Indications for operative hysteroscopy

Improvements in the design of hysteroscopes have made it possible to carry out operative hysteroscopy in awake patients; other ad­vances include the use of bipolar energy thus making it possible to use normal saline rather than non-ionic distention media (glycine).

• Targeted biopsy: suspicious or abnormal-looking focal lesions in the endometrium are best biopsied using a grasping forceps passed down the operating channel.

• Endocervical and endometrial polypectomy: polyps in the endocervix can be removed by avulsion or using a large loop excision of the transformation zone if they are sessile. Endometrial polyps are formed by proliferation and hyper­trophy of the basal layer of the endometrium, with varying degrees of malignancy (18). At hysteroscopy, they are smooth and soft. They are either sessile or pedunculated; they can be removed using scissors, graspers, or a bipolar electrode. The disadvantage of this latter method is there is no histology. Most experts would recommend that polyps less than 3 cm in diam­eter can be removed this way.

• Treatment of submucous fibroids: submucous fibroids can be re­moved with the operative hysteroscope. Most experts would rec­ommend that the fibroids should be treated if more than 2 cm in size, in the inpatient setting. They can be treated using mechanical instruments or ablated using the bipolar spring electrode.

• Division of intrauterine adhesions: adhesions are classified as mild, moderate, or severe. Mild adhesions are thin and of recent oc­currence, moderate adhesions are thicker and bleed on division. Severe adhesions may be composed of connective tissue and are unlikely to bleed. Division of moderate and severe forms often require general anaesthesia and concomitant laparoscopy and/ or intraoperative ultrasound. Usually scissors or a twizzle elec­trode are used for division under hysteroscopic control.

• Division of uterine septa: approximately 25% of women with a septate uterus have recurrent pregnancy loss (16). Hysteroscopic division with scissors or a cutting electrode or using the resectoscope under general or regional anaesthesia is generally performed. The operation may need to be carried out under lap­aroscopic or ultrasound control. Hysteroscopic division offers high success and pregnancy rates of 85-90% have been quoted (19, 20). Generally patients are advised to delay pregnancy for at least 4-7 weeks.

• Hysteroscopic sterilization: performed in the outpatient setting, this aims to reduce the risks of general anaesthesia, to have a shorter recovery period, and to be cost effective. Essure consists of a micro-insert, a disposable delivery system which is delivered down a hysteroscope. The micro-insert consists of a stainless steel inner coil, a nitinol and super-elastic outer coil, and polyethylene fibres. The micro-insert is inserted into the fallopian tube and remains anchored across the uterotubal junction. Fibrous tissue grows, anchoring the micro-insert into the fallopian tube and the occlusion results in sterilization. Studies have shown 96% of cases have bilateral occlusion at 6 months and it is 99.8% effective in preventing pregnancy after 3 months of follow-up (21, 22). It can be performed in 15-20 minutes and the bilateral placement rate is 90%; alternative methods of contraception must be used in 3 months after the procedure (23).