Diagnostic hysteroscopy

L'Diagnostic Hysteroscopy is an endoscopic technique that can be performed in an outpatient setting that uses the hysteroscope, a thin instrument with optics connected to a camera, to explore the uterine cavity and cervical canal and to diagnose or rule out various pathological conditions at these sites.

Moreover, thanks to technological advances and the consequent improvement in hysteroscopic technique, modern gynaecology offers the possibility of performing operative procedures using miniaturised instruments (Outpatient Office Hysteroscopy) for the treatment of numerous endometrial and endocervical pathologies within the same outpatient session and therefore at the same time as the diagnostic phase ('see and threat').

Diagnostic/Office Ambulatory Hysteroscopy has undoubted advantages over hysteroscopy performed in the operating room in terms of reduced costs and time, reduced risks related to the use of anaesthesia drugs, less discomfort, and faster physical recovery of the patient.

According to both Italian and international guidelines ( 1; 2) all gynaecology operating units should offer an outpatient hysteroscopy service for the management of endocavitary uterine pathology given the undoubted clinical and economic advantages.

When to perform diagnostic hysteroscopy 

For the study of endouterine pathology, transvaginal ultrasound (TV), sonohysterography, and outpatient diagnostic hysteroscopy have proven to be accurate and easy to perform methods (2).

The role of the three diagnostic methods varies depending on the type of pathology present and also on the age of the patient, but in general in clinical practice transvaginal ultrasound is used as a first-line investigation, as it is easily accessible, non-invasive and capable of suspecting, with good accuracy, a large proportion of uterine and endometrial pathology (3). 

In the case of protruding lesions in the cavity (such as endometrial polyps, submucosal myomas, benign or malignant hyperplastic lesions), these can be more clearly detected by performing sonohysterography, i.e. injecting a few cc of saline solution into the uterine cavity; sonohysterography can increase the diagnostic sensitivity of ultrasound up to 93-100%, however this procedure can be more unpleasant for the patient than ultrasound and even painful, can give false positives in 6-15% of cases and cannot discriminate the malignant or benign nature of the identified lesion (4).

Diagnostic hysteroscopy, thanks to direct visualisation of the uterine cavity, can confirm or exclude the presence of endocavitary lesions, allowing the number, size and position of the lesions to be better defined. The information obtained by inspecting the uterine cavity may in some cases (e.g. in the case of patients with uterine myomas or uterine malformations) be complementary to that obtained from the ultrasound study of the uterus in the definition of a subsequent therapeutic procedure. The possibility, as we shall see, of performing a targeted biopsy under vision of the lesion at the same time increases the accuracy of diagnostic hysteroscopy in discriminating benign and malignant lesions. The confirmation of the diagnosis performed with an outpatient procedure makes it possible to schedule in the operating room with resectoscopic surgery only the operations of patients who really need it, avoiding unnecessary hospitalisations and anaesthesiological procedures in patients who can benefit from medical therapy, outpatient treatment only or who do not need any therapy at all.

The indications for performing a hysteroscopic examination of the uterine cavity (5) include:

• the presence of abnormal uterine bleeding in the reproductive and postmenopausal years
• the evaluation of abnormal or doubtful findings by other methods (transabdominal or transvaginal ultrasound, sonohysterography, magnetic resonance imaging) of the uterine cavity
• Evaluation of suspected Mullerian anomalies
• Retention of foreign bodies in the uterine cavity
• Retention of products of conception in the postpartum or after an abortion
• The postoperative evaluation of the uterine cavity after extensive operations involving the uterine cavity (resectoscopic or abdominal myomectomies with cavity entry, lysis of intracavitary adhesions)
• Unexplained persistent leucorrhoea

In particular, the evaluation of the uterine cavity has become crucial today in the diagnostic pathway of infertile patients, patients with repeated implantation failure ( >2) after in vitro fertilisation (IVF) and patients with repeated miscarriages (>2):  In fact, it has been described how certain abnormalities of the endometrium or myometrium are more common in these patients than in the general population and may be the cause of infertility or pregnancy prediction by interfering with proper implantation of the embryo or development of the placenta (2). In particular, these abnormalities include endometrial polyps (FIG 1), submucosal or voluminous myomas causing distortion of the uterine cavity, certain congenital uterine morphologic abnormalities, the presence of intrauterine synechiae/Asherman's Sd or the presence of endometritis (FIG 2).

