uterine abnormalities , congenital or acquired , are implicated as one of the causes of infertility . in fact , infertility related to uterine cavity abnormalities has been estimated to be the causal factor in as many as 10% to 15% of couples seeking treatment . moreover , today , hysteroscopy is considered the gold standard for evaluating the uterine cavity , and due to improved endoscopic developments , can be performed reliably and safely as an office procedure . direct view of the uterine cavity offers a significant advantage over other blind or indirect diagnostic methods . although fayez reported hysterosalpingography ( hsg ) to be as accurate as hysteroscopy in the diagnosis of normal and abnormal cavities , the nature of the intrauterine filling defects is more accurately revealed by hysteroscopy . later studies have shown a correlation of only 65% between findings diagnosed with hsg compared with those diagnosed with hysteroscopy . the role of hysteroscopy in infertility investigation is to detect possible intrauterine changes that could interfere with implantation or growth , or both , of the conceptus , and to evaluate the benefit of different treatment modalities in restoring a normal endometrial environment . oliveira reported detection of significant , unsuspected intrauterine abnormalities , found only with hysteroscopy , in 25% of patients with repeated failed in vitro fertilization and embryo transfer ( ivf - et ) cycles . more importantly , relevant therapeutic interventions significantly improved the clinical pregnancy rate in those with abnormal uterine cavity at hysteroscopy . hysteroscopy can diagnose much more precisely , compared with hsg and even transvaginal ultrasonography , small intrauterine lesions that might affect fertility . in view of all of the above , it is clear why many authors believe that uterine and endometrial integrity should be evaluated primarily by hysteroscopy in the infertile / ivf treated population . still , many consider hysteroscopy as only a complementary procedure in case of abnormal findings detected by other methods ( primarily hysterosalpingography and ultrasound ) . the aim of this study was to examine the role of diagnostic hysteroscopy in a basic infertility workup and to compare its use in primary versus secondary infertility . included in this retrospective study were 221 women who had undergone hysteroscopy as part of their infertility workup in our outpatient clinic between october 1997 and june 2000 . of these a detailed explanation of the procedure was given by the operating physician and a nurse , and all women signed an informed consent before undergoing the procedure . diagnostic hysteroscopy was performed as an office procedure , using a 2.3-mm diameter continuous - flow endoscope ( mr - pc , circon acmi ) . the procedure was considered complete only when the entire uterine cavity and both tubal ostia were visualized . uterine anomalies were diagnosed according to the american society of reproductive medicine classification within the limits of hysteroscopy . in particular , we could not differentiate between bicornuate and septate uterus . arcuate uterus was diagnosed when fundal protrusion was less than one fifth of the uterine cavity . at the end of the hysteroscopy , under direct vision , included in this retrospective study were 221 women who had undergone hysteroscopy as part of their infertility workup in our outpatient clinic between october 1997 and june 2000 . of these a detailed explanation of the procedure was given by the operating physician and a nurse , and all women signed an informed consent before undergoing the procedure . diagnostic hysteroscopy was performed as an office procedure , using a 2.3-mm diameter continuous - flow endoscope ( mr - pc , circon acmi ) . the procedure was considered complete only when the entire uterine cavity and both tubal ostia were visualized . uterine anomalies were diagnosed according to the american society of reproductive medicine classification within the limits of hysteroscopy . in particular , we could not differentiate between bicornuate and septate uterus . arcuate uterus was diagnosed when fundal protrusion was less than one fifth of the uterine cavity . at the end of the hysteroscopy , under direct vision hysteroscopy was performed in 221infertile women : 106 ( 48% ) were diagnosed with primary infertility and 115 ( 52% ) with secondary infertility . the median age was 30 years ( range , 18 to 52 ) and 34 years ( range , 20 to 50 ) , respectively . in the group with secondary infertility , the parity ranged from 1 to 5 , the spontaneous abortions ranged from 0 to 7 , and induced abortions ranged from 0 to 5 . the most common indication for diagnostic hysteroscopy was as a part of an early infertility workup . other indications included cases being part of a continuous workup either before ivf treatment or after a number of failed ivf cycles ( table 1 ) . hysteroscopy revealed a normal uterine cavity in 156 ( 70% ) women ( table 2 ) . indications for hysteroscopy in 221 infertile women hysteroscopic findings in 219 infertile women among women with primary infertility , intrauterine pathologies were diagnosed in 28 ( 26% ) . these pathologies were divided into acquired findings diagnosed in 15 women ( 14% ) and congenital malformations found in 13 women ( 12% ) . considering the group with secondary infertility , intrauterine pathologies were diagnosed in 36 women ( 31% ) . of these , 23 ( 20% ) had acquired findings , and 13 ( 11% ) were diagnosed with congenital uterine malformations ( table 2 ) . a significantly higher rate of patients with submucous fibroids and a significantly higher rate of patients with arcuate uterus were found in the group with secondary infertility ( p<0.04 and p<0.02 , respectively ) . besides that , no statistically significant difference was found in other uterine findings while comparing the 2 groups ( table 2 ) . one of the basic steps of an infertility workup is to evaluate the shape and regularity of the uterine cavity . acquired uterine lesions , such as uterine fibroids , endometrial polyps , intrauterine adhesions , or all of these , may cause