Tuesday, April 20, 2010

Do you need a hysteroscopy before doing IVF ?

In order for an IVF treatment cycle to succeed, the embryos need a healthy uterus in which they can implant. There are many tests to evaluate the uterine cavity and the endometrial lining. These include noninvasive tests such as ultrasound scans ( including 3-d vaginal ultrasound scans) and a HSG ( hysterosalpingogram); and invasive tests such as hysteroscopy. The most accurate method for evaluating the uterine cavity is a hysteroscopy, because it allows the doctor to actually look inside the uterus . However, because it involves a surgical procedure, it is expensive; and while this is a reason why many doctors what to do this, many patients are not keen on getting it done !

It's quite interesting to analyse the attitude of IVF clinics towards hysteroscopy. Some doctors will routinely perform a hysteroscopy for every patient prior to doing an IVF cycle. They consider this to be a part of their basic pre-IVF evaluation, along with the semen analysis and the testing for ovarian function.

Others will perform a hysteroscopy only selectively. Both these options have pros and cons, so let's look at these.

Doctors who routinely perform a hysteroscopy justify this by saying that it allows them to pick up ( and correct) problems which would otherwise be missed by other techniques such as ultrasound scanning , because these noninvasive tests are not as reliable or sensitive as a hysteroscopy. They remember all the patients in whom they identified a small polyp or adhesion prior to doing the IVF - a finding which was missed on the HSG or the ultrasound scan. They feel that if patients are going to spend so much money on an IVF, it makes sense to make them spend a little bit more, if this will improve their chances of having a baby. They feel a hysteroscopy is a simple , office-based procedure which can be done very easily; and that even if it is normal, it can still be justified, because it can provide additional reassurance to the patient that her uterus is normal. The big ( often unstated) benefit for doctors is that it is a great additional source of revenue.

So why don't all IVF doctors do hysteroscopy routinely prior to doing IVF ? Many doctors are quite conservative and feel that it is not justified to make the patient spend money on invasive procedures - especially if this information can be obtained less expensively and easily by non-invasive tests. It is possible that the hysteroscopy can pick up abnormalities which are missed by the ultrasound, but is it justified to subject hundreds of patients to a procedure in order to pick up a problem in only a few of them ? And is identifying these minor abnormalities of any clinical use ? Does correcting them actually improve IVF pregnancy rates ?

This is a vexed issue; and there is still no consensus on what the right approach is.

In fact, IVF doctors often find themselves in a bind. If you make patients do lots of tests, then patients feel that you are greedy and are making them waste their time and money on medical testing . On the other hand, if you do not do the test, then patients feel you are sloppy and your workup is incomplete and shoddy !

We try to take a balanced approach in our clinic. For the three critically important tests prior to IVF - semen analysis; blood tests for ovarian function ( FSH,LH,PRL,TSH,AMH); and the ultrasound scan, we will insist that patients do these from labs we can trust, as our entire treatment depends upon these results. These tests are easy to perform and inexpensive.

However, for expensive and invasive tests, we will take conservative attitude ; and do these ( or repeat them) only if our simple screening tests suggest there is a problem.

I have learned that there is no "one size fits all" solution. We try to tailor our approach to each patient and try to factor in the patient's preference when making these decisions. Thus, for patients who are fed up of tests, we will try to minimise these. However, for patients who have failed multiple IVF cycles or who demand a "complete checkup ", we will be more liberal with ordering tests. We do not have a rigid policy and try to involve the patient in these important decisions, so the patient is well-informed about the pros and cons of both approaches !
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  1. Anonymous5:01 PM

    Dear Dr Aniruddha:
    Thank you for your suggestion. I am a 33 yr chinese lady. I failed twice in IVF,and my doctor suggest me to have a hysteroscopy before the 3rd one and I hesidated this afternoon. I wish I saw your article earlier.
    I will take that check. thank you.
    best regards.

  2. Anonymous12:12 AM

    I've done a hysteroscopy over a year ago before my first IVF. I had my baby and now I'm ready for a frozen embryo transfer. My RE is INSISTING I pay $600 for ANOTHER hysteroscopy even though I am perfectly fertile, my first hysteroscopy was totally fine and our only problems are male factor. I am frustrated beyond belief and feel my doctor is greedy.

  3. Anonymous2:26 AM

    Thank you Dr Malpani, your information is very helpful. I became pregnant on my third IVF following a hysteroscopy and immune therapy. I am now returning for a frozen embryro transfer and it has been suggested that I have another hysteroscopy at £1200 tomorrow? I don't feel it's needed but then again, don't want to regret not doing it if it doesn't work.

    Cindy, London (treatment at ARGC)

  4. Anonymous1:42 PM

    Hi bros pls where did u go for the hysteroscopy pls can u give the address ? Is it in london

  5. Excellent text and excellent blog altogether. Thank you for writing it, I wish I had found it earlier.
    I am struggling with this question myself. I am a 43 year old woman, I have undergone two inseminations and wondering about IVF. My hormonal levels are all normal, my AMH is 2,44; I have an ovarian cyst (endometrial), and now a doctor whose second opinion I inadvertantly got (because my own was absent so I was seen by another one) is saying how I shouldn't even bother pursuing treating infertility until this endometrioma is not treated, because levels of CA 125 is 24, and CA 19-9 is 48 (other markers were also done, like CEA, He4, RomaIndex, Ca 15-3 and are all normal). The thing is I have known about this cyst for 3 years now, and the doctors suggested at the time that due to my age I should not treat it before giving birth, but rather I should pursue pregnancy which would also minimize it. And now, at 43, she is saying the opposite. That in my age the rates of conception are nil and even smaller with endometriosis. And before seeing her, I was wondering if I should do hysteroscopy as well, because I have two submucous myomas which do not deform uterine cavity. Now I don't know what to do. What would you suggest?

    1. I would NOT advise you to have surgery for the cyst. Unnecessary surgery reduces your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

      Intramural fibroids ( in the wall of the uterus) do not need to be removed as they do not affect embryo implantation.
      You can read more about this at www.drmalpani.com/knowledge-center/articles/fibroids-and-infertility

      Only submucous fibroids ( which are in the uterine cavity) need to be removed. These can be best removed with an
      operative hysteroscopy ( www.drmalpani.com/knowledge-center/articles/hysteroscopy) to normalise the uterine cavity.

      I agree that IVF (www.drmalpani.com/our-services/ivf)
      would be your best treatment option
      as it would maximise your chances of conceiving quickly.

      Time is now at a premium for you - please don't waste it ! You should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment.
      We look forward to helping you to have a baby !

  6. Anonymous5:17 PM

    Hello from Greece!

    I admire your way of thinking . Just thought to ask for your advice. I am 34 years old,have been pregnant 5 times (in chronological order: 2 biochemical pregnancies, 2 ectopic-lost both tubes, 1 missed miscarriage on 11 weeks after my first IVF with fresh blastocysts.I am a poor responder, so i havent taken ivf meds, i had been on natural cycles)
    I had a D&C on 10th December. Now i am on my first period cycle, have done an ultrasound and everything is OK. My IVF DOCTOR told me to proceed to Frozen EMbryo Tranfer as i have two frozen blastocysts. I said no, as i am not psychologically ready yet. My question is:
    1. What is your opinion about the right time of a FET for my case?
    2. Is it necessary to have an hysteroscopy before the FET?

    Thank you for your reply.


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