Does hysteroscopy improves the outcome of fertility treatments in infertile couples? A systematic review and meta-analysis.

Clinical Pearls:

• Women with no intrauterine pathology should not be offered routine hysteroscopy as a part of basic work up for infertile couples when they have not undergone IVF/ICSI.
• It does not increase the live birth rate(LBR) in these patients.

Globally Hysteroscopy is considered a very important diagnostic modality to evaluate the inside of the uterine cavity. Congenital and acquired uterine abnormalities are responsible for infertility in 10-15% of couple seeking treatment.[1]

Due to improvement in endoscopic armament and technique, it can be safely and reliably performed as an office procedure and diagnoses many intrauterine lesions precisely that have been missed earlier by HSG and transvaginal ultrasound.   Because of the diagnostic accuracy, many researchers advocate it to be the first procedure performed to know the integrity of the uterine cavity while other advice it use only as a complimentary procedure next to HSG and sonography.[2]

A review of literature shows many small observational and few RCTs designed to evaluate the efficacy of hysteroscopy in improving the reproductive outcome in infertile couples. A recent systematic review and meta-analysis published in the current issue of ESHRE journal Human Reproduction Update aims to assess the efficacy of diagnostic and operative hysteroscopy in improving the outcome of fertility treatment at any stage of workup. [3]

After the literature search, all the studies till June 2014 were included in the analysis.  It comprises of RCTs in which women underwent hysteroscopy prior to IVF/ICSI or failed IVF/ICSI with no earlier known cause of uterine abnormality. Also women with known intrauterine pathology comparing operative versus diagnostic hysteroscopy were included.

The primary outcome studied was live birth rate while secondary outcomes were pregnancy rate, miscarriage rate and procedure-related complications. 

Out of 588 studies retrieved nine studies were included, totaling to 2976 participants. Studies included consisted of diverse population of women with one or more failed IVF/ICSI cycles, or just infertile women for treatment, women waiting for the first IVF/ICSI procedure or women with fibroid or endometrial polyps.

The results showed that compared to no hysteroscopy prior to any ART procedure, there was very low quality evidence that it increased LBR (1088 women) and moderate quality evidence showed that it increased the chances of pregnancy. When studies related to operative hysteroscopy for fibroids and polyps were analyzed in relation to pregnancy rate, the evidence was very poor that it contributed to an increase.

To conclude, women with no intrauterine pathology should not be offered routine hysteroscopy as a part of basic work up for infertile couples.  More evidence in the form of high qualities RCTs are still needed to offer hysteroscopy as front line procedure in couples under treatment for infertility. This is especially true for those couples who are not planned to undergo any ART procedure.  

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[1] Brown SE, Coddington CC, Schnorr J, Toner JP, Gibbons W, Oehninger S. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography and hysterosalpingography in infertile women: a prospective, randomized study. Fertil Steril. 2000; 74: 1029– 1034

[2] http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00231-2/abstract

[3] http://humupd.oxfordjournals.org/content/22/4/479.abstract