Efficacy of Hysteroscopy in Improving Fertility Outcomes in Assisted Reproductive Techniques

INTRODUCTION

In the multifaceted field of fertility interventions, emphasis has historically been placed on the embryo as the central determinant of success in assisted reproductive technologies (ART). Nonetheless, achieving successful implantation and ongoing pregnancy depends on a triad of interdependent factors: the embryo, the uterine cavity, and the endometrium. Even a morphologically high-quality embryo may fail to implant or may result in early pregnancy loss if the uterine milieu is compromised by conditions such as uterine fibroids or chronic endometritis.^[1] This review examines the role of hysteroscopy, used in conjunction with other diagnostic modalities, in enhancing fertility outcomes among patients undergoing ART.

THE TRIAD OF FERTILITY: EMBRYO, UTERINE CAVITY, AND ENDOMETRIUM

In the multifaceted realm of fertility treatment, the embryo has historically been regarded as the primary determinant of success in ART. However, successful implantation and ongoing pregnancy hinge on three closely interdependent factors: the embryo, the uterine cavity, and the endometrium. Even a morphologically high-quality embryo may fail to implant or may result in early pregnancy loss if the uterine milieu is compromised by pathological conditions such as fibroids or chronic endometritis.^[1,2]

A distorted uterine cavity whether due to structural anomalies like fibroids [Figure 1] or an endometrium affected by chronic inflammation [Figure 2] can markedly reduce implantation rates and adversely influence pregnancy outcomes. In this context, hysteroscopy, in conjunction with advanced imaging modalities, provides a comprehensive diagnostic and therapeutic strategy. By directly visualising and, when necessary, correcting intrauterine abnormalities, this combined approach aims to enhance fertility outcomes for patients undergoing ART.

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Figure 1:

Big fibroid inside the cavity.

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Figure 2:

Micropolyps on the endometrium showing chronic endometritis.

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COMPLEMENTARY ROLE OF IMAGING TECHNIQUES

HYSTEROSCOPY: THE BRIDGE BETWEEN DIAGNOSIS AND TREATMENT

Hysteroscopy provides a unique, integrated approach to the evaluation and management of uterine pathologies by enabling direct visualisation of the endometrial cavity and simultaneous therapeutic intervention.^[3] This real-time ‘see and treat’ capability can streamline patient care, potentially reducing both the time to diagnosis and the need for multiple procedures.

IMPROVING ART OUTCOMES THROUGH HYSTEROSCOPY

A growing body of evidence underscores the value of hysteroscopy in optimising ART outcomes, particularly by identifying and managing intrauterine pathologies:

1. Live Birth Rate (LBR)

   Moderate-quality evidence indicates that performing hysteroscopy before initiating ART or after an unsuccessful cycle is associated with a higher LBR (RR 1.24, 95% CI: 1.09–1.43).^{[2, 3]}

2. Clinical Pregnancy Rate (CPR)

   Hysteroscopic evaluation and treatment have been linked to increased CPR (RR 1.36, 95% CI: 1.18–1.57), suggesting improvements in endometrial receptivity and embryo implantation.^[3]

3. Implantation Failure

   Among patients with a history of implantation failure, hysteroscopy significantly enhances reproductive outcomes (RR 1.40, 95% CI: 1.12–1.74 for CPR).^[3]

4. Treating Intrauterine Pathologies

   Although based on low-quality data, operative hysteroscopy for removing or correcting pathologies such as polyps or fibroids has demonstrated an increase in CPR (RR 2.13, 95% CI: 1.56–2.92).^[2,3]

Collectively, these findings highlight the critical role of hysteroscopy in ART. By identifying and remedying intrauterine abnormalities that may otherwise impair embryo implantation, hysteroscopy can improve pregnancy rates, enhance LBRs, and reduce the incidence of repeated implantation failure.

SYNERGY OF HYSTEROSCOPY AND 3D USG

The integration of hysteroscopy with 3D USG affords a comprehensive assessment of the uterine cavity:

1. Diagnostic Accuracy

   3D Transvaginal Ultrasound: Demonstrates high specificity (99.21%) but comparatively lower sensitivity (88.46%) when detecting uterine abnormalities, as measured against hysteroscopy.^[1]

2. Complementary Strengths

   3D USG: Offers superior measurement of uterine cavity dimensions and contour.

   Hysteroscopy: Allows direct visualisation and concurrent treatment of intrauterine lesions.^[1,2]

CONCLUSION

Hysteroscopy, in conjunction with 3D USG and other diagnostic modalities, plays a pivotal role in optimising fertility outcomes for patients undergoing ART. By combining both diagnostic precision and therapeutic capability, hysteroscopy bridges the gap between imaging findings and active management, with the potential to enhance perinatal outcomes.

The synergy of hysteroscopic evaluation and ultrasound-based imaging supports a more holistic approach to fertility, addressing the three principal factors required for successful implantation and pregnancy: the embryo, the uterine cavity, and the endometrium. As research continues to evolve, the integration of hysteroscopy into standard fertility evaluations may gain even greater clinical relevance.

Current evidence endorses the judicious use of hysteroscopy, particularly in cases of recurrent implantation failure or before ART in women with suspected uterine anomalies. Nonetheless, additional high-quality randomised controlled trials are necessary to delineate the exact role of routine hysteroscopic evaluation in diverse patient populations and to further clarify its utility in initial fertility assessments.

This is an invited article to the author, on the topic presented in the Indian Fertility Society Conference.