TREATMENT

Hysteroscopic Surgery in Uterine Cavity for Infertility Patients

When some patients did not have successful treatments even though their embryo chromosomes have been examined to be normal, or there were no obvious problems after an evaluation, we can assume that this group of patients may have embryo implantation problem. Usually, the patients will be recommended to be examined for possible causes in uterine cavity whether they have any symptoms or not. In general, the symptoms that can cause pathology of uterine cavity are abnormal heavy menstrual bleeding, irregular menstrual cycle, or menstrual pain.

Nowadays, the well-known examination for pathology of uterine cavity is Hysteroscopy, which can be used for diagnosis and also for treatments.

Generally, there are two types of the method.

1.  Diagnostic Hysteroscopy

It is a minor surgery that can be done at outpatient department. A small hysteroscope with the size around 2.9 – 4 millimeters will be inserted inside uterine cavity to perform pathology examination. These are the types of uterine cavity that usually can be found:

- Normal endometrium is a normal uterine cavity with no fibroid or polyps that might be an obstacle for embryo implantation. The surface is smooth with the size shown in picture 1.

Picture 1 demonstrates a normal uterine cavity from performing diagnostic hysteroscopy.

- Endometrial polyp is uterine polyp that is commonly found in abnormal uterine cavity, and might have no symptoms. With the small size, the polyp could come out with menstrual bleeding, and it is noncancerous. After a treatment, it could occur again.  However, endometrial polyp surgery needs to be dome because it can interfere with embryo implantation as shown in picture 2. 

Picture 2 demonstrates endometrial polyp inside uterine cavity.

- Submucous myoma is a fibroid that usually can be found in reproductive age women. The one that develops in uterine cavity can interfere with pregnancy. As shown in picture 3, this can create no symptoms at all or can cause excessive heavy menstrual bleeding, and it will lead to anemia.  This kind of fibroid mostly will not be cancerous, but need to be removed before pregnancy.

Picture 3 demonstrates fibroid that grows inside uterine cavity.

- Septate uterus is a deformity that happens before birth. The inner portion of the uterine cavity was divided by a wall of tissue, and the embryo cannot be implanted, or there is a high risk for having miscarriage later.  This could be treated with a surgery to remove the wall of tissue inside uterine cavity as shown in picture 4.

Picture 4 demonstrates the surgery to remove a wall of tissue inside uterine cavity.

- Uterine synechiae is a condition that usually happens after having dilatation and curettage or after having severe infection in uterine cavity that can cause adhesion. Therefore, a surgery needs to be done to remove the adhesion before pregnancy. 

Picture 5 demonstrates adhesion band inside uterine cavity.

2.  Hysteroscopic surgery 

The procedure is done in surgery room. Usually, the size of hysteroscope will be bigger than the one used during diagnosis, and the cervix needs to be enlarged before inserting the camera.  These are additional tools such as electric loops, small scissors, and morcellator to help remove polyps, fibroids, adhesions or a wall of tissue inside uterine cavity. So, the patient may be given medication to help her relax and to block the pain during the surgery. 

The appropriate time to schedule for diagnostic hysteroscopy and the surgery is after menstrual period until before ovulation. During the time, uterine cavity is not thick and not swollen from ovulation’s discharge, so we can clearly see the pathology. 

Preparation for uterine cavity hysteroscopy

1.  Diagnostic Hysteroscopy

This procedure can be done at outpatient department (OPD), and anesthesia is not required. So, the patient does not have to prepare many things in particular. However, the procedure should not be performed right after having a meal to avoid vomiting during the hysteroscopy. So, the patient should avoid having food 2 – 3 hours before the procedure.  Make sure to use toilet and may also take some pain killer medicines an hour before the procedure. 

2.  Hysteroscopic surgery 

- Refrain from eating and drinking 6-8 hours before the surgery.

- Medicine will be inserted into vagina 6-8 hours before the surgery. This is necessary because it will open the cervix and help with the process to be smoother. However, there might be some side effects such as having a low grade fever, stomach pain, or having blood show from vagina due to the medicine that causes contraction. These symptoms will be gone after the surgery.

Post-surgery Instructions

1.  Complete the course of antibiotics.

2.  Avoid having sexual intercourse, swimming and heavy exercise for the first 2 weeks after the surgery.

3.  Eat healthy meals. There is no specific restriction. 

4.  There might be some blood from vagina within the first week after the surgery but it should not have any smell.  Stomach cramps that are similar to menstrual cramps might occur, but they are not harmful.  Should there be any serious symptoms, please contact your doctor. 

By Doctor Warawun Lupthalug