**6.4. Hysteroscopic cervical canal refashioning prior to difficult embryo transfer (48)**

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 (Olympus).

**Figure 2.** Hysteroscopic cervical canal refashoning

36 Enhancing Success of Assisted Reproduction

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

they do with the current "blind" embryo transfer technique.

**6.3. Subendometrial embryo delivery (SEED) (47)** 

and tubal disease.

on the embryos.

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

Patients will actually see the process on video monitor. It will reduce the chances that the embryo will fall out of the uterus, or that it will fall into the fallopian tube causing tubal pregnancy. Post embryo implantation, the woman does NOT need to stay in bed for 2 days. The main disadvantage includes a possible scratching of the lining of the uterus so that pregnancy may not ensue. Candidates include any patient undergoing IVF, specially patients with previously failed standard embryo transfers, patients with ectopic pregnancies

It is done in an office setting using a special fiberoptic scope and camera plus a special tubing with a needlepoint, and it takes approximately two minutes to perform. It utilizes flexible hysteroscope and an inert gas (nitrous gas) to avoid the deleterious effect of CO2 gas 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

outwards the cervical canal projections distorting linearity of the canal are visualized. Linear releasing incisions of approximately a centimeter are made into these projections and a straightening of the canal is achieved. Subsequent to the procedure, dilatation is done to further stretch the incised fibrous tissue, and it is now possible to dilate the cervix up to size 10/12 Hegar in even the most resistant cervix.

Endoscopy versus IVF: The Way to Go 39

intestinal reanastomosis, or kidney transplantation. This situation may pave the way to hysteroscopic occlusion of the fallopian tubes based on the reported success in hysteroscopic tubal cannulation and sterilization techniques. The effectiveness of draining of hydrosalpinges or performing salpingostomy on improving live birth rate prior to IVF/ICSI

**7.1. Methods of endoscopic proximal occlusion of functionless and harmful** 

1. **Laparoscopic:** this can be easily performed using a bipolar grasping forceps or monopolar grasping forceps. In either approach, take care to apply a little traction on the tube medially to avoid scattered secondary coagulation towards the lateral pelvic wall particularly when utilizing monopolar diathermy. By this way, the ureter would

2. **Hysteroscopic:** this approach can be performed whenever laparoscopic approach is impossible or dangerous like cases with history of extensive abdominal surgery like resection anastomosis of the intestine or previous colonic surgery, or patients with a history of extensive or recurrent surgery for pelvic endometriosis. Practically, endoscopists may face some cases without feasibility to perform laparoscopy from the start. These cases deserve searching for an alternative approaches. Hysteroscopy comes as an attractive valuable alternative. Some studies used Essure devices to hysteroscopically occlude the proximal part of the fallopian tube. They reported some case reports of successful pregnancy. Nevertheless, we believe that leaving a foreign body in-utero would lead to decreasing implantation rate. Herein, I'll discuss in details our previous unique study on hysteroscopic tubal occlusion in cases with hydrosalpnix (56). The in-vitro safety phase of this study is done on fresh uterine specimens removed by abdominal or vaginal hysterectomy. In this phase the study, fresh hysterectomy specimens are placed on the return electrode of diathermy, then the corneal ends of both tubes are coagulated simulating the same manner as in the clinical phase. Temperature study is done using digital thermometer over the uterine serosa at site of the coagulation. Histopathologic sections are made to assess tissue effects and depth of penetration using Nitro Blue Tetrazolium (NBT) to evaluate the extent of coagulation on the tubal uterine junction. Computerized image analyzer (Leica Q 500 MB Computerized Image Analyzer) is used to measure the depth of diathermy damage to the surrounding myometrium. The clinical phase of this study is conducted at the outpatient Infertility clinic of Women Health hospital, Assiut University, from April 2004 to October 2006 and included 27 patients with definite uni- or bilateral laparoscopicallyproved functionless hydrosalpinges scheduled for IVF/ICSI. All patients gave a written consent and the study is approved by the institutional ethics committee. They were randomly divided into 2 groups. Randomization is done using simple computer generated randomization tables method. Group A comprised 14 patients who were randomly allocated for laparoscopic occlusion. Laparoscopy is performed under general endotracheal anesthesia using a standard double puncture technique. Once the

needs further evaluation.

be perfectly secured. Some center using clips.

**hysrosalpnix** 