In the diagnosis of such pathologies in premenopausal patients, diagnostic hysteroscopy: 

• appears to be highly accurate, but with no evidence in the literature of superiority over TV ultrasound or sonohysterography in the diagnosis of endometrial polyps (2); however, hysteroscopy has the advantage of being able to accurately describe the number, location and size of polyps, to perform targeted biopsies and, as we shall see, in many cases to convert the procedure from diagnostic to operative (6)
• can provide complementary information regarding the diagnostic framing of submucosal uterine myomas: in fact, diagnostic hysteroscopy makes it possible to establish the exact location and the proportion of the intracavitary component, while ultrasound examination provides a complete picture of the depth of myometrial involvement: for this reason, a diagnostic framing involving both methods is advisable in order to establish the best therapeutic approach (5, 7) 
• can provide useful and complementary information in the evaluation of congenital uteine anomalies (Mullerian anomalies), for which, however, a 3D ultrasound scan is also necessary in order to define not only the morphology of the cavity but also the external contour of the uterine viscera(8)
• It is the gold standard for the diagnosis of intrauterine adhesions/ Asherman's Sd, which are difficult to visualise by ultrasound evaluation and for which sonohysterography can only provide partial information (8)
• Recent studies suggest a key role of hysteroscopy in the diagnostic suspicion of chronic endometritis, a condition that cannot be diagnosed with CT ultrasound (9)

Risulta interessante come dato il fatto che, in  donne che subiscono ripetuti fallimenti nell‟impianto dopo procedure di la fecondazione in vitro,  anomalie della cavità uterina, non diagnosticate da una precedente ecografia TV e/o sonoisterosalpingograifa , siano individuate nel 25-50%dei casi  all’esame isteroscopico ( 2).

The diagnosis of benign intracavitary uterine pathologies allows either their concomitant treatment or the planning of an appropriate subsequent therapeutic course. This is of great relevance for patients. In fact, although there are few randomised studies, the available data seem to indicate that hysterosocpic treatment of endometrial polyps is effective in increasing pregnancy rates both spontaneously and after IUI (2, 10, 11, 12) ; hysteroscopic incision of uterine septa (metroplasty), and medical (antibiotic) treatment of endometritis also appears to be effective in increasing pregnancy rates both spontaneously and in women who experience repeated implantation failure after IUI (8, 13, 14, 15, 16, 17); It has also been reported that treatment of uterine septa, endocavitary adhesions and endometritis can improve live birth rates in patients with recurrent miscarriages (18, 19); however, the effectiveness of removing submucosal myomas in increasing pregnancy outcomes in all these categories of patients is still debated (8, 10).

For these reasons and given the low invasiveness and safety of outpatient diagnostic hysteroscopy, there is currently an indication to perform this examination for the evaluation of the uterine cavity:

• in infertile patients, in the event of a clinical indication or clinical or instrumental suspicion of intrauterine pathologies or abnormalities (2, 20),
•  in women who suffer repeated implantation failures after in vitro fertilisation (2)
• in women with recurrent miscarriages (2).

In the case of repeated implantation failures after IVF there is also evidence that pregnancy rates are improved even in women with a normal cavity at hysteroscopy compared to women who do not perform hysteroscopy, thus indicating that simply performing the procedure has a positive prognostic value for achieving pregnancy (21, 22). However, there are not enough studies to date to determine whether such an advantage actually exists before the first IVF cycle or after a failed IVF (2).

