Abstract

PIP: Hysteroscopy has been recommended as a procedure to replace hysterosalpingography (HSG), but the 2 procedures should be considered complementary rather than competing techniques. HSG is a relatively inexpensive procedure that provides important information about the endocervical canal, the region of the internal os, the uterine cavity, and the entire course of the fallopian tubes. The latter information is invaluable for the infertile patient. HSG may reveal information that would alter the patient's management. A comparison of HSG and hysteroscopy is presented in a table which clearly demonstrates the advantages of hysteroscopy over HSG. The hysteroscope is an important instrument for the diagnosis of some causes of infertility, yet its primary value lies in treatment. Intrauterine diagnosis and surgery for the infertile patient should be confined to 6 procedures. Of these, the use of hysteroscopy for both the diagnosis and treatment of intrauterine adhesions has been shown to be mandatory. Less data are available to support the use of hysteroscopy to resect submucous myomas and even less information is available regarding its use for resection of a uterine septum. The manifestations of intrauterine adhesions include menstrual aberrations, pregnancy wastage, intrauterine fetal demise and errors of placental implantation, and infertility. Prior to the advent of hysteroscopy, the diagnosis of intrauterine adhesions depended upon historic criteria, physical findings, and laboratory data, and the treatment consisted of an attempt to bluntly disrupt the adhesions by using a uterine sound or small curette. Early hysteroscopic efforts toward treatment of intrauterine adhesions led to an overall pregnancy rate of about 40% and fewer than 60% of these patients delivered at term. A table presents data on the author's 1st 67 patients who underwent treatment for intrauterine adhesions. The patients ranged in age from 19-41 years. 60 had been pregnant on 1 or more occasions, but only 31 had delivered an infant. The most common antecedent factor in this group of patients was curettage for elective pregnancy termination. The most common menstrual pattern was that of amenorrhea. 1 great value of hysteroscopy is that it permits the operating surgeon to classify the extent of the disease. Treatment consisted of visualization of the adhesions under direct visualization. Hysteroscopy was performed in the follicular phase for those patients who were menstruating. All adhesions were lysed under direct vision. An IUD was inserted into the cavity. The patient was initially given conjugated estrogens for 60 consecutive days. After withdrawal bleeding, the IUD was removed. The patient's uterus was reinvestigated after the 1st spontaneous menstrual period. 75% of patients who wanted to conceive and in whom no other infertility factors could be identified have done so.