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Received: 26 June 2017 Revised: 7 September 2017 Accepted: 14 December 2017 DOI: 10.1002/ijgo.12429
CLINICAL ARTICLE Gynecology
Audit of operative hysteroscopies among infertile women in a resource-poor setting Joseph O. Ugboaja1,* | Charlotte B. Oguejiofor1 | Onyecherelam M. Ogelle2 1 Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria 2
Abstract Objective: To evaluate the operative hysteroscopy procedures performed among
Blessed Specialist Hospital and Maternity, Onitsha, Nigeria
infertile women at two hospitals in Nigeria.
*Correspondence Joseph Odirichukwu Ugboaja, Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria. Email:
[email protected]
who underwent operative hysteroscopy between November 2015 and April 2017.
Methods: A prospective case series was undertaken among all patients with infertility The outcome measures included the frequency and type of operative hysteroscopy and the reproductive outcome. Results: The series included 159 women, 70.4% (n=112) of whom had abnormal findings at hysteroscopy. A total of 162 operative hysteroscopic procedures were performed; the most common procedures were adhesiolysis (76 [46.9%]), polypectomy (28 [17.3%]), and septum resection/incision (17 [10.5%]). The instruments used were mainly scissors (65 [40.1%]) and a resectoscope (52 [32.1%]). Complete removal of the lesions was achieved in 86.4% (n=140) of the procedures and a normal cavity in 87.0% (n=141). The complication rate was 6.8% (n=11); the most common complication was minor hemorrhage (5 [3.1%]). The main challenges included poor distention (10 [6.2%]) and poor vision (8 [4.9%]). Menstrual normalization was achieved in 64 (40.3%) of the patients, the cumulative pregnancy rate was 19.5% (n=31), and the live birth rate was 3.8% (n=6). Conclusion: Operative hysteroscopy was feasible and safe in the present resource- poor region. There is a need to build capacity for the performance of hysteroscopy to facilitate the management of infertility in the region. KEYWORDS
Infertile women; Nigeria; Operative hysteroscopy
1 | INTRODUCTION
The indications for operative hysteroscopy include intrauterine adhesions, endometrial polyps, submucosal fibroids, and müllerian
Hysteroscopy is considered the gold-standard procedure for the
duct abnormalities.1–4 Operative hysteroscopy can also be performed
detection of intrauterine lesions.1,2 In addition to its diagnostic value,
for the diagnosis and management of a lost intrauterine contraceptive
hysteroscopy enables the use of a minimal access approach for the
device (IUCD) or retained fetal bones, and for tubal cannulation in the
surgical management of identified intrauterine lesions either in the
treatment of proximal tubal occlusion.
same or in a subsequent setting. Both diagnostic and operative hyst-
Before the performance of operative hysteroscopy, thorough
eroscopies are invaluable in the management of infertility, especially
patient evaluation through history-taking, physical examination, and
in the use of assisted reproductive techniques.
other relevant investigations is required to establish the diagnosis and
Int J Gynecol Obstet 2018; 1–6
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Ugboaja ET AL.
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evaluate for comorbidities. Moreover, endometrial thinning can be
The population of the present study comprised all consecu-
indicated using agents such as progestins, combined oral contracep-
tive infertile women who presented to the fertility and gynecologic
tive pills, gonadotropin-releasing hormone agonists, or gonadotropin-
endoscopy units of the two hospitals and who gave written informed
releasing hormone antagonists to induce endometrial atrophy.5
consent for participation in the study. Those who withheld consent
It is also important to define the size and orientation of the uterus through pelvic examination before the commencement of operative
were excluded. Ethics clearance was obtained from the hospitals’ ethics boards.
hysteroscopy. Therefore, the procedure should start with diagnostic
At presentation, a coded data form was used to collect sociodemo-
hysteroscopy to systematically examine the cervical canal, cervical os,
graphic and reproductive data as well as data on the type and duration
uterine cavity, and tubal ostia.
of infertility. The clinical evaluation included a transvaginal ultrasound
Cervical os dilation can become challenging especially in women
scan and, in some women, a hysterosalpingogram to map the pathol-
with cervical stenosis, but the difficulty of, and the pain associated
ogy. Subsequently, the patients were scheduled for hysteroscopy and
with, cervical dilation can be decreased by administering 100 μg miso-
laparoscopy, which were performed under general anesthesia in the
prostol orally or vaginally in the evening before the procedure.6,7 The
immediate postmenstrual phase.
available data do not show a significant difference in efficacy between oral and vaginal misoprostol.8
The procedure started with the administration of anesthesia, patient placement in the lithotomy position, bladder drainage, and pel-
To ensure optimal visualization, hysteroscopic examination requires
vic examination. This was followed by exposition of the cervix with a
distention of the uterine cavity with a liquid. Because diagnostic hys-
Sims speculum, grasping of the anterior lip with a vulsellum, estimation
teroscopy typically does not involve the use of an electrical energy
of the uterine depth, and cervical os dilatation. In nulliparous women,
source, many options are available in terms of choice of the distention
misoprostol (50 μg) was inserted into the posterior fornix the night
medium. For operative hysteroscopy, the choice of distention medium
before the procedure to aid cervical os dilatation.
is limited because of the use of monopolar energy; both electrolyte- 9
rich fluids and non-electrolyte-containing fluids can be used.