 The Abnormal Uterine Bleeding (Abnormal Uterine Bleeding or AUB), defined as excessively heavy menstruation or intermenstrual vaginal bleeding in women of childbearing age, or also as any postmenopausal uterine bleeding (2) represents another of the most frequent indications for the performance of outpatient diagnostic hysteroscopy. In fact, although in some cases AUB can be related to haemorrhagic diathesis conditions secondary to systemic pathologies or to the assumption of drugs, or simply of a dysfunctional nature on a hormonal basis, in many cases it is associated with the presence of benign uterine pathology (e.g. fibroids, polyps, adenomyosis, isthmocele) or malignant pathology ( 5). After having ruled out the presence of systemic alterations and after having ruled out a possible pregnancy in women of childbearing age, the clinical-instrumental evaluation of the uterus and in particular of the endometrium to exclude the presence of any intrauterine pathology can once again make use of transvaginal ultrasound (TV), sonohysterography and diagnostic hysteroscopy. There is no official consensus on which method is absolutely the most accurate and on the time sequence in which the different procedures should be performed in these patients (2, 3), although in many studies hysteroscopy is used as the gold standard examination to evaluate the diagnostic accuracy of the other methods in the diagnosis of intrauterine pathology in patients with AUB.

 In premenopausal women with AUB, the sensitivity and specificity of hysteroscopy is reported to be between 90 and 97 % and between 62 and 93% for the diagnosis of any intrauterine pathology, and between 90 and 100% and between 97% and 100% for the diagnosis of endometrial hyperplasia and carcinoma, respectively. Ultrasonography and sonohysterosalpingography have also shown high diagnostic accuracy for intrauterine pathology in these patients, although the reported sensitivity and specificity values are extremely variable, making it difficult to compare the methods (e.g. the sensitivity of ultrasonography in the diagnosis of endometrial hyperplasia and endometrial carcinoma varies between 33 and 100% in the different studies, and the specificity between 79 and 99%) (2, 23, 24). In postmenopausal women, on the other hand, some data suggest that hysteroscopy has greater accuracy in assessing the presence of polypoid lesions, endometrial hyperplasia and endometrial cancer than VT ultrasound (2, 25): in fact although it is reported that the risk of malignancy is related to increased endometrial thickness and that a negative ultrasound examination (endometrium < 4 mm) decreases the risk of endometrial carcinoma by 90% (4), it is also reported that endometrial carcinoma may also be present in postmenopausal women with atrophic or only focally hyperplastic endometrium, which cannot be visualized on CT scan, so that endometrial cancer in postmenopausal women cannot be excluded even in the presence of a thin endometrial rhyme (<4 mm) on ultrasound evaluation (4) ; We also know that the risk of endometrial carcinoma being the cause of AUB increases with increasing age (from 9% at age 50 to 60% at age 60) and if AUB is persistent over time(4, 26).

In light of these data, some guidelines ( 2) suggest that hysteroscopy should always be performed in women with AUB in whom other methods (sonohysterography and/or transvaginal ultrasound) have previously diagnosed or cannot exclude endouterine pathology, and that it may be reasonable to perform a hysteroscopic evaluation of the endometrial cavity in postmenopausal women with endometrial thickness > 4 mm, or with endometrial thickness < 4 mm (negative ultrasound) and repeated episodes of AUB.

The possibility offered by modern hysteroscopy to perform targeted biopsies under vision increases its diagnostic accuracy especially with regard to atypical or malignant lesions, allowing the nature of the lesion to be defined (2). This method has also proved to be much more accurate than the techniques 'blindly'such as cavity revision or endometrial dilatation and curettage: these techniques in fact, used as standard glod in the past, blindly sample only part of the endometrial cavity, risking missing some of the focal lesions of the endometrium both benign and malignant (2, 4, 5,7), in particular for endometrial carcinoma a false negative rate of between 11 and 20% is reported with blind techniques, while only 3-7-% with diagnostic hysteroscopy with targeted biopsy (4). 

