The role of diagnostic hysteroscopy in infertility is still debated today. Despite the growing literature demonstrating that treatment of adhesions, submucosal fibroids and uterine septa improve pregnancy rates, managing dysfunctional or inflammatory disorders remains doubtful. As mentor of young laparoscopists, I was surprised that the first objective of apprentices is the diagnosis of structural and functional abnormalities such as endometrial polyps and fibroids. However, experience shows that often these conditions are absent, while other images, such as congestion or endometrial hypertrophy, are present.
What is the real significance of these findings in infertility? We analyzed two groups of couples whom underwent diagnostic hysteroscopy before or after the first cycle of in vitro fertilization (IVF) and showed (ESGE, 2012) that pregnancy rates are doubled if the findings of endometritis were treated (and therefore diagnosed) before the first IVF cycle. How was the diagnosis made? Simply through images of suspected hysteroscopic endometritis, since microbiology or endometrial biopsy are often inconclusive and show low diagnostic sensitivity.
Moreover, there is still a high number of reproduction units that do not perform diagnostic hysterocopy before the first IVF cycle, but who diagnose “endometrial normal” after a “normal endometrium” apparent after ultrasound study, hysterosalpingogram, saline infusion or sonohysterography. Elaborating on the issue of treatment of infertility, a recent Cochrane (Cochrane Database Review, 2013) demonstrated that the findings on
the treatment of endometrial polyps are not possible given the diversity of imaging and medical decisions on which it is based. Obviously, endometrial hypertrophy is the result of hyperestrogenism and creates an unfavorable environment on which an embryo should be implanted. If the focal hypertrophy create futures polyps, why should we treat focal endometrial growths, but not widespread growths?
There is a need for randomized control trials. However, if the diagnostic techniques are not homogeneous, the results will not be. Therefore, while we diagnose polypoid endometrium, will be resected without the use of energy before an IVF cycle.