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Pre-IVF hysteroscopy to enhance uterine receptivity may be justified

Reproductive BioMedicine Online, Volume 28, Issue 2 , Pages 151-161, February 2014

Imaging technology, endocrine, omics and genetic testing form the basis of treatment strategies in today’s gentle, hands-off approach to infertility care. These complex and expensive laboratory tests, although adequate in asymptomatic women, have led to lesser usage of surgical diagnostic procedures. Such latter options are now aimed at excluding pathology in women with symptoms suggestive of uterine disease.

The meta-analysis of Pundir et al. (2014) in this issue is timely, serving as a prompt to re-consider some of the traditional surgical tools that have been available for many decades to evaluate a woman’s reproductive health. The reference here is to the gynaecological procedure of dilatation and curettage. Specialist teaching moved from “D&C is informative in nulligravida but not in multiparous women” in the mid 1960s ( Jeffcoate, 1966 ) to no mention at all of this intervention in one of the influential postgraduate texts of the mid 1970s ( Shearman, 1972 ). This latter volume trumpeted the arrival of robust endocrine and metabolic tests that are both sensitive and specific, shifting the performance of diagnostic tests from the hands of the gynaecological surgeon to the domain of the physician reproductive endocrinologist. The latter, not necessarily trained in procedures such as endometrial biopsy, curettage or hysteroscopy, are less likely to consider them of clinical value.

Is the report of Pundir and colleagues a sign that the pendulum is beginning to swing back to a useful role for surgery, refined over the decades from “scrape” to the more gentle “strip endometrial biopsy”? The vastly improved hysteroscopically-directed endometrial biopsy has been made possible by the development of smaller, less traumatic surgical instruments. Its use will not lead to the loss of the informative armamentarium of diagnostic tests referred to above, as the purpose of the surgical procedures evaluated by Pundir and colleagues is to address matters beyond the capacity and skill-mix of imaging technology and non-surgically orientated physician practitioners. Is there sufficient evidence to argue the case for a therapeutic benefit in doing the hysteroscopic procedure itself? The authors introduce the notion that there may be “benefits beyond correcting pathology”. The conduct of a more efficient embryo transfer procedure is self-evident. Despite indications that endometrial receptivity might be enhanced, the underlying mechanisms remain to be defined. It may be that provocation of an inflammatory reaction to the surgical intrusion is part of the explanation, a process that is known to occur in rodent species (de Greef et al, 1977 and Kaushik et al, 2006). This view is supported by observations of increased implantation rates after endometrial biopsy performed blindly, that is, not hysteroscopically-directed (synonyms scratch, scrape, localised endometrial injury), although we wish to introduce a less traumatic terminology, personalised endometrial procedure or PEP ( El-Toukhy et al., 2012 ).

If the latter turns out to be responsible for enhanced implantation rates then once again we move forwards by going backwards. Were Jeffcoate and his generation correct in concluding that the surgical test was only of value in nulligravid women? Answers to this and other questions regarding timing of the procedure and duration of effect may soon emerge. In discussions about the timing, some colleagues practise hysteroscopy just prior to the trigger injection, others in the prior secretory phase. Is there a difference? Future patients can look forward to the conclusions from well-conducted studies.

References

  • Jeffcoate, 1966 T.N.A. Jeffcoate. Principles of Gynaecology. 3rd ed. (Butterworths, London, 1966)
  • Pundir et al., 2014 J. Pundir, V. Pundir, K. Omanwa, T. El-Toukhy, Y. Khalaf. Hysteroscopy prior to the first IVF cycle: a systematic review and meta-analysis. Reprod. Biomed. Online. 2014;28:151-161 Crossref
  • Shearman, 1972 R.P. Shearman. Human Reproductive Physiology. (Blackwell Scientific, Oxford, 1972)
  • El-Toukhy et al., 2012 T. El-Toukhy, S.K. Sunkara, Y. Khalaf. Local endometrial injury and IVF outcome: a systematic review and meta-analysis. Reprod. Biomed. Online. 2012;25:345-354 Crossref
  • de Greef et al., 1977 W.J. de Greef, J. Dullaart, G.H. Zeilmaker. Serum concentrations of progesterone, luteinizing hormone, follicle stimulating hormone and prolactin in pseudopregnant rats: effect of decidualization. Endocrinology. 1977;101:1054-1063 Crossref
  • Kaushik et al., 2006 Kaushik, D., Reese, J., Paria, B.C., 2006. Methodologies to study implantation in mice. In: Soares, M.J., Hunt, J.S. (eds.), Placenta and Trophoblast Methods and Protocols, vol. 1. In: Methods in Molecular Medicine, vol. 121. Springer, pp. 9–34.