Materials and Methods: This study was conducted at the In Vitro Fertilization (IVF) Unit of Firat University Hospital, between March 2010- January 2012. The 219 patients with no OH within the previous 6 months were enrolled the study with rigid hysteroscope (continous flow; 30-degree forward-oblique view) assembled in a 4-mm diameter diagnostic sheath with an atraumatic tip. After OH investigation, endometrial sampling was performed with biopsy catheter. The patients in whom the findings were normal proceeded to an IVF cycle within 1 month.

Results: The procedure was succesful in 219 patients, with mean (±SD) age of 31.9 (±5.2) years, duration of infertility of 6.2 (±4.5) years and number of previous ART trials 1.6 (±1.1). The type of infertility were as follows: 150 primary (68.5%) and 69 secondary infertility (31.5%). Endometrial polyp and uterine subseptum were the major intracavitary abnormalities. Chronic endometritis and endometrial polyp were the major histopathologic abnormalities. Chronic endometritis, uterine subseptum and endometrial hyperplasia were higher in patients ≥35 years (p<0.01). There was a decrease in the pregnancy rate (40% vs 46%), implantation rate (51% vs 56%) and fertilization rate (69% vs 74%) in the patients with hysteroscopic abnormality compared to patients without abnormality respectively.

Conclusion: To improve the outcome of ART cycles, OH could be performed as a routine procedure for the patients who will experience IVF treatment.

Hysteroscopy is feasible in an office setting, that employs thinner instruments and saline solution infusion distension, becoming minimally invasive and effective in the detection of intra-uterine pathologies¹². In this study we reported our results about the uterine cavity pathologies that were detected during pre-IVF evaluation.

Endometrial polyps were defined as smooth margined masses with a homogeneous texture of variable size and shape, bulging from the endometrium. Submucosal myomas were defined as solid, round structures protruding into the uterine cavity, covered by intact epithelium. Endocavitary polyps and submucosal myomas were distinguished, their location, number and size were noted. Septum or subseptum resection, polypectomy and adhesiolysis were performed with operative hysteroscopy. Only endometrial polyps which were extirped during OH were not exceeded to operative intervention. Endometrial injury was performed after office or operative hysteroscopy with biopsy catheter. The collected endometrial samplings were analysed by histopathologic evaluation.

Data were analyzed using SPSS Version 12.0 (SPSS, Chicago, IL, USA). Results were reported as mean ± standard deviation. Ki- square statistics were used to compare discontinuous data and student's t-test were used to compare continuous data. A p value of <0.05 was considered as statistically significant.

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Table 1: Characteristics of all patients in the study

The frequency of office and operative hysteroscopy findings were presented in Table 2. The major OH findings were endometrial polyp and uterine subseptum. After histopathologic evaluation, the major abnormality was chronic endometritis and than endometrial polyp was reported. Among 219 women, 31 intrauterine abnormality was observed and 15 operative intervention was performed. In the ROC analysis to determine the possibility of OH abnormality according to age, the area under curve was 0.73 and the highest LR+ value was 6,02 in the point of 35 years. The comparison of histopathologic abnormalities according to cut off value of 35 years revealed out increament in the percentage of chronic endometritis and endometrial hyperplasia over 35 years (p=0.002). And also endometrial polyp, uterine septum/ subseptum and intrauterine adhesion were significantly high in the women over 35 years (p=0.035).

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Table 2: Office H/S findings and histopathologic evaluation of all women in the study

During IVF procedure, 19 women did not experience embryo transfer. Among 200 women, 92 women came pegnant and the comparison of OH abnormalities between pregnant and nonpregnant women revealed no significant difference (Table 3). Although the differences were not significant, the pregnancy rate (46.9 % vs 40%), implantation rate (56% vs 51%) and fertilization rate (74% vs 69%) of women without OH abnormality were higher than that women with OH abnormality.

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Table 3: Comparison of H/S results according to IVF outcome

In particular, a very high incidence of chronic endometritis and endometrial polyp were observed in our study, but the real influence of these pathologies on the outcome of infertility and IVF techniques is still a matter of debate^8,15,16. An investigator reported endometrial polyps in 41% of 82 infertile patients with no dysfunctional uterine bleeding¹⁷. In an another study, endometrial polyps were detected in 46.7% infertile patients with endometriosis and in 15% infertile controls¹⁸. The higher incidence of uterine septum/subseptum among infertile patients, which has already been reported by other authors seems to be confirmed in our study population, too^19,20. However, no clear evidence showing potential impairment of reproduction because of this pathology has been reported^21-23.

OH is applicable at any time of the menstrual cycle¹. However, endometrial polyps are best visualized during the follicular phase, and submucosal myomas during the secretory phase with SH³. Suboptimal timing during the menstrual cycle may give false results by SH. This limitations makes the SH second choice in infertility practice. There is little risk for intracavitary infection during fluid instillation of procedure²⁴. This could be excluded with antibiotherapy before (patients with signs of infection)/after the procedure. We concurrently performed endometrial sampling for histopathologic evaluation. This procedure was a kind of endometrial injury and it was suggested that endometrial injury before ART cycle improves the outcome by the way of increased endometrial receptivity^25-29. In this study we did not have the ability of comparing the effect of endometrial injury on IVF outcome because of the absence of control group and heterogenous IVF population. For our study population, comparison of the incidence of intracavitary pathologies between women according to becaming pregnant, revealed out no significant difference. On the other hand when the pregnancy rate compared according to the presence of intracavitary pathology, the pregnancy rate was high in the absence of intrauterine pathology.

Flushing of malignant cells from the uterine cavity to the peritoneal cavity during hysteroscopy and SH may also happen³⁰. However, the slower and low-pressure infusion of saline should be expected to carry a lower risk of cell transportation. Moreover, this risk does not appear to be greater than that involved in HSG.

In conclusion, we suggested that OH is an easy, fast, well tolerated evaluation procedure before the ART cycles to improve the IVF outcome.

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