Effectiveness of Hysteroscopic Surgery for Intrauterine Lesions on Pregnancy Rates in Patients with Primary infertility

DISCUSSION

All women in reproductive age suffered from primary infertility for at least 1 year. The mean period of follow-up was 15.51±8.2 months. The median time required to get pregnant was 8.59 ±3.4 months. They underwent operative hysteroscopy for resection of submucous myoma, polypectomy or resection of intrauterine septum. All operations were done during the mid-follicular phase of the menstrual cycle.

While hysteroscopy has a high diagnostic performance, distinguishing the uterine septum from the uterus bicornis and the saddle-shaped uterus might be challenging, resulting in misdiagnosis. The combination of hysteroscopy and laparoscopy, as the gold standard for uterine septum diagnosis, increased the diagnostic accuracy of the uterine septum to 100%.⁹

For about two years in this study, we advocated the use of operative hysteroscopic septoplasty, polypectomy and myomectomy for uterine septum, polyps and fibroids respectively in patients with primary infertility prior to any infertility treatment in general and assisted reproductive therapy as well, we compared the treatment results of each pathology treated to those of other pathologies in the whole group. The data in our study suggest that hysteroscopic septoplasty, polypectomy, and myomectomy, for accessible uterine lesions in patients with primary infertility are beneficial prior to infertility treatment in general and IVF/ET as well. In addition, based on the outcomes of full term, preterm and live birth rates and mean gestational age in pregnancy, again, it appears that the surgery is of benefit with respect obstetric outcome.

In a study done by Ghahiry et al.¹⁰ Before hysteroscopic myomectomy, the most common complaint was AUB, which was treated in more than half of the cases.

In current study the reproductive outcome in all participants was as follows: fifty-four women out of 100 (54%) achieved pregnancy. Of those, 51 women (94.5%) had singleton pregnancies while 3 women (5.5%) had twin pregnancies. Of the 54 patients who achieved pregnancy, 14 patients (26%) aborted, 32 patients (59%) continued to term pregnancy and 8 patients (14%) had preterm delivery.

85% of pregnancies occurred within the first year of follow-up, with an average period from surgery to conception of 8.5 months. Others have seen a similar little delay in conception. ¹¹ As a result, it is highly advised that people try to conceive as soon as possible following the treatment.

Several studies have shown that hysteroscopic procedures on endometrial polyps, intrauterine septum, and/or uterine myoma enhance conception rates. After hysteroscopic myomectomy, septum resection, and polypectomy, 24 percent of women got pregnant, according to Szymaski et al.¹².

Sanders¹³ found a pregnancy prevalence of 47 percent in prior infertile patients and a greater pregnancy rate following hysteroscopy polypectomy (78 percent) compared to 42 percent in infertile patients with normal endometrial cavities in a literature evaluation of published case series.

Because the presence of eumenorrhea chronic functioning endometrial polyps, even if small, is likely to hinder fertility, Shokeir et al.¹⁴ indicated that diagnostic hysteroscopy should be utilised frequently in the workup of infertile women. Pérez-medina et al.⁶ and Spiewankiewicz et al.¹⁵ found that 65 percent and 80 percent of patients having surgery were conceived, respectively.

According to type of pathology in the study, after hysteroscopic metroplasty which had been done for 22 patients with intrauterine septum 12 patients had gestation  (54.5%), of which 2 had abortions and 10 had term gestation  (83%). Among the 20 patients with uterine myoma for whom hysteroscopic myomectomy done, 10 patients (50%) achieved pregnancy, 6 had live births while abortion occurred in 4 patients. Best results had been achieved in the 21 women with intrauterine polyps as 24 (57.1%) achieved pregnancy of which 20 patients (47.6%) had live births. The gestation  rate in patients with diagnosed polyps concomitant with myoma was (50%) 8 patients out of 16 after polypectomy and myomectomy, 4 of them (25%) had term pregnancy.

The findings of this research are comparable to those of Ghahiry et al.¹⁰, who found that 13 patients (65%) had pregnancy following hysteroscopic metroplasty, 4 experienced abortion, and 9 had term pregnancy (45 percent ). After myomectomy, 25% of women became pregnant (4 out of 16 patients). And 62% of patients with abnormal uterine bleeding were improved.

In current study after hysteroscopic metroplasty for uterine septum 12 patients of 22 achieved pregnancy (54.5%), 2/22 had abortion and 10/22 had term delivery (45.5%). While 12 patients of 22 (54.5%) improved completely from associated symptoms (AUB, dysmenorrhea and/or hypomenorrhea). These results, regarding pregnancy rate, are similar to those of a research done by Wang et al. ⁹ in which pregnancy rate was (58%) (18 of 31 patients) underwent hysteroscopic resection of uterine septum), live births rate in the same study was (55%).

In a study done to evaluate the reproductive outcome after hysteroscopic septoplasty through analysis of medical records of 28 women with a history of infertility underwent hysteroscopic resection for uterine septum, which was performed in those patients, After hysteroscopic metroplasty for uterine septum, 64% of women get pregnant, yielding a rate of live births more than 48%; and 19% of patients had spontaneous abortions.¹⁶ Although these results are near that of current study, but miscarriage rate was higher in that study than that of current study.

In Our study we followed 36 primary infertile women with submucous uterine fibroids, twenty of the women who had hysteroscopic myomectomy had a single fibroid discovered intra-operatively, 15 of type 0 and 5 type one and the remaining 16 were found to have both fibroids and polyps. 18 of the 36 women (50%) achieved pregnancies; 10 of these women had live births while 8 patients aborted.

Although vaginal birth is possible after hysteroscopic myomectomy, and uterine rupture has never been documented, obstetric treatment should be very cautious. 17 All women with full-term pregnancies who were delivered via caesarean section were included in our study.

The existence of extra infertility issues has a negative impact on postoperative reproductive outcomes. In their retrospective study, Fernandes et al.¹⁶ found that when the myoma was the sole obvious cause, the pregnancy rate was 41.6 percent, compared to 26.3 percent with one factor and 6.3 percent with two or more additional causes. The inclusion of additional infertility factors might explain the poor pregnancy rate found in our series in the present prospective investigation (50 percent ).

Endometrial polyps ranging in size from 0.5 to 3 cm were found in 42 of the women in our research. Twenty-six of the patients had multiple polyps (16 patients had two polyps, 6 had three polyps and 4 patients had more than three polyps). During hysteroscopy, all polyps were removed.

In our research, polypectomy provided the greatest obstetrical outcome, proving that tiny intrauterine lesions like polyps that cause implantation failure had superior outcomes following polypectomy.^18,19

In our study, the majority of patients with polyp pathology and irregular uterine hemorrhage were treated after hysteroscopy polypectomy; similarly, endometrial polyp is the most common hysteroscopic finding in patients with abnormal uterine hemorrhage who respond well to this treatment, as mentioned in Lasmar's research.²⁰

As regards reproductive outcome 24 women out of 42 got pregnant, of those women 20 gave live birth (47.6%) this is similar to a study where the pregnancy rate after hysteroscopic polypectomy was about 70%.¹⁰

Ayas et al.²¹ reported in a research done on 83 patients with infertility who underwent hysteroscopic polypectomy pregnancy rate (60.9%) which was near the results which have been achieved in current study.

CONCLUSION

The data revealed that operational hysteroscopy for uterine septa resection, myomectomy, and polypectomy improves the chances of clinical pregnancy in primary infertile women, however the evidence is not definitive at this time. As a consequence, it is proposed that operational hysteroscopy is a safe and effective surgery for women with intrauterine lesions and a history of infertility, resulting in a greater conception rate.