The significance of hysteroscopy screening prior to assisted reproduction

Abstract

In the Netherlands, yearly 7000 couples rely on IVF or intracytoplasmic sperm injection (ICSI) treatment as a tool to enhance their chances for a live birth. Despite the numerous advances in the field of IVF/ICSI, there still exists a maximum implantation rate per embryo transferred of about 30%. Implantation failure could be due to the embryo, the uterine environment or a combination of both. Since hysteroscopy has become easy to perform in an outpatient setting, it is increasingly recommended to implement routine hysteroscopy screening prior to a first IVF/ICSI. However, high quality evidence for this recommendation is absent. The aim of this thesis was to assess the true value of routine hysteroscopy in IVF/ICSI indicated patients, who are not suspected of intrauterine pathology. Focus was on the prevalence of intrauterine pathology, the observer agreement in evaluation of the uterine cavity, the endometrial biopsy and the cost-effectiveness of screening hysteroscopy. At the University Medical Center Utrecht (UMCU) and the Academic Hospital at the Dutch-speaking Brussels Free University (AZVUB) a group of 678 consecutive, unselected patients, indicated for IVF/ICSI and allocated for a randomized trial, underwent office hysteroscopy. Only asymptomatic patients, aged ≤42 years, with normal TVS findings and no previous hysteroscopy were included. The observed prevalence of intrauterine abnormalities at hysteroscopy in our patient population was 11%, which is lower than reported in similar previous reported articles (20-45%). Next to differences in the investigated patient populations, one of the explanations for this discrepancy could be the unsatisfying interobserver agreement on evaluation of the uterine cavity. Perfect agreement occurred in 77.6% of the cases. The interobserver agreement on the appearance of any of the predefined intrauterine abnormalities was moderate (kappa = 0.491). Also, the value of the hysteroscopy guided endometrial biopsy to diagnose chronic endometritis was assessed. The histopathology examination of the endometrial biopsy for diagnosing chronic endometritis was found to be reproducible between two pathologists. The prevalence of chronic endometritis was low, 2.8%. Moreover, the live birth rate did not significantly differ between patients with or without chronic endometritis, 76% versus 54% (P-value: 0.11). Also, the cumulative live birth rate per embryo transfer was not significantly different (Hazard Ratio 1.456, 95% CI: 0.770 - 2.750, P-value: 0.2). Therefore, the hysteroscopy guided endometrial biopsy did not seem to be useful as a routine procedure. Finally, the cost-effectiveness of two distinct strategies (hysteroscopy after 2 failed IVF cycles and routine hysteroscopy prior to IVF) was compared to the reference strategy (no hysteroscopy). In general, based on data obtained from the current literature, screening hysteroscopy seemed to be a cost effective procedure. Thus, during a screening hysteroscopy prior to IVF/ICSI only a small amount of intrauterine abnormalities are detected, nevertheless, it might be a cost-effective procedure. Future research to the true prevalence of intrauterine abnormalities at hysteroscopy, the precise increase in pregnancy rate after hysteroscopy and the aetiology behind the positive effect of a hysteroscopy must be performed before routine hysteroscopy should be implemented in the daily clinical infertility practic