Despite the numerous advances in the field of in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), the maximum implantation rate per embryo transferred is still approximately 30%. Even if both ovum pick-up and fertilization occur successfully in the process of IVF, there is a large unexplained gap between successful embryo transfer and occurrence of pregnancy. Implantation failure presents a major clinical challenge and is a cause of considerable stress to patients and clinicians in assisted reproductive technology (ART). Besides the psychological and physical burden of each IVF treatment cycle, it also adds to the considerable costs associated with fertility treatment . If progress is to be made in improving implantation rates, a greater understanding of the factors which determine successful implantation is required.
Implantation failure could be due to the embryo, uterine environment or a combination of both. Even minor uterine cavity abnormalities, such as endometrial polyps, small submucous myomas, adhesions, and septa are considered to have a negative impact on the chance to conceive through IVF . The prevalence of unsuspected intrauterine abnormalities, diagnosed by hysteroscopy prior to IVF, has been reported to be 11–45% [3–13]. Therefore, it has been proposed that these abnormalities should be diagnosed and treated in order to optimize the condition of the uterine environment and thus the outcome of IVF treatment. However, this recommendation is not based on high quality evidence [3, 5, 7–10]. In addition, the benefits of hysteroscopy in patients who will undergo a first IVF/ICSI treatment have not yet been investigated.
At present, the basic work-up for evaluation of the uterine cavity prior to IVF consists of transvaginal ultrasound, possibly followed by saline infusion sonography (SIS), hysterosalpingography (HSG) or hysteroscopy. The accuracy of HSG in assessment of the uterine cavity integrity in subfertile patients has been reported to be rather disappointing [14, 15]. SIS is increasingly considered to be useful in diagnosing intrauterine abnormalities. It is an inexpensive, non-invasive diagnostic test, and has been proven to be very accurate [16, 17]. Yet hysteroscopy is still considered to be the gold standard. It has become easy to perform in an outpatient clinic without anesthesia. Moreover, hysteroscopy enables diagnosis and treatment of intrauterine pathology in the same setting.
The NVOG (Dutch society of Obstetrics and Gynaecology) as well as the ESHRE (European Society for Human Reproduction and Embryology) and RCOG (Royal College of Obstetricians and Gynaecologists) do not recommend SIS nor hysteroscopy as initial investigation prior to starting IVF [18–20]. It has been argued that the significance of treating unsuspected intrauterine abnormalities has not yet been proven.
So far, none of the guidelines considered the most recent literature on this topic. In a retrospective cohort analysis, Gera et al. compared the pregnancy rate after operative hysteroscopy of patients with intrauterine abnormalities at SIS to the pregnancy rate of patients with a normal uterine cavity. A 31.6% increase in pregnancy rate was observed after treatment of detected abnormalities . Furthermore, two randomized trials reported exceptional improvements in pregnancy rates after office hysteroscopy and instant treatment of detected pathology in patients after two failed IVF attempts. Intervention resulted in a 9–13% increase in clinical pregnancy rate in the subsequent IVF cycle [7, 9]. These results endorsed the findings of other, previously published prospective studies [3, 5]. Despite some methodological weaknesses in the study design, the results of these studies indicate a trend towards a beneficial effect of screening hysteroscopy on IVF outcome. This finding, combined with the observed high prevalence of intrauterine abnormalities, has led to a general debate on the beneficial effect of pre-IVF work-up of the uterine cavity.
The current study aims to clarify the additive value of routine SIS and/or hysteroscopy prior to IVF/ICSI . Also, patient preferences and the cost-effectiveness of these tests as routine procedures for assessment of the uterine cavity prior to starting IVF will be assessed.