**6.2. Hysteroscopic Endometrial Embryo Delivery (HEED) (46)**

It refers to visually confirmed placement of the embryo(s) at a specific area on the surface of the uterus. It is done in an office setting, using a special fiberoptic scope and camera plus special tubing, and it takes approximately two minutes to perform. It uses nitrogen gas to avoid deleterious effect of CO2 gas o n the embryos. HEED can also be used for earlier (day 2 or 3) embryos as well as the more advanced embryos. This is especially advantageous in situations where the numbers of embryos are limited, or embryo quality is of concern. It is particularly useful in patients with advanced reproductive age, or when egg production is low, or in patients with poor sperm parameters. Patients will actually see the process on video monitor. The entry into the uterus is not always easy, as the non-stirrable tip of the catheter must usually go through different curvatures in the cervical canal and the uterine cavity while minimizing injury to the lining of the uterus, before it reaches the final destination. The flexible hysteroscope has a stirrable tip, helping guide the endoscope in a gas expanded uterine cavity. The slightly expanded uterine cavity also helps avoid contact between the hysteroscope and uterine surface. The final destination of the tip of the catheter is visually confirmed. This more precise placement and lower volume of transfer fluid may help reduce incidence of ectopic pregnancies even further. It may also reduce chances placenta previa, where the after birth is lying over the uterine opening. Presence of uterine contraction at the time of transfer that are otherwise not noticeable by using the "Blind" embryo transfer technique, can be visually confirmed and embryo transfer deferred. Precise and visually confirmed placement, may reduce percentage of multiple pregnancies, by reducing number of embryos transferred because of the less uncertainty of the placement of embryos with the "Blind" technique. Nevertheless, since the embryo(s) are laid on top of the uterine surface, due to inherent uterine contractions over the next few days after the embryo delivery and prior to their natural implantation in the uterine cavity, the embryo(s) may be expelled either into the fallopian tube (causing ectopic pregnancy) or out of the uterus, as they do with the current "blind" embryo transfer technique.

Endoscopy versus IVF: The Way to Go 37

**6.4. Hysteroscopic cervical canal refashioning prior to difficult embryo transfer** 

In some cases, access to the endometrial cavity is extremely difficult or even impossible. In some scarce studies. Sonographically-guided fine needle transmyometrial embryo transfer was tried but this technique is not universally accepted. An attractive recent hysteroscopic approach was described. The procedure is performed under general anesthesia. Patients are taken into the theater with a full bladder in case ultrasound guidance is required to access the uterine cavity. A Versapoint electrode (twizzle electrode) with a 1.9 mm Versascope (Gynecare division, Johnson and Johnson) is used for the procedure. The Versapoint electrode works on bipolar energy, so saline is used as the distension media. Versascope sheath has a small diameter (3.5 mm) and it can be inserted into the cervical canal without prior dilatation or with minimal dilatation. In two patients the canal is extremely tortuous and fibrotic and it is not possible to negotiate with the delicate Versascope. Cervical dilatation is achieved under ultrasound guidance in these women and the Versapoint twizzle electrode is introduced through the operating channel of an operating hysteroscope

For women with a false passage and acute angulation of the uterus, the tissue between the actual cervical canal and false passage is cut thus leaving a clean path which could be negotiated with an ET catheter. For the problem of a severely fibrotic OS, 1 or 2 linear releasing incisions are made with the Versapoint electrode, extending from the posterior aspect of the internal OS towards the external OS for approximately 1 cm. In patients who had a tortuous cervical canal, several projecting ridges are seen arising from the anterior, posterior and/or lateral walls of the cervical canal. The hysteroscope is introduced into the uterine cavity and then withdrawn towards the external OS. As the hysteroscope is moved

**(48)** 

(Olympus).

**Figure 2.** Hysteroscopic cervical canal refashoning
