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Clinical Relevance of Diagnostic Hysteroscopy with Concurrent Endometrial Biopsy in the Accurate Assessment of Intrauterine Alterations

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Clinical Relevance of Diagnostic Hysteroscopy with Concurrent Endometrial Biopsy in the Accurate Assessment of Intrauterine Alterations Arch Gynecol Obstet DOI 10.1007/s00404-015-3634-0 GENERAL GYNECOLOGY Clinical relevance of diagnostic hysteroscopy with concurrent endometrial biopsy in the accurate assessment of intrauterine alterations Joji Ueno • Renato M. Salgado • Renato B. Tomioka • Juliana A. Colucci • Eduardo Schor • Filomena M. Carvalho Received: 5 November 2014 / Accepted: 22 January 2015 Ó Springer-Verlag Berlin Heidelberg 2015 Abstract Conclusions Our results show that diagnostic hysteros- Purpose The aim of this retrospective observational study copy demonstrated intrauterine alterations in half of was to evaluate the reliability of diagnostic hysteroscopy, infertile patients; histopathological endometrial alterations routinely performed along with endometrial biopsy, by suggest high rate of false-negative outcomes. Therefore, analyzing and comparing both hysteroscopic and histopa- diagnostic hysteroscopy and concurrent endometrial biopsy thological outcomes in asymptomatic infertile patients, should be used as complementary diagnostic and thera- previously to their IVF cycle. peutic approach, especially for patients with previous IVF Methods The study included 84 consecutive infertile failures. patients who underwent diagnostic hysteroscopy followed by endometrial biopsy. Four-micrometer sections were Keywords Hysteroscopy Á Endometrial biopsy Á Uterine stained with hematoxylin and eosin and examined micro- alterations Á Infertility Á In vitro fertilization scopically. The data evaluated the frequency and charac- teristics of endometrial abnormalities found in the biopsies of patients with normal hysteroscopy outcome. Descriptive Introduction data are presented as percentages, and the sensitivity, specificity, positive predictive value (PPV) and negative Infertility is a disease defined by the American Society for predictive value (NPV) of hysteroscopy for diagnosis of Reproductive Medicine as the failure to achieve a suc- endometrial alterations were calculated on the basis of cessful pregnancy after 12 months or more of regular pathologic reports. unprotected intercourse [1]. There are numerous etiologic Results The hysteroscopy evaluation showed 50.0 % of factors that contribute to female infertility, such as endo- patients with a normal uterine cavity, 40.5 % with endo- metriosis, polycystic ovarian syndrome, ovarian failure, metrial polyps, 6.0 % with endometrial hyperemia, and uterine abnormalities, and around 10 % of patients present 3.5 % with other endometrial abnormalities. Among the 42 idiopathic infertility. patients with a normal uterine cavity at hysteroscopic Unsuspected intrauterine abnormalities have been examination, 60.0 % also had a normal biopsy outcome, recorded to be up to 45 % of gynecological diagnoses, but in other 40.0 % of patients at least one histopatholo- which may play an important role in subfertility, implan- gical abnormal aspect was diagnosed at biopsy. The sen- tation failure or miscarriage [2–5]. Transvaginal ultraso- sitivity (67.3 %), specificity (80.6 %), PPV (85.4 %) and nography can be used to diagnose some endometrial NPV (59.5 %) of diagnostic hysteroscopy were calculated abnormalities; however, it has been proven to present on the basis of histopathological findings. certain drawbacks, and the best method of diagnosis is hysteroscopy. Hysteroscopy enables the direct visualiza- tion of the cervical canal and uterine cavity, and allows a & J. Ueno ( ) Á R. M. Salgado Á R. B. Tomioka Á more accurate assessment of intrauterine alterations, such J. A. Colucci Á E. Schor Á F. M. Carvalho GERA-Institute of Reproductive Medicine, Sao Paulo, SP, Brazil as endometrial polyps and hyperplasia, intrauterine syn- e-mail: [email protected] echiae and septum, myoma and endometritis [6, 7]. 123 Arch Gynecol Obstet Interestingly, it has been reported that it is possible to hysteroscopy-guided endometrial biopsies, previous to the remove endometrial polyps by hysteroscopy, using the IVF cycle [16–18]. In fact, a recent retrospective study mini-resectoscope, in an office setting [8]. demonstrated that chronic endometritis is frequently found Even though office hysteroscopy as a first-line investi- in routine office hysteroscopy and suggests the procedure is gation in all subfertile women is not a consensus in the efficient in assessing or ruling out endometrial factor for literature, in patients with recurrent implantation failure, female infertility [19]. However, for the diagnosis of endo- with at least two failed IVF attempts, a simple diagnostic or metritis and endometrial hyperplasia, the validity of hys- operative hysteroscopy previous to a subsequent