infertility by interfering with proper embryo implantation and growth . hysteroscopy has been proved to be the definite method for evaluation of the uterine cavity and diagnosis of associated abnormalities . several studies have demonstrated that once the uterine cavity has to be investigated as part of the infertility workup , hysteroscopy is much more accurate than other diagnostic methods , mainly hsg . in the current study , this also was the main indication for performing diagnostic hysteroscopy . based on the results of the previous studies , it appears that more than 1/3 of the patients interpreted as normal following hsg are found to have a uterine abnormality after diagnostic hysteroscopy , which might be a significant cause of reproductive failure . these women may be wrongly treated , or unnecessarily investigated , while their intrauterine lesion has been missed . in the current study , 30% of women , undergoing infertility evaluation , had abnormal uterine findings on hysteros - copy . these results are comparable to those of the other studies reporting that only 43% to 69% of infertile patients have a normal uterine cavity . no significant differencein the rate of uterine pathology was found between women with primary and secondary infertility ( 26% and 31% , respectively ) . yet , more cases of arcuate uterus ( p<0.02 ) and submucous fibroid ( p<0.04 ) occurred in the group of women with secondary infertility . while the relationship between congenital uterine malformations and impaired pregnancy outcome ( such as recurrent pregnancy loss , late abortions , preterm deliveries , and malpresentations ) is quite established , the issue of these malformations as a cause of infertility is still debatable . the incidence of uterine malformations in other series of infertile patients varies between 1% and 26% , with a mean incidence of 3.4% . in concordance with other reports , septate / bicornuate uterus was the most common anomaly found . the reported incidence of myomas in infertile women without any obvious cause of infertility is estimated to be between 1% and 2.4% . in the current study , donnez and jadoul tried to address the issue of whether myomas influence fertility , by reviewing 106 relevant articles . they concluded that they do influence fertility , mainly based on the favorable pregnancy rates obtained after myomectomy . furthermore , they concluded that submucous and intramural myomas distort the cavity , impairing implantation and pregnancy rates in women undergoing ivf . several theories have been proposed regarding this issue , including alteration of uterine contractility or induction of inflammatory and vascular changes leading to a less receptive implantation site . hysteroscopy can not only diagnose these pathologies accurately , but also enables optimal assessment for possible myomectomy . endometrial polyps were diagnosed in both primary and secondary infertility groups with no statistically significant difference ( 7.6% vs 4.3% , ns ) . the true incidence of endometrial polyps in the general population is difficult to determine , because many of them are clinically asymptomatic . nevertheless , shokeir found such lesions to be more frequent in the unexplained infertility population compared with fertile women . the possible role of these polyps in infertility is yet unclear , although follow - up on these women revealed improved reproductive outcomes after polypectomy . he concluded , in view of his results , that it seems logical to propose surgical treatment of all endometrial polyps among eumenorrheic infertile women , since even if small , they are likely to impair fertility . no significant difference was found in the rate of intrauterine adhesions comparing the patients with primary versus secondary infertility , in spite of the known relationship between secondary infertility and the existence of adhesions , being mostly the result of uterine curettage for postpartum or postabortion residua . oliveira also found intrauterine adhesions in 10% of patients with repeated failed ivf cycles of whom none had undergone previous abortions or other uterine manipulation . while debating the need for routine diagnostic hysteroscopy in the evaluation of the infertile woman , one must keep in mind that this procedure today is no longer a complicated  in - patient - general - anesthesia one ,  but rather a simple , fast , outpatient procedure , requiring short training with high success rates . diagnostic hysteroscopy allows complete , accurate identification of intrauterine abnormalities that might negatively affect endometrial receptivity and implantation . the information derived from hysteroscopy helps the physician to institute appropriate therapy , and by doing so improve conception rates over shorter intervals . our results show that the incidence of uterine pathologies ( congenital and acquired ) in women with primary or secondary infertility approximates 30% , thus , justifying , in our opinion , the use of diagnostic hysteroscopy in the primary routine investigation of infertile women . because no significant difference was found regarding the intrauterine findings between women with primary and secondary infertility , we believe that diagnostic hysteroscopy has a similar importance in the evaluation of patients with both primary and secondary infertility .
objective : to assess the value of diagnostic hysteroscopy in a primary workup of infertility.methods:we performed a retrospective analysis ( canadian task force classification ii-2 ) of 221 infertile patients referred to the outpatient center for uterine cavity evaluation and the tel - aviv university affiliated assaf harofe medical center for evaluation of the uterine cavity . 
 patients underwent a diagnostic office hysteroscopy.results:hysteroscopy revealed an abnormal uterine cavity in 30% of women evaluated for either primary or secondary infertility . 
 no significance was found regarding the total number of intrauterine pathologies when comparing the groups of primary versus secondary infertility.conclusion:routine diagnostic hysteroscopy should be part of an infertility workup in primary and secondary infertility .