Rolul histeroscopiei în diagnosticul și tratamentul infertilității – un studiu retrospectiv

Introduction

Infertility affects approximately 10-15% of couples of reproductive age and remains a major challenge in modern medical practice. With the advancement of assisted reproductive technologies, the accurate identification of infertility causes has become increasingly important⁽¹⁾.

Uterine factors play a significant role in infertility by interfering with embryo implantation and pregnancy maintenance⁽²⁾. Common intrauterine abnormalities include endometrial polyps, submucosal fibroids, intrauterine adhesions and congenital uterine anomalies⁽³⁾.

Hysteroscopy has emerged as the gold standard for evaluating the uterine cavity, offering the advantage of direct visualization and the possibility of simultaneous therapeutic intervention⁽⁴⁾. This technique allows precise diagnosis and minimally invasive treatment of intrauterine lesions^(5,6).

The present study aims to assess the role of hysteroscopy in infertile patients and to highlight the clinical and pathological characteristics observed in this population.

Materials and method

This study was designed as a retrospective analysis conducted on a cohort of 54 patients diagnosed with infertility who underwent hysteroscopic evaluation in a specialized medical center.

The inclusion criteria were: confirmed diagnosis of infertility (primary or secondary), type of hysteroscopy (diagnostic and/or operative) and availability of complete clinical data.

The exclusion criteria were: absence of a confirmed infertility diagnosis, hysteroscopy performed for other indications and incomplete or missing data.

The analyzed variables were age, Body Mass Index (BMI), area of residence, medical and surgical history, risk factors (for example, smoking), obstetric history, presenting symptoms, hysteroscopic diagnosis and the type of intervention performed. The statistical analysis was performed using descriptive methods, including mean values, frequency distributions and percentages.

Results

Demographic characteristics

The patients’ age ranged from 18 to 43 years old, with a mean age of approximately 33 years old. The majority of patients (around 79%) were between 30 and 39 years old, reflecting the current trend of delayed childbearing (Figure 1).

Body Mass Index distribution revealed a predominance of patients with normal weight and overweight, suggesting a potential influence of metabolic factors on fertility (Figure 2).

Types of infertility

Primary infertility was more frequent in the studied group, with a percentage of 61.11%, although a significant proportion of patients were diagnosed with secondary infertility (38.89%), often associated with previous obstetric events or uterine procedures.

Clinical presentation

The most common symptoms were abnormal uterine bleeding (metrorrhagia, menorrhagia), pelvic pain and dysmenorrhea. These symptoms indicated the presence of underlying intrauterine pathology (Figure 3).

Past medical history

Hysteroscopic findings

The most frequently identified intrauterine pathologies are presented in Table 2.

The findings confirmed that a substantial proportion of infertile patients suffered from uterine abnormalities that impair physiological implantation.

Therapeutic interventions

Depending on the identified pathology, the following procedures were performed: polypectomy, myomectomy, adhesiolysis, endometrial curettage⁽⁷⁾. All procedures were successfully completed, with no major complications reported.

Statistical analysis of correlations

The statistical analysis demonstrated that menorrhagia was significantly more frequent among patients diagnosed with endometrial polyps, being present in 30 out of 36 cases. Menorrhagia was also identified in all cases of submucosal fibroids (6/6 cases) and in the majority of patients with intrauterine adhesions (six out of seven cases). These findings suggest a clear association between the presence of intracavitary uterine lesions with abnormal volume or structure and excessive menstrual bleeding (Table 3).

Metrorrhagia was less commonly observed, occurring in seven cases of endometrial polyps and in only one case of uterine septum. The presence of metrorrhagia in these situations may reflect endometrial inflammation or localized vascular disturbances without significantly affecting the overall menstrual cycle.

It is noteworthy that all cases of submucosal leiomyoma and intrauterine adhesions presented with menorrhagia rather than metrorrhagia. This finding may be explained by the nature of these lesions, which alter the architecture of the uterine cavity and contribute to excessive bleeding during menstruation rather than intermenstrual bleeding⁽⁸⁾.

In the case of endometrial hyperplasia, the single identified patient presented with menorrhagia, consistent with the clinical profile commonly described in the literature for this condition. Furthermore, most cases of uterine septum (three out of four) were associated with menorrhagia, possibly due to anatomical alterations of the uterine cavity that may influence menstrual flow.

