Friday, May 30, 2014

Why hysteroscopy before IVF is not a good idea

Lots of IVF clinics routinely do a hysteroscopy prior to doing IVF . They justify this because they say it's important to have a normal uterine cavity in which to transfer the embryos, and that a hysteroscopy is the best technique available to ensure that the cavity is normal.  They claim that this is a simple procedure, which involves doing minimally invasive surgery , and if by doing this they can increase the chances of pregnancy for even one patient by picking up a problem which would otherwise have been missed, they are justified in doing so.

I do not agree. I think doing a hysteroscopy routinely prior to IVF is practicing mindless medicine – and while cookbook medicine can be profitable for large clinics, it’s rarely in the patient’s best interests.

I agree it’s good for the doctor. Doctors like doing procedures , because they get paid for doing them ! The question is – is it worthwhile from the patient's perspective ?

The truth is that if a vaginal ultrasound scan shows that the endometrium is trilaminar, thick and normal, the chances of finding anything abnormal on the hysteroscopy are extremely low . If the doctor wants to be doubly sure, he can do a sonohysterogram to visualize the uterine cavity even more clearly.

The point is that if we can get the information we need by doing a simple, cheap and noninvasive test, then how are we justified in doing a surgical procedure ? ( The word minimally invasive is a clever oxymoron invested by a smart surgeon – it’s a bit like saying some one is a “little pregnant” ! For the doctor, this might be a minor procedure, but for the patient, every medical procedure is “major”.)

Tests should be tailored to meet the needs of individual patients , and hysteroscopy should be reserved for patients where the ultrasound scan is abnormal or difficult to interpret.

The irony is that if the hysteroscopy result is normal ( as it usually is !), then instead of feeling bad that he subjected the patient to an unnecessary surgical intervention, the doctor is very pleased because he can now tell the patient – your hysteroscopy was normal, which means your chances of getting pregnant are very good ! The poor patient does not even realize that she was subjected to unnecessary surgery !

It’s true that a hysteroscopy can be useful prior to IVF, but it should be used selectively . Thus. when the ultrasound scan result suggests there is an abnormality, a hysteroscopy allows us to confirm the diagnosis , and treat it as well.

The danger of routine hysteroscopy is that doctors have “itchy fingers”. When they insert the telescope inside the uterine cavity, they will often “find” problems ( of no clinical importance, because they are just normal variants) , which then they will “ treat” . This has the benefit that it allows them to charge even more. The downside is that doctors will then do a “metroplasty” or treat a “ subseptate uterus”, but this kind of unnecessary surgery can reduce the patient’s fertility , by causing scarring and adhesions.

If your doctor advises you to do a hysteroscopy prior to doing IVF, you should push back and ask – How will this change my IVF treatment plan  ? and is it possible to get this information by doing a noninvasive test ? Unless patients take the initiative and invest in Information Therapy to protect themselves, we will continue to see lots of unnecessary hysteroscopies being performed.

Worried that your doctor is doing too many tests routinely before your IVF cycle ? Please send me your medical details by filling in the form at so I can guide you sensibly!

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