Some authors have also proposed diagnostic hysteroscopy with biopsy as a first-line examination in postmenopausal women with AUB, also in light of the less invasiveness and less patient discomfort due to the modernisation of this technique ( 4)

A special category of patients who may present with AUB or endometrial thickening on TV ultrasound is represented by patients in Tamoxifen therapy. Administration of tamoxifen for 5 years is the main adjuvant endocrine therapy after conservative surgical treatment of oestrogen receptor-positive breast cancer, due to its anti-oestrogenic effect at this level. However, at the endometrial level tamoxifen behaves as an agonist and prolonged therapy may result in a higher incidence of endometrial proliferative disease. The most frequently found histological lesion is cystic atrophy, due to retention of mucous secretions due to atrophy of the glandular cells caused by the drug, but an increased risk of endometrial carcinoma has also been found in these women (2). In these cases TV-ultrasound has low diagnostic accuracy for endometrial carcinoma with a high number of false positives due to the inability to determine the benign or malignant nature of the thickening (25). In women on tamoxifen who present with an episode of abnormal uterine bleeding or in whom endometrial thickness > 8 mm is found, diagnostic hysteroscopy combined with targeted biopsy is indicated in order to diagnose carcinomatous lesions early (2, 27). Furthermore, since the role of tamoxifen in endometrial carcinogenesis appears to be primarily to promote existing precancerous lesions, and given the high prevalence of precancerous endometrial lesions in patients with a history of breast cancer (28), some guidelines suggest hysteroscopic screening prior to initiating tamoxifen therapy (2).  

How 'modern' diagnostic hysteroscopy is performed

Today, diagnostic hysteroscopy can be performed on an outpatient basis thanks to the technological evolution of the instruments used, which has made it possible to reduce patient discomfort during the procedure.

The use of the speculum for access to the portio has been superseded by the possibility of performing vaginoscopic entry ('no touch technique'): the hysteroscope is inserted at the level of the vulvar ostium, the vaginal cavity is minimally distended by a liquid or gaseous medium allowing visualisation of the vaginal walls up to the posterior fornix and cervix. The small calibre of modern hysteroscopes (3-5mm) allows at this point the entry into the external uterine ostium and the cervical canal without the need to use traumatic instruments such as neck forceps (tentaculum) or cervical dilators, which were used in the classical hysteroscopic technique to facilitate the insertion of larger diameter hysteroscopes.

This type of approach has proven to be effective in reducing the pain perceived by the patient, limiting the need for sedation and/or anaesthesia and therefore increasing patient compliance (29). For this reason, modern guidelines (1, 2, 30) recommend to use the vaginoscopic approach as the standard technique for the performance of an outpatient hysteroscopy and to limit the use of the speculum and traditional instruments in cases where anatomical obstacles or technical impediments outweigh the disadvantage of the potential discomfort related to its routine use (RECOMMENDATION A).

The oval, rather than round, cross-sectional shape of modern hysteroscopes also adapts better to the shape of the OUE, helping to reduce patient discomfort during insertion. 

Once past the OUE and cervical canal, the uterine cavity is distended with a physical medium, which may be gaseous (carbon dioxide) or liquid (commonly saline). CO2 has been widely used in the past; it requires an insufflation pressure of 100-120 mmhg with a flow of 30-60 ml/min to maintain an endouterine pressure of between 40 and 80 mmHg (higher pressures expose to the risk of gas embolism); this medium allows for exclusively diagnostic, not operative, procedures. Alternatively, more recently liquid distention media have been introduced, to be used with an irrigation pressure of approximately 70-100 mmHg (100-150 cmH2O) and a flow of 200 ml/min to maintain an intrauterine pressure of 30-40 mmHg (bear in mind that for higher pressures liquid can pass retrograde into the abdomen via the tubes) (30, 31); the pressure can be adjusted manually, by means of a pressurised cuff wrapped around the bag containing the liquid medium, or more precisely by an electronic pump (31); for diagnostic procedures, saline is commonly used, for operative procedures using monopolar electrified instruments, a non-electrolyte medium such as glycine or sorbitol/mannitol is required; both media can be used in the case of bipolar electrified instruments (30), however, non-electrolyte media are associated with a greater risk of electrolyte imbalance if intravascular absorption of the medium (intravasation) occurs. Intravasation is a phenomenon that can occur for all liquid distention media, which is why it is recommended in these cases to monitor the difference between the incoming and outgoing fluids and to stop the procedure if this difference exceeds a certain threshold value (1.5 L for glycine, 2 L for sorbitol-mannitol, 2.5 L for saline) (32).

