Hysteroscopy: the most cost-effective test, yet the one most often overlooked

Diagnostic hysteroscopy involves inserting a thin optical probe through the cervix to look directly inside the uterus. It takes a few minutes, is usually carried out in the doctor’s surgery without anaesthesia, and reveals what no ultrasound scan can show with certainty.

What it reveals

• Endometrial polyps, which are present in a significant proportion of women undergoing infertility assessment. Removing them improves pregnancy rates, even in the case of small polyps.
• Uterine septa, congenital abnormalities associated with miscarriages. Removing them is straightforward.
• Synechiae, intra-uterine adhesions often resulting from a curettage or an infection.
• Submucosal fibroids, which distort the uterine cavity and hinder implantation, unlike fibroids located outside the muscle.
• Chronic endometritis, the most interesting finding of recent years.

Chronic endometritis

This is a persistent and subtle inflammation of the endometrium, without fever, pain or abnormal discharge. It therefore goes completely unnoticed. On hysteroscopy, it presents as micropolyps, oedema of the mucosa and a dotted redness. The diagnosis is confirmed by an endometrial biopsy to detect plasma cells, which are marked by the CD138 antibody.

It is found in a high proportion of patients with recurrent implantation failure or recurrent miscarriages — published series report figures ranging from 15 to over 40 per cent, depending on the criteria. Treatment consists of an oral antibiotic, most commonly doxycycline for two to three weeks, followed by a histological review. Several studies report a marked improvement in implantation rates following recovery, although the level of evidence remains moderate and high-quality randomised trials are still lacking.

My takeaway in practice: this is a simple test and an inexpensive, well-tolerated treatment for a common, asymptomatic abnormality. After several failed attempts, it would be a shame not to have investigated this. The article on recurrent pregnancy loss puts this point into the context of the full assessment.

When to request it

Routinely after two failed transfers of good-quality embryos, after two miscarriages, before a transfer using donor eggs — because it would be absurd to transfer an embryo from a young donor into an unexplored uterine cavity — and in the event of any abnormality or uncertainty identified on ultrasound. Many Greek clinics request this before the first transfer, which is good practice.

How is it carried out

The ideal time is in the first half of the cycle, after your period and before ovulation, when the endometrium is thin. The examination takes three to ten minutes. Without anaesthesia, it causes cramps similar to painful periods; taking a painkiller an hour beforehand helps. For women who have never given birth or in cases of a difficult cervix, light anaesthesia may be offered. Light bleeding for one or two days is normal, and sexual intercourse is possible after a few days.

If an abnormality is found, it is sometimes treated at the same time — this is known as operative hysteroscopy, usually carried out under anaesthesia in the operating theatre. In this case, you should allow one to two cycles before resuming fertility treatment.

Where to have it

In France, the procedure is covered by the French health insurance system and is carried out by most gynaecologists with the necessary equipment, with a waiting time of a few weeks. This is one of the tests I recommend having done in your home country rather than whilst abroad: the report and images are sufficient for the overseas clinic, and this avoids the need for an additional stay. The full list of tests to prepare for covers this point.

Frequently asked questions

Source: https://fertilitegrece.com/en/blog/hysteroscopy-chronic-endometritis/ — Triada Baloukoudis, IVF patient coordination in Greece. General information, not medical or legal advice. Printed on