanwhile, video systems improved remarkably, if not
by month certainly by year, and became necessary in any
416 Journal of Minimally Invasive Gynecology, Vol 14, No 4, July/August 2007
therapeutic or diagnostic hysteroscopic procedure as 3-chip
cameras with high-sensitivity light units were replacing
single-chip cameras. Similarly, flexible hysteroscopes were
greatly improved and used for diagnostic and therapeu-
tic procedures, including interventions in early preg-
nancy.102–105
While hysteroscopic tubal sterilization began to be tested
in the 1920s and generated some interest in the 1950s, it was
not until the early 1970s that the initiation of major clinical
trials triggered enthusiasm for this approach. Electrocoagu-
lation with thin electrodes placed in the intramural portion
of the fallopian tubes and injection of chemicals in the tubal
luminal area were then tested for permanent tubal occlusion.
However, when the trial results were analyzed, it became
evident that tubal occlusion was not consistently achieved.
Moreover, serious complications, such as thermal injury to
the fallopian tubes and other adjacent organs, particularly
the bowel, had occurred because of the difficulty in control-
ling the electrical energy applied to the area. Therefore, in
the late 1970s, these clinical trials were terminated.
Mechanical tubal plugs, which were also tested, did not
provide more consistent tubal occlusion, as their rate of
expulsion was significant, even after more than 1 attempt.
Thus, the concept of tubal hysteroscopic sterilization
seemed to be abandoned.
But an innovation, the Essure Permanent Birth Control
System (Conceptus, San Carlos, CA), was successfully
tested in clinical trials in the early 2000s. With this method
of hysteroscopic tubal sterilization, retention of the intra-
tubal microinserts and subsequent permanent tubal occlu-
sion consistently occur, and the procedure can be performed
in the physician’s office.106 For these clinical and practical
reasons, enthusiasm for the Essure System is growing rap-
idly worldwide.
After many years of attempts and trials, hysteroscopic
tubal sterilization came to fruition in 2002 with the FDA
approval of the Essure intratubal insert. The device, which
consists of inert metallic coils encasing a mesh of polyeth-
ylene terephthalate fibers, is deployed hysteroscopically
into the intramural portion of the fallopian tube.107,108 Tis-
sue growth among the fibers assures complete tubal occlu-
sion in about 3 months.
Continuous-flow hysteroscopes
Established and newly formed companies competing for
markets began to design continuous-flow instruments. Dif-
ferent systems appeared that finally made the use of low-
viscosity fluids practical in hysteroscopy, both diagnostic
and therapeutic. And as managed care and cost-containment
policies were driving many procedures from the operating
room to the office, industrial competition adapted the con-
tinuous-flow systems to small-caliber endoscopes, 4 to 6
mm in outer diameter, thereby greatly facilitating office
procedures. Additionally, with improvements in optics, par-
ticularly in fused-fiber bundle systems, mini-endoscopes 2
to 3 mm in outer diameter, with or without continuous flow,
made their appearance on the market.
As continuous-flow systems began to replace unidirec-
tional hysteroscopes, electronic fluid pumps were intro-
duced for delivery of fluid and assessment of both flow and
intrauterine pressure. These modifications also prompted
the industry to continually improve the design of micromor-
cellators and other new ancillary instruments, and to perfect
electrodes—particularly vaporizing electrodes to be used
with monopolar or, especially, bipolar energy. At the same
time, new methods of delivering electrolytic fluids while
using electrical energy were introduced to decrease the
chances of hyponatremia, a problem that may occur when
fluids devoid of electrolytes are used during monopolar
electrosurgery. This multifaceted, extraordinary progress
stimulated more and more physicians to adopt therapeutic
hysteroscopy.
Linking to the future
What is now the present was a distant future at the
beginning of hysteroscopy, and the future soon will be the
present as we go on building on the foundations and pillars
our predecessors have laid or erected. The future looks to
further simplification of instrumentation and a safer and
easier delivery of energy sources, be it for laser surgery,
electrosurgery, or cryosurgery. The appearance of micro-
morcellators providing adequate uterine distension, and per-
mitting the collection of good specimens for histopathologic
evaluation under a panoramic view as good as that offered
by today’s resectoscopes, will enhance therapeutic hyster-
oscopy. Various ancillary instruments and electrodes will be
added to those already in use. The number of operative
procedures performed in an office setting will increase as
technological simplification increases safety and accuracy
and expedites performance. In turn, this trend will increase
the use of diagnostic and operative hysteroscopy.
Additionally, with the major improvements in sono-
graphic resolution and accuracy, particularly those brought
about by fluid enhancement, hysteroscopy and sonography
have become complementary modalities in the evaluation of
the uterus and uterine cavity in women with abnormal
uterine bleeding, especially menopausal women.
Conclusion
Hysteroscopy is rich with more than 200 years of accu-
mulated patient observations, and of accumulated inven-
tions and instrument modifications geared at overcoming
problems pertaining to intrauterine visualization and disten-
sion. As we review the history of hysteroscopy, it is with
humble reverence that we pay tribute to our forerunners
who patiently attempted to resolve these problems; who, in
Valle Development of hysteroscopy
a long gestation, gave us the safe tools and simple tech-
niques that we use today. Learning from history, we will
continue to observe and improve to better serve our patients
as we keep pursuing our original goal, which we have not
yet reached.
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