Is pre-ivf hysteroscopy necessary?

Screening and diagnostic modalities are important in all fields of clinical medicine, and assistive reproductive therapy is no exception. In the female patient with a suspected fertility issue, the uterine cavity and endometrial lining can be evaluated by several means, such as noninvasive imaging examinations like transvaginal ultrasonography and hysterosalpingography. A hysteroscopy is an invasive test, but is the most accurate evaluative method available for visualizing the uterine cavity. Hysteroscopy allows the doctor to look directly inside the uterus, but it involves a surgical procedure. It is no surprise, therefore, that the examination is expensive, and patients are usually reluctant to subject themselves to such an invasive and costly examination.

In the Philippines, IVF clinics have a variety of philosophies towards invasive measures such as hysteroscopy. In some centers, hysteroscopy is a standard procedure for all patients prior to starting 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.

Some doctors routinely perform hysteroscopy, based on the ability to detect and correct certain problems that would otherwise be missed by less-invasive techniques such as ultrasound. Such noninvasive tests are not as reliable, sensitive or specific as hysteroscopy. Since IVF is expensive, and patients who seek this therapy are already committed to spending money on the full treatment, it makes sense for the patients to spend a little bit more, especially if it would improve their chances of a successful pregnancy. For many doctors who embrace this philosophy, hysteroscopy is a simple procedure that can be done very easily. If findings are determined to be normal, it justifies the additional reassurance to the patient of a normal uterus. Hysteroscopy allows doctors to defer cases that would not be successful before they even start an IVF cycle, and their success rates can remain higher than if dubious cases were included.

Other clinics will selectively perform a hysteroscopy based on certain criteria. Many doctors tend to be conservative, and cannot justify making a patient spend money on invasive procedures if this information can be obtained at less cost and with non-invasive procedures. Although hysteroscopy can detect abnormalities unseen by the ultrasound, it may not be justified to subject all patients to the procedure in order to pick up a problem in only a few of them. Also, identifying minor abnormalities may not be clinically useful, and may not be relevant in improving pregnancy rates for patients seeking IVF.

For many centers dealing with infertility in the Philippines, the three critically important tests prior to IVF are semen analysis; blood tests for ovarian function (FSH, LH, PRL, TSH, AMH); and the ultrasound scan. The entire treatment can be based upon these results, and can suggest whether an invasive technique such as hysteroscopy is really necessary. These tests are easy to perform and inexpensive.