 For diagnostic procedures there is no evidence as to which medium (gaseous or liquid) is better: no significant differences are reported in terms of pelvic pain and quality of vision, however the liquid flow, compared to CO2, may favour vision even in the presence of intracavitary bleeding, and a reduction in vasovagal reactions and a slight reduction in examination times with the liquid medium has been shown (2, 30). Current guidelines leave the choice of medium to the discretion of the operator (1, 2) , however in modern hysteroscopy the use of CO2 as a distension medium is increasingly abandoned in favour of the use of saline.

Upon entering the cavity, the operator performs a panoramic assessment of the uterine cavity by observing the bottom of the cavity, the tubal ostia, and the anterior and posterior walls (FIGURE 3). The use of 30° optics with foroblique vision allows these operations to be performed simply by rotating the optics clockwise and counterclockwise, without the need to perform lateral movements (which are necessary if 0° optics are used) that may increase patient discomfort.

Modern guidelines (1,2) specify that outpatient hysteroscopy should be performed in an appropriately sized room with suitable equipment, a resuscitation trolley and an area for a possible stay after the procedure where assistance and/or comfort can be provided. 

The presence of qualified personnel, and in particular dedicated nurses to assist and calm the woman during the procedure is reported as a key element for the success of the examination. 

The outpatient hysteroscopy is nowadays a method recognised as safe and convenient, characterised, compared to the hysteroscopy performed in the operating room with general anaesthesia, by a faster mobilisation, a better recovery after the procedure, a reduced absence from work and less loss of earnings and reduced transport costs (34, 35), with a high degree of satisfaction for the patients and with considerable economic advantages both for the woman and for the Health System. For these reasons, several authors and guidelines (1, 2, ,30, 31, 32) agree that, nowadays, hysteroscopy for diagnostic purposes should be performed in this way.

 Tools make the difference

The technological advancement of instruments over the last 15-20 years has been the key that has made it possible for hysteroscopic examinations to be performed on an outpatient basis.

In particular, the progressive miniaturisation of endoscopes coupled with improvements in image transmission technology has made it possible to create hysteroscopes of ever smaller calibre, without sacrificing the quality of the image obtained and thus the quality of the examination performed.

The endoscope, consisting of an optical lens system, is the component of the hysteroscope that transmits light from the anatomical site (uterine cavity) to the camera. It also allows the passage of distension medium, which is essential for viewing otherwise virtual cavities. The diameter of the most commonly used endoscopes in outpatient/office hysteroscopy is 4-5 mm; in particular (7, 31, 32):

• L' Bettocch hysteroscope (FIG 4)i, which has been the most widely used in recent years, is equipped with an optical system with a diameter of 2.9 mm, lined with an inner liner that allows the incoming distension medium to pass through, onto which a further outer liner is inserted, reaching a maximum diameter of 5 mm; the outer liner allows a continuous flow system to be set up, i.e. it allows the distension medium (a liquid medium is required for this system) that is introduced into the cavity to flow out quickly through the outer liner, thus facilitating the cleaning of the medium in the cavity and better visualisation of the image; the outer liner is also equipped with a 5 French diameter operating channel that allows operating instruments to be inserted (see next paragraph).A very recent version of this hysteroscope sees the diameter of the optical system reduced to 2 mm and the total diameter of the hysteroscope reduced to 4 mm, including the outer liner, with further gain in comfort for the patient.
• L'integrated hysteroscope B.H.O.I. (Bettocchi integrated office hysteroscope, FIG 5) which represents an evolution of the Bettocchi 4 mm in which the different components (optics, inner sleeve, handle with connection for the optical fibres and wash tubes, operating channel) are integrated in a single shape for better ergonomics
• The hysteroscope TROPHYscope (FIG 6) which can be used with only one liner and single flow (3.5 mm diameter) for diagnostic purposes, but on which an external liner can be inserted, reaching a total diameter of 4.4 mm, resulting in an operating system with a 5 Fr channel and continuous flow
• The flexible hysteroscopewhich has an overall diameter of 3.5 mm with an operating channel of 4 Fr and a flexible stem that should be even less traumatic for the patient; there is a real reduction in pain reported by patients with this hysteroscope, which, however, has not been widely used due to its high cost and delicate maintenance; reduced image quality and a higher failure rate of the procedure with this instrument are also reported (2, 30).

