Recently, Dr Makrakis published in the American ‘Journal of Minimally Invasive Gynecology’ a study with a remarkably large population sample including women with a history of two consecutive implantation failures after IVF who had a hysteroscopy, and they evaluated the hysteroscopic findings as well as the effect of the procedure on subsequent pregnancy rates. The vast majority of hysteroscopies were performed with the vaginoscopic ‘no-touch’ approach, which allows the insertion of a hysteroscope with working channel (for insertion and use of operative instrumentation) as well as with input/output fluid channels (for evaluation of the amount of distention fluid in order to be safe for the patient), without using dilators, not even a speculum, thus ensuring a really minimally invasive technique. The study included almost 1500 women (the largest sample from a single investigator/surgeon); in 36.6% of them abnormal hysteroscopic findings were noted (endometrial polyps in the 16.7%, endometrial adhesions in the 12.5%, endometritis in the 4.3%, endocervical adhesions in the 1.5%, uterine septa in the 0.9%, and submucous myomas in the 0.8% of the study population). In 22.2% of the study population the abnormal hysteroscopic finding was also unsuspected on previous ultrasound scan. Comparison of the outcomes in the new (after the hysteroscopy) IVF cycle revealed that subjects with abnormal and treated hysteroscopic findings had significantly increased clinical pregnancy rates compared to those with normal findings. Among the subjects with abnormal hysteroscopic findings, clinical as well as ongoing (beyond the 1st trimester) pregnancy rates were significantly higher in cases of corrected uterine septa compared to cases with any other kind of corrected abnormality. In the same study, patients having a hysteroscopy were matched to controls with similar characteristics and IVF history (two implantation failures) that did not have a hysteroscopy; clinical as well as ongoing pregnancies were significantly increased in the new IVF cycle of subjects who had a hysteroscopy regardless the finding or not of pathology. The application of appropriate statistical analysis proved that hysteroscopy (with or without abnormal findings) significantly increases the chances of achieving a clinical (odds ratio: 0.71, 95%CI: 0.55-0.92, P=0.009), as well as an ongoing (odds ratio: 0.75, 95%CI: 0.57-0.99, P=0.04) pregnancy in women with IVF failures. The conclusion was that women with two implantation failures after IVF demonstrated a remarkably high possibility for unsuspected abnormalities on hysteroscopy and that hysteroscopy could serve as a positive prognostic factor for achieving a subsequent pregnancy.
After the publication of the previous study, Dr Makrakis was invited by the Editorial Board of the Journal ‘Current Opinion in Obstetrics and Gynecology’ to perform a literature review on ‘The outcomes of hysteroscopy in women with implantation failures after in vitro fertilization: findings and effect on subsequent pregnancy rates’. Information from three review publications indicates that the incidence of abnormal hysteroscopic findings in women with repeated implantation failures (RIF) varies between 25% and 50%, whereas by pooling data from randomized studies, hysteroscopy significantly increases the clinical pregnancy rate (CPR) on the subsequent IVF cycle (pooled RR=1.57, 95%CI: 1.29-1.92, P<0.00001). Two recent clinical articles reported that the incidence of abnormal hysteroscopic findings in RIF patients was approximately 37%; the one study reported no differences in CPR between RIF patients with abnormal versus normal hysteroscopy; the second study reported significantly increased CPR in RIF patients with abnormal/treated hysteroscopic findings compared to those with a normal hysteroscopy, as well as in RIF patients having a hysteroscopy compared to controls not having the procedure. Dr Makrakis concluded that There is accumulated evidence that hysteroscopy is beneficial for women experiencing implantation failures after IVF. Uterine cavity abnormalities, mostly unsuspected on previous ultrasound scan, are identified in a remarkable proportion (25%-50%) of such women. The correction of these abnormalities improves pregnancy rates, at least when compared to RIF controls not having a hysteroscopy. There is also evidence that subsequent pregnancy rates are improved even in RIF women with normal hysteroscopy compared to controls, and that just the application of the procedure has a positive prognostic value for achieving a subsequent pregnancy. Consequently, it seems reasonable that hysteroscopy should be recommended for women with RIF. Whether a similar beneficial effect applies for women who are going for their first IVF attempt needs to be further investigated.