in the past few decades many artificial reproductive techniques have been invented raising the hopes of infertile couples . it has been known that the uterine factor plays about a 15  20% role in contributing to female infertility . hence , ruling out any evidence of any intrauterine pathology by hysteroscopy becomes an important step before subjecting the patient to any of the assisted reproductive techniques ( art ) . with the invention of miniature hysteroscopes , it is possible to perform hysteroscopy in an office setup , with or without local anesthesia , for diagnostic and certain therapeutic interventions . in the present study , we have evaluated intrauterine pathologies with hysteroscopy and in vitro fertilization - embryo transfer ( ivf - et ) outcome in patients with unexplained previous ivf cycle failures , after excluding all other possible etiological factors . the aim of the present study is to evaluate the importance of subjecting the patient to hysteroscopy prior to art , to study the incidence of intrauterine pathology in the selected group and to study the success of ivf post hysteroscopic procedures in women with previous ivf failures . the aim of the present study is to evaluate the importance of subjecting the patient to hysteroscopy prior to art , to study the incidence of intrauterine pathology in the selected group and to study the success of ivf post hysteroscopic procedures in women with previous ivf failures . the study is a retrospective study of 292 women who attended our infertility clinic over a period of 18 months ( january 2007 to june 2008 ) . the inclusion criteria for the study were the women who had one or more previous ivf cycle / cycles failure . all women in whom hysteroscopy was done were informed about the technique and the potential risks in the form of a written consent . the selected women underwent the procedure of hysteroscopy under general anesthesia in the lithotomy position . a rigid hysteroscope was put into the uterine cavity under visual control after cervical dilatation of five to nine milimeters ; normal saline was used as the distension medium , keeping the uterine pressure between 100 and 150 mm of mercury . intrauterine lesions , such as , synechiae , polyps , submucosal myomas , septae , and so on , were treated with scissors and resectoscope . every hysteroscopy was followed by endometrial biopsy or curettage , and the material obtained was sent for histopathological examination . depending upon the diagnosis and the procedure done , the women were either stimulated immediately or after some period for ivf / icsi cycle . the women were downregulated with oral contraceptive pills and gonadotropin - releasing hormone ( gnrh ) analogues . injection hmg ( human menopausal gonadotrophin ) was started from the second day of menses and simultaneous follicular monitoring was done from the sixth day . injection hcg ( human chorionic gonadotrophin ) was given when a minimum of three leading follicles were 1618 mm size . thirty - six hours later oocyte retrieval was performed followed by ivf / icsi , and then the embryo transfer . all women in whom hysteroscopy was done were informed about the technique and the potential risks in the form of a written consent . the selected women underwent the procedure of hysteroscopy under general anesthesia in the lithotomy position . a rigid hysteroscope was put into the uterine cavity under visual control after cervical dilatation of five to nine milimeters ; normal saline was used as the distension medium , keeping the uterine pressure between 100 and 150 mm of mercury . intrauterine lesions , such as , synechiae , polyps , submucosal myomas , septae , and so on , were treated with scissors and resectoscope . every hysteroscopy was followed by endometrial biopsy or curettage , and the material obtained was sent for histopathological examination . depending upon the diagnosis and the procedure done , the women were either stimulated immediately or after some period for ivf / icsi cycle . the women were downregulated with oral contraceptive pills and gonadotropin - releasing hormone ( gnrh ) analogues . injection hmg ( human menopausal gonadotrophin ) was started from the second day of menses and simultaneous follicular monitoring was done from the sixth day . injection hcg ( human chorionic gonadotrophin ) was given when a minimum of three leading follicles were 1618 mm size . thirty - six hours later oocyte retrieval was performed followed by ivf / icsi , and then the embryo transfer . out of 292 patients , majority were in the age group of 31 to 35 years [ table 1 ] . patients were categorised into four groups on basis of period of infertility , ranging from 2 years to more than 10 years [ table 2 ] . out of the 292 women undergoing hysteroscopy , 218 ( 75% ) had normal findings and 74 ( 25.3% ) had intrauterine pathology [ table 4 , figures 1 and 2 ] . the table also gives a review about the conception rate post procedure , which varied from 19 to 72% , depending upon the pathology in the study group . despite advances in the field of artificial reproductive techniques over the past 20 years , implantation rates per embryo transferred still remain low , at about 15 to 20% . the two key factors in question for this problem are the quality of the embryo and the receptivity of the uterus . although it is possible to assess the