Hysteroscopy is the inspection of the uterine cavity that allows for the diagnosis and treatment of various uterine conditions. Some of which, could lead to fertility problems.

Uterine Septum (Septate uterus)

This is the most common uterine malformation and a common cause of miscarriage. It is unclear whether a uterine septum increases the chances for infertility or not. A wedge of tissue is present inside the uterine cavity, which divides it into two halves (also called uterine horns).

When seen through a hysteroscope, the uterine horns are seen as two dark openings separated by a wedge of tissue. By introducing an electrode through the hysteroscope, the septum can be shaved or vaporized all the way to the top of the cavity. The finished product is a uterine cavity that is unified into one large space instead of divided in two.

Polyps

These are uterine growths a few millimeters to centimeters in size. Polyps arise from the uterine lining (endometrium). A polyp may be attached to the uterine wall directly or by a thin “stalk”.

Patients often have no symptoms from polyps but will occasionally notice irregular vaginal bleeding. This bleeding may occur in between periods or cause the period to be longer in duration or heavier than normal.

Polyps are also associated with an increased risk for miscarriage. Large polyps, which occupy the majority of the uterine cavity, are also probably responsible for infertility. Small polyps can be most easily vaporized in place. Polyps which are attached by a stalk can sometimes be removed by cutting through the stalk and removing the entire polyp through the cervix. Larger polyps may have to be removed by shaving small strips one at a time until the polyp is completely gone, or slightly deeper, taking a margin of the myometrium.  This tissue is sent out for pathology.

Fibroids

These benign tumors arise from the muscle layers of the uterus. Often they will stay in the muscle layer but on occasion, fibroids can grow into the uterine cavity. Like polyps, fibroids can cause bleeding, infertility, and as well as miscarriage. Removal of fibroids from the uterine cavity is performed using the same methods as for polyps.

Scar tissue

Scar tissue inside the uterine cavity, also called adhesions, can arise from infection or trauma to the uterine lining. Although rare, the most common cause for uterine adhesions to form is from a previous D&C procedure. Scar tissue inside the uterus can be small and isolated to a certain spot. This type of adhesion looks like a band running from one wall of the uterus to another. Sometimes adhesions take the form of two walls that are stuck together causing the cavity at that spot to be completely obliterated. In rare instances, the entire cavity can be obliterated. Uterine adhesions can cause infertility or miscarriage. If the uterine cavity is partially or completely obliterated, a woman may notice that her period are lighter or even stop altogether. Band adhesions can be easily cut restoring the normal anatomy of the uterine cavity. When the walls are stuck together, the surgeon must carefully dissect between them in order to separate the walls. This can be a very difficult process if there is little normal uterine cavity that remains to serve as a guide.

You will be able to watch the sonohysterogram on a monitor while it is being performed. Afterwards, the doctor will review the findings with you and answer any questions about those findings. If there are any abnormalities that are found on the inside of your uterus, don’t worry! Nearly all of these conditions are easily corrected with minimally invasive, outpatient surgery (usually with hysteroscopy).

Occasionally, a woman might experience some cramping during or after a hysterosonogram. If she desires, she may take 1-2 tablets of ibuprofen (Motrin or Advil) 1-2 hours before the procedure to decrease cramping. This may be repeated 3-4 hours later in the unlikely event that cramping persists.

The procedure for performing a sonohysterogram is very simple and usually takes about 5 minutes. In order to schedule a sonohysterogram, you will need to call with the first day of your period. You will be given an appointment for some time point after the bleeding from the period has ended but before it is thought that ovulation might occur. This ensures that the uterine lining is as thin as possible. This is important since it will assist the doctor in the visualization of the cavity. The hysterosonogram is performed in the office. Using a speculum, a very thin, soft, flexible plastic catheter will be inserted through the vagina and cervix into the lower part of the uterine cavity and a balloon is inflated.  The speculum is then carefully removed so as not to disturb the catheter. A vaginal ultrasound probe is then placed into the vagina. Through the catheter, a small amount of saline (sterile salt water) is injected into the uterine cavity to separate the walls.

During a sonohysterogram, the ultrasound probe can be rotated to show the long axis of the uterus or a transverse axis. In the long axis, the uterine cavity appears long and ovoid. Sometimes after the procedure, a small amount of the saline fluid may leak out of the vagina. It is also possible that the patient may experience some bleeding or spotting. It is recommended that the patient wear a light pad or tampon for the rest of the day.

A hysterosonogram is often recommended for women who are having difficulty conceiving a pregnancy or for women who are having recurrent miscarriages. In some cases, a hysterosonogram may be used for a woman who is having abnormal vaginal bleeding. Since a sonohysterogram gives such a detailed view of the inside walls of the uterus, it can identify many abnormalities that might prevent a normal pregnancy from developing. Studies have shown that it can detect over 90% of abnormalities inside the uterus. Some of these abnormalities include:

• Polyps
• Fibroids
• Scar tissue
• Uterine septum
• Bicornuate Uterus

A sonohysterogram or SHG is a saline ultrasound, saline sonogram, or saline infusion sonogram. A sonohysterogram is a minimally invasive ultrasound procedure that can determine if there are abnormalities inside the uterus that might interfere with pregnancy. It is important to have an evaluation of the uterine cavity with a sonohysterogram or other method before proceeding with an IVF cycle. This test involves no radiation, and there are very few risks from the procedure. Compared to a regular ultrasound, a sonohysterogram is better at detecting abnormalities on the inside walls of the uterus because it involves infusing sterile fluid inside the uterus. This way, the walls of uterus separate from each other and any abnormalities that might have been hiding right along the sides of the walls will be easily identified.

Here is an example to help understand why we do a sonohysterogram. Think of your uterus like a collapsed balloon. If there was a small growth or bump on the inside wall of the collapsed balloon, it might be hard to see since the top and bottom walls are touching each other. However, if we inflated the balloon, the small growth will be easier to see since it will likely be able to hang away from the wall.

Traditionally, the “best” way to look for abnormalities inside the uterus was a test called a hysteroscopy, which involves an out-patient surgery using a type of endoscope to look inside the uterus. However, in recent years, the techniques for a sonohysterogram have become so advanced that it has usually replaced hysteroscopy as the first procedure to look for abnormalities in the uterus. Compared to a hysteroscopy, a sonohysterogram is less invasive, less expensive and nearly as effective at detecting abnormalities.

AMH or anti-mullerian hormone is a hormone produced by the viable follicles (which contain eggs) that remain in the ovary. It is an excellent indicator of ovarian reserve. Young women with large numbers of healthy eggs tend to have high AMH levels whereas older women or women with a low number of healthy eggs will have lower levels of AMH.  New information is suggesting that very high levels of AMH may not simply indicate a plethora of antral follicles, but may indicate a follicular dysfunction.

AMH levels do not fluctuate very much throughout the cycle and are not impacted by the levels of other hormones such as estrogen or progesterone.

Abnormal AMH levels are usually determined by comparing a woman’s own AMH level with that of a large group of women her own age who do not have infertility. For example, an AMH of 1.4 would be considered very low for a fertile 18-year-old but would be considered average for a 36-year-old.

Fertility decreases with age. This decrease is most likely due to aging of the eggs and the chromosomes inside them. The risk of miscarriage and chromosomal abnormalities in babies also increase with age. The most successful method for achieving a pregnancy and taking home a baby at advanced female age is with the use of egg donation.