Overall, the data support a strong relationship between menorrhagia and the most frequently identified uterine pathologies, particularly endometrial polyps, endocervical polyps and submucosal leiomyomas. In contrast, metrorrhagia was less frequent and occured mainly in association with endometrial polyps. This symptom-diagnosis distribution further emphasizes the importance of hysteroscopy as a differential diagnostic tool in cases of abnormal uterine bleeding associated with infertility⁽⁹⁾.

Study limitations

This study had several limitations: retrospective design, relatively small group and the lack of long-term follow-up regarding pregnancy outcomes. These factors may limit the generalization of the results and indicate the necessity of future prospective studies.

Discussion

The findings of the present study are consistent with data reported in recent literature regarding the role of hysteroscopy in the assessment of infertility in female patients. Most patients included in our study were between 30 and 39 years old, a reproductive period generally considered optimal for conception, although fertility progressively declines during these years. This age distribution is similar to that reported in a study conducted on a cohort of patients investigated in a medical center in Bucharest⁽¹⁰⁾.

Regarding clinical presentation, menorrhagia, pelvic and abdominal pain were the most frequently reported symptoms⁽¹¹⁾. Similar associations have been described in previous studies, where abnormal uterine bleeding was observed in more than half of the patients, being frequently correlated with the presence of endometrial polyps⁽¹⁰⁾. Furthermore, a significant association between intrauterine adhesions and secondary amenorrhea has also been reported in literature, an indirect connection supported by our study through the correlation between symptoms and hysteroscopic findings.

Another important observation was that, in several cases, intracavitary uterine abnormalities were not identified through ultrasonography, but were detected only during hysteroscopic evaluation. Previous research demonstrated that approximately 17% of endometrial polyps were diagnosed exclusively by hysteroscopy, while transvaginal ultrasound showed limited sensitivity in certain cases⁽¹⁰⁾. This finding further supports the superior diagnostic accuracy of hysteroscopy in evaluating uterine cavity pathology.

Most hysteroscopic procedures performed in our study were therapeutic rather than purely diagnostic, reflecting the immediate clinical applicability of this technique. In another large cohort study, pregnancy rates following hysteroscopic polypectomy or adhesiolysis were reported to be significant, even in the absence of assisted reproductive techniques⁽¹²⁾. Additionally, studies evaluating the role of hysteroscopy prior to in vitro fertilization (IVF) demonstrated improved reproductive outcomes and higher implantation success rates among patients who underwent hysteroscopic evaluation before initiating IVF treatment⁽¹³⁾.

In patients with unexplained infertility, the combination of hysteroscopy and laparoscopy enabled the diagnosis of previously undetected conditions, including pelvic adhesions, fine intrauterine synechiae and minor uterine malformations⁽¹⁴⁾. A study conducted on a younger patient population reported that nearly 40% of secondary infertility cases presented lesions identified only through combined endoscopic exploration⁽¹⁵⁾.

Therefore, the role of hysteroscopy extends beyond simple uterine cavity assessment and represents an important complementary investigation in complex infertility cases. The results of our study are consistent with current literature and support the utility of hysteroscopy as an essential method in infertility evaluation. The identification and treatment of intracavitary lesions may significantly improve reproductive prognosis, regardless of whether conception is achieved spontaneously or through assisted reproductive techniques^(11,13,16).

Conclusions

Hysteroscopy proved to be an effective method for both the diagnosis and treatment of intracavitary pathologies in infertile patients. Endometrial polyps were the most frequently identified lesions and were particularly associated with menorrhagia. Primary infertility was more common in our study group, in contrast to other clinical series reporting a predominance of secondary infertility. A significant proportion of intracavitary lesions were not detected by ultrasonography and were identified exclusively through hysteroscopy, supporting its use even in the absence of imaging abnormalities. Therapeutic interventions performed during hysteroscopy, including polypectomy, adhesiolysis and curettage, allowed the simultaneous treatment of potential causes of infertility. The most common symptoms among patients were menorrhagia and pelvic-abdominal pain, both strongly correlated with the hysteroscopic findings^(3,17). Our results support the role of hysteroscopy as a first-line investigation in the diagnostic algorithm of female infertility.

Overall, this study highlights the value of hysteroscopy as an essential method in the investigation and management of female infertility, demonstrating that the identification and correction of intracavitary lesions may improve conception rates and contribute to individualized therapeutic management.

Corresponding author: Romina-Marina Sima E-mail: romina.sima@umfcd.ro

Conflict of interests: none declared.

Financial support: none declared.

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