IVF teroscopy may be limited, and the biopsy of the endometrium treatment is known to improve positive pregnancy results is considered to be the gold standard procedure [17, 20]. [5, 7]. On the other hand, hysteroscopy has been increas- The hysteroscopy examination has been used as part of ingly recommended in the first-line infertility investigation, the infertility investigation in order to assess endometrium as it offers great assistance for the interpretation of previous to IVF cycle. Nevertheless, the literature needs to uncertain findings from other diagnostic methods and be enriched of studies around the agreement in diagnosing allows a directed biopsy and therapeutic intervention for benign intrauterine abnormalities by hysteroscopy and correction of most of these abnormalities [4, 6]. concurrent endometrial biopsies. Therefore, the aim of this In a previous work, the authors analyzed 2,500 diag- retrospective observational study was to evaluate the reli- nostic hysteroscopies performed in infertile patients prior ability of diagnostic hysteroscopy, routinely performed to IVF, and demonstrated endometrial pathology at hys- along with endometrial biopsy, by analyzing and compar- teroscopy from 22.9 % of patients [9]. These findings ing the hysteroscopic with the concurrent histopathological suggest a significant percentage of patients that may have outcomes in asymptomatic infertile patients, previously to impaired IVF success, due to lack of a proper diagnosis and their IVF cycle. infertility assessment. Interestingly, the most prevalent intrauterine alteration was endometrial polyps. A meta-analysis study evaluated the impact of diag- Materials and methods nostic hysteroscopy on the outcome of subsequent IVF cycle of 1,691 participants. Although the quality of these This is a retrospective descriptive study conducted at Gera studies was considerably variable, the results showed Reproductive Medicine Institute, a private assisted repro- strong evidence of the benefits of hysteroscopy in duction and education center in Sao Paulo, Brazil. Insti- improving pregnancy rates in the subsequent IVF cycle tutional review board approval was not required, as all of [10]. Later, the same group published another systematic the procedures are routinely performed, and a written review and meta-analysis (n = 901 participants), evi- informed consent was previously obtained from all dencing a statistically significant augment in clinical patients, in which they agreed to share the data of the pregnancy rates after local endometrial injury [11]. How- procedures for research purposes. In the informed consent, ever, more robust randomized trials are necessary to a detailed explanation of all the procedures involved was strengthen the benefits of hysteroscopy and endometrial given, thus all patients were able to understand the scope of biopsy in women undergoing assisted reproduction tech- the study in which they were participating [21]. niques. A recent clinical trial conducted a randomized controlled study in which the intervention group was sub- Patients mitted to two consecutive endometrial biopsies, one in the follicular phase and another in the luteal phase of the cycle All patients were undergoing infertility investigation, con- preceding the embryo transfer cycle. They showed a sig- sisting of medical history, physical examination, hormone nificant increase in implantation, clinical pregnancy and status, transvaginal ultrasonography, hysterosalpingography live birth rates, when comparing to the control group (no for tubal evaluation, hysteroscopy and endometrial biopsy. intervention) [12]. The data was collected in a period of 24 months. The study Concerning endometrial alterations, a randomized trial included 84 consecutive patients who underwent diagnostic [13] evidenced higher pregnancy rates after polypectomy in hysteroscopy and endometrial biopsy at the proliferative women undergoing intrauterine insemination compared with phase (days 7–12 of the menstrual cycle). Patients with those who had routine hysteroscopy and biopsy without hysteroscopy on secretory phase ware not included. treatment or surgery. Other retrospective studies, however, did not observe benefits of polypectomy of small polyps in Hysteroscopy procedures patients undergoing IVF cycles [14, 15]. Another common intrauterine abnormality is chronic endometritis, which is All of the hysteroscopy procedures were performed by the diagnosed in up to 45 % of patients undergoing clinical director in an ambulatory setting without 123 Arch Gynecol Obstet anesthesia, using the standard 30° forward-oblique lens and Results a 2.9-mm single-channel sheath with a 300-W light source (Storz). Saline solution was used for distention of the At the anamnesis, patients were scheduled for routine uterine cavity. All of the procedures were performed diagnostic hysteroscopy and concurrent endometrial between days 7 and 12 of the menstrual
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