After cervical os dilatation, the diagnostic hysteroscope was introduced under fluid distention to conduct a systematic survey of the
Operative hysteroscopy is associated with a complication rate of
cervical canal, cervical os, and uterine cavity including the fundus
0.95%–3.0%.10 The most common complications are hemorrhage,
and the anterior, posterior, and lateral walls. The tubal ostia were also
uterine perforation, and cervical lacerations. Fluid overload and elec-
examined for normalcy, fibrosis, and occlusion. Any identified lesions
trolyte imbalance are potential serious complications of operative hys-
were recorded.
teroscopy and are reported to occur among 0.2%–0.76% of procedures, especially if electrolyte-free fluids are used for uterine distention.11 In Nigeria, reports of operative hysteroscopy in the management 7–10
This was followed by operative hysteroscopy using a 7.5-mm operative sheath with a working channel and with normal saline as the distention medium. The operative procedure was routinely started
There is need to bridge this gap. The pres-
with microinstruments such as scissors, graspers, and biopsy forceps.
ent study reports on the experience with operative hysteroscopy
To limit thermal injury to the endometrium, a resectoscope was used
of infertility are scarce.
among infertile women seen at two fertility/gynecologic endoscopy
only when necessary. If its use was indicated, further cervical os dila-
units in Nigeria during an 18-month period. The aim was to study the
tation was performed to accommodate the 9-mm monopolar resecto-
rate, pattern, characteristics, and reproductive outcomes of operative
scope and the distention medium was changed to either 5% dextrose
hysteroscopy among infertile women in Nigeria.
in water or glycine. The distention medium was delivered at a pressure of 100–150 mm Hg, using a manual pressure bag pump with a gauge
2 | MATERIALS AND METHODS
suspended from a drip stand. All diagnostic and operative procedures were performed with a camera, monitor, and light source from Stryker (Kalamazoo, MI,
The present study was a prospective case series of infertile women
USA) and the hysteroscopes used were made by Tekno-Medical
who presented to the fertility and gynecologic endoscopy units of
(Tuttlingen, Germany).
Nnamdi Azikiwe University Teaching Hospital in Nnewi, Nigeria, and
Postoperatively, the patients were given antibiotics, discharged
Holy Rosary Specialist Hospital in Onitsha, Nigeria, for management
home on the same day, and followed up for reproductive outcomes
between November 1, 2015, and April 30, 2017. Nnamdi Azikiwe
through follow-up visits and phone calls. Estrogen therapy for endo-
University Teaching Hospital is a tertiary health institution that
metrial regeneration and intrauterine catheter balloons were used
receives referrals from Anambra, Enugu, Abia, Imo, and Ebonyi States
when necessary.
in the South East geopolitical region of Nigeria. The two hospitals
Following
diagnostic
hysteroscopy,
diagnostic
laparoscopy
acquired the capacity to perform gynecologic endoscopy after a series
was performed. This was then followed by operative hysteroscopy.
of training abroad in 2015. Diagnostic hysteroscopy is now routinely
The data form was completed with the findings at diagnostic hys-
performed as a day procedure in all patients with infertility present-
teroscopy, the type of operative hysteroscopy, and further oper-
ing to the fertility and gynecologic endoscopy units for management.
ative details including the duration of the procedure, the nature
Operative hysteroscopy is conducted to remove any intrauterine
and volume of the distention medium used, and the challenges and
lesions identified before or during the diagnostic procedure.
complications encountered.
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Ugboaja ET AL.
Descriptive analyses were performed with Stata version 12.1 (StataCorp, College Station, TX, USA). Continuous variables were expressed as means, medians, and modal values and categorical variables were represented as absolute numbers and percentages.
3 | RESULTS
T A B L E 2 Reproductive and clinical characteristics of the women who underwent operative hysteroscopy (n=159). Characteristic
No. (%)
Type of infertility Primary
69 (43.4)
Secondary
90 (56.6)
Duration of infertility, y
The study included 159 women with infertility. Table 1 shows the