In order to maintain good image quality with such small-diameter hysteroscopes, the evolution of the components that allow vision was crucial, and in particular(31):

• the light source: today's most widely used machine (XENON COLD LIGHT SOURCE-Storz) uses Xenon as a source of high-intensity cold light; the material is characterised, among other things, by a very long half-life (up to 500 hours).
• the light cable, which transmits light from the source to the endoscope, is generally a fibre-optic cable; there are liquid crystal light cables that transmit greater light intensity but are less flexible.
• the high-definition camera, which captures images from the anatomical site via the endoscope and transmits them to a monitor for viewing

The images obtained can now be stored in accurate archiving systems, as well as printed by high-definition colour printers and delivered to the patient in the report documentation.

The 'see and threat' outpatient surgical approach

Towards the end of the 1990s, the introduction of innovative miniaturised instruments made it possible to incorporate these components in the instrumentation used for diagnostic hysteroscopy. In fact, as has already been described, modern hysteroscopes are equipped among their components with an external sleeve that allows the establishment of a continuous flow system of the distension medium and is equipped with an operative channel (usually 5 French in diameter) through which it is possible to introduce very thin operative instruments and perform small interventions. This means that some pathologies that are detected during outpatient diagnostic hysteroscopy can be treated and resolved at the same site (see and threat)without dilatation of the cervical canal, without anaesthesia and without the need to schedule a hospitalisation to perform an operative hysteroscopy in the operating theatre.

The miniaturised instruments used in Ambulatory Office Hysteroscopy include (30, 31, 32) a number of 'cold' mechanical instruments, such as blunt-tipped or pointed scissors, and different types of forceps (e.g., notched grasping forceps, tentaculum grasping forceps, biopsy forceps) (FIG. 7): notched grasping forceps, grasping forceps with tentaculum, biopsy forceps) (FIG 7); recently, a graduated intrauterine palpator has been created that allows measurements to be taken inside the uterine cavity (very useful in the case of uterine septic surgery). 

Electrified instruments are also available. The application of these instruments necessarily requires the use of a liquid distension medium. The instruments are powered by a high-frequency bipolar generator, of which there are 2 models available. The most commonly used, Versapoint (Gynecare, Ethicon Inc) can be connected to 3 types of disposable electrodes of 5 French thickness: the Twizzle, the most widely used, vaporises small and specific portions of tissue, the Spring vaporises larger portions of tissue and the Ball is used for coagulation. These are bipolar electrodes, so their use is compatible with the use of saline, which is already applied for the diagnostic phase. The second model, Autocon II 400 (Karl Storz, Germany) is similar to Versapoint, but the electrodes are polymeric, which is useful in a cost-cutting perspective.

Recently, for the removal of endometrial polyps and small endocavitary myomas, they have also been introduced commercially:

• a 5 mm (15 Fr) diameter miniresectoscope with 0° optics and electrified bipolar loops 

• some models of hysteroscopic morcellators with a diameter of 5.6-6 mm, capable of resecting and aspirating tissue formations protruding into the cavity, which, however, due to cost and application only in selected cases are not yet widely available in hysteroscopic surgeries

Today, a large proportion of the pathology detected can be treated with these instruments in an outpatient setting, with a clear reduction in the number of cases that have to be treated in the operating theatre with the aid of the resector (2) procedure, which is reserved for cases in which outpatient office hysteroscopy does not allow for the optimal performance of the operation 

They are described as easy to perform in office mode(32):

• Targeted endometrial and cervical biopsies under videoscopic guidance (performed with scissors or forceps)
• removal of intrauterine devices (IUDs) deemed
• the placement of tubal sterilisation devices (Essure) with a reported success rate between 88 and 98% for insertion via the office procedure(35)

They can also be performed safely and successfully with these instruments in an outpatient office setting (2, 31, 36): 

• removal of endometrial and endocervical polyps (7): small polyps ( 2 cm, fundic polyps and multiple polyps are more difficult to perform and may benefit from resectoscopic treatment