**4.1. What is the ideal approach prior to IVF?**

In recent years, conflicting opinions on the role of hysteroscopy before any case of IVF/ICSI or after failure once or more times. This conflict is due to different circumstances in different parts of the world regarding:availability of free health insurance for IVF, experienced hysteroscopists, availability of high-resolution 2D ultrasonography with or without SIS, use of office versus conventional hysteroscopes, use of vaginoscopic approach or not and socioeconomic level of the couple. Our opinion is summarized as follows:


In cases of failed IVF once, hysteroscopy is valuable and recommended.

34 Enhancing Success of Assisted Reproduction

team reported perfect diagnosis in 77.6% of cases (37).

**4.1. What is the ideal approach prior to IVF?** 

in the general subfertile population can be recommended (38).

they can proceed for IVF without prior hysteroscopy.

socioeconomic level of the couple. Our opinion is summarized as follows:

hypervascularisation, irregular endometrium with endometrial defects, or cystic haemorrhagic lesion which are commonly seen with adenomyosis (28). Future high-quality randomized trials are needed to confirm the favorable effect of standard hysteroscopy in different IVF populations and examine whether newer and less invasive techniques of uterine cavity evaluation such as mini-hysteroscopy (29) or hysterocontrast sonography (30) would have an equally beneficial effect when compared with no intervention before IVF.

With the advent of technical refinements and advancement in hysteroscopic surgery, it is expected that preoperative hysteroscopic evaluation of uteri prior to IVF/ICSI would be widely performed. Unfortunately, many of studies on this topic focus on the central role of hysteroscopic examination of the endometrial cavity in cases with recurrent failures (28,31,32). This concept should be reviewed since office hysteroscopy or minihysteroscopy is a simple outpatient conscious procedure (33-34) that provides excellent information on the implantation site in the endometrial cavity in a very short time. Relying on hysterosalpingography alone may be fallacious in some cases of fine intrauterine adhesions that may be masked by dye especially oily dye. Likewise, transvaginal ultrasonography as well as sonohysterograohy may miss some important fine intrautrerine lesions thatwould simply contribute for failures (3). In one study, hysteroscopy succeeded to diagnose and treat intrauterine lesions in 26% of patients prior to starting trials of assisted reproduction (31). In a big sample sized study (36), intrauterine pathology was diagnosed in about 23% of 2500 cases prior to IVF trial. Another study diagnosed abnormalities in only 11 out of 678 cases. On reevaluation of DVD records of hysteroscopy by an experienced team, the same

Following recurrent IVF failure there is some evidence of benefit from hysteroscopy in increasing the chance of pregnancy in the subsequent IVF cycle, both in those with abnormal and normal hysteroscopic findings. Various possible mechanisms have been proposed for this beneficial effect, but more randomized controlled trials are needed before its routine use

In recent years, conflicting opinions on the role of hysteroscopy before any case of IVF/ICSI or after failure once or more times. This conflict is due to different circumstances in different parts of the world regarding:availability of free health insurance for IVF, experienced hysteroscopists, availability of high-resolution 2D ultrasonography with or without SIS, use of office versus conventional hysteroscopes, use of vaginoscopic approach or not and

 In centers where health insurance is covering the cycles, experienced sonographers performing high-resolution 2D ultrasonography with or without SIS, we believe that

 In centers where health insurance is not covering the cycles, experienced sonographers performing high-resolution 2D ultrasonography with or without SIS are not available,

we believe that hysteroscopy specially office is very useful in such cases.

In cases with recurrent implantation failure, hysteroscopy is mandatory.