embryo quality by microscopy , uterine receptivity can not be fully evaluated . some uterine factors that can be measured by transvaginal sonography are endometrial thickness , pattern , and blood flow in the uterine and subendometrial arteries . structural abnormalities of the uterine endometrial cavity may affect the reproductive outcome adversely , by interfering with the implantation and causing spontaneous abortion . the incidence of uterine abnormalities in patients undergoing hysteroscopy has been reported to be between 19 and 50% . different hypotheses have been suggested to define the mechanism of infertility due to intrauterine pathologies . polyps may cause infertility by virtue of their location , thereby causing mechanical block ( e.g. , tubocornual polyp ) by their association with endometriosis , or by expression of the enzyme aromatase . myomas that protrude into the cavity may decrease vascular supply to the trophoblastic tissue when implantation takes place on the overlying endometrium . most septa are relatively avascular and hence result in implantation failure when implantation takes place over them . other pathologies like synechiae , endometritis , cervical stenosis , and chronic cervicitis can be causes of subfertility . the place of routine hysteroscopy in the management of infertile women without other diagnosed or doubtful intrauterine pathologies is still a matter of debate . the two main problems that argue against the case of hysteroscopy are : first , it is an invasive procedure , and second , there is still an ongoing debate about the real significance of the observed intrauterine pathology on fertility . currently , the european society of human reproduction and embryology ( eshre ) guidelines indicate hysteroscopy to be unnecessary , unless it is for the confirmation and treatment of doubtful intrauterine pathology . , it was suggested that 26% of the patients with normal hysterosalpingography were with abnormal hysteroscopic findings . the impact of polyps on infertility is mainly dependent on their size and location . a prospective randomized study of the impact of polyps on an ivf program , by lass et al . , concluded that small endometrial polyps ( less than two centimeters ) do not decrease the pregnancy rate after ivf , but a trend toward increased pregnancy loss exists . the available data on the role of submucous myomas in infertility and the impact of hysteroscopic myomectomy on pregnancy outcome shows encouraging results . women who had myomectomies for myomas more than two centimeters had significantly higher pregnancy and live birth rates than women in whom myomectomy was not done . hysteroscopic resection is said to be the gold standard for the treatment of submucous or intracavitary myomas . the role of hysteroscopic septum resection in patients with septate uterus has also been studied extensively . a meta analysis of retrospective data comparing pregnancy outcome before and after hysteroscopic septoplasty indicated a marked improvement after surgery , in increasing the pregnancy rate and decreasing the miscarriage rate . several studies have also been performed to find out if hysteroscopic treatment of intrauterine pathologies increases the success of ivf - et . kirsop et al . , suggested that intrauterine abnormalities may be a cause for failure of ivf - et or gamete intrafallopian transfer ( gift ) and therefore hysteroscopy should be part of the infertility workup for all patients , prior to undergoing ivf treatment . faghali et al . , have also recommended screening the uterus by hysteroscopy before proceeding with ivf , to minimize implantation failures . the role of hysteroscopy in patients with previously failed ivf cycles has also been studied . a recent systematic review and meta analysis of two randomized and three non - randomized control trials on 1691 patients concluded that hysteroscopy before a subsequent ivf attempt significantly increases the odds for conception in patients with at least two failed ivf attempts . the role of hysteroscopy in patients undergoing ivf seems to be vital for patients in whom an ivf is being contemplated , for treatment of infertility . intrauterine pathologies and structural uterine abnormalities that may be responsible for the failure of ivf can be detected and treated , resulting in improved pregnancy rates . this would also save the patient additional costs of ivf cycles , where failures occur because the intrauterine pathology is missed on other screening investigations like hysterosalpingography .
background : there have been numerous advances in the area of assisted reproduction . among the various reasons of implantation failure , intrauterine lesions play an important role.objective:the aim of the present study is to evaluate the role of hysteroscopy prior to any assisted reproductive technique.materials and methods : it is a retrospective study of 292 women who attended our infertility clinic over a period of 18 months , who had a variable number of failed ivf cycles previously.results:out of the 292 women studied , in 74 women , that is 25% , intrauterine pathology was detected , which when rectified by hysteroscopy , gave a considerable increase in pregnancy rate.conclusion:according to this study it can be concluded that evaluating the uterine cavity is an important step before any assisted reproductive procedures .