Review
Sejal Dharia-Patel, M.D.

The objective of this study was to assess the prevalence of intrauterine pathology after two failed cycles of in vitro fertilization and the outcome after surgical correction. This was accomplished in two arms: the first, a prospective observation arm that assessed the presence of intrauterine pathology by hysteroscopy after two failed cycles of IVF in the presence of one good quality embryo, and the second, a matched case-control study that compared pregnancy rates in those that had an operative hysteroscopy as compared with those who did not.

A total of 1475 patients were enrolled in the first arm and 414 patients in the control arm. Patients were matched for age, type of stimulation type of IVF, and a similar number of embryos transferred. All patients had a hysterosalpingogram prior to the first IVF attempt. All hysteroscopies were performed by the same operator with both diagnostic and therapeutic hysteroscopy performed as indicated.

In the first arm of 1475 patients, 935 (63.4%) had a normal hysteroscopy finding and 540 (36.6%) had an abnormal finding. The abnormal findings included endometrial polyps (16.7%), endometrial adhesions (12.5%), endocervical adhesions (1.5%), endometritis (4.3%), uterine septa (0.9%) and submucous myomas (0.8%). In the matched trial, no significant differences were noted between the two groups concerning age, duration of infertility, causative factor of infertility, number of transferred embryos and number of ET where the embryos were grade 2. 

Clinical pregnancy rates were significantly increased in the subgroup of women with abnormal hysteroscopic findings. More specifically, there was a greater increase in pregnancy rates after correction of uterine septa. 

The findings support the role for hysteroscopy in patients with repeated failed IVF cycles.

Comments 
Daniel B. Williams, M.D.

This study supports hysteroscopy as the “gold standard” for evaluation of the uterine cavity, particularly in patients who are undergoing IVF. It also supports other studies suggesting that hysterosalpingography is less sensitive than both saline-infused sonohystography (as other studies might suggest) and hysteroscopy for the identification of intrauterine pathology.

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