I will be doing my first IVF cycle in a few months. I had an HSG two years ago, and a laparoscopy and another HSG four months ago. Now my fertility clinic wants me to have an office hysteroscopy before I have my IVF. Is this really necessary? If so, why did they not do it along with my laparoscopy? >From what I have read, this procedure requires sedation. I am very confused about this and am starting to feel that the practice I go to is too busy and unorganized. Does this approach sound appropriate?

Allison

For your best chance of success during IVF, it is necessary to be certain that the uterine lining is optimal for pregnancy to implant and develop. We start assessing this by performing a transvaginal ultrasound around the time of ovulation. This ultrasound should demonstrate a thickened uterine lining, usually 7-8mm or more with a characteristic sort of appearance on ultrasound. This ultrasound will indicate whether a fibroid tumor or endometrial polyp stand in the way of success. If the ultrasound indicates a problem may be present, I will often repeat the ultrasound immediately after the menstrual period stops. If we use a method that involves placing a small catheter into the uterine cavity and injecting a small amount of saline solution, the anatomy clearly stands out, enabling us to clearly identify any defect in the uterine cavity. If an abnormality is seen, a diagnostic or operative hysteroscopy is performed. The HSG test is not sensitive enough to ensure a normal uterine cavity and as such, is not sufficient to proceed without further evaluation.

The diagnostic hysteroscopy is easily done in an office setting using minimal sedation. Many patients do quite well with low dose of ibuprofen. Others benefit from a combination of oral Valium and Demerol. Newer equipment can often enable the physician to perform simple operative hysteroscopic procedures in the office. In certain cases, procedures such as removal of polyps or treatment of adhesions may be successful in an office setting. I can't comment why your physician did not complete the hysteroscopy at the time of laparoscopy. I think it best to ask why this was not done and what findings on the HSG or ultrasound led to the recommendation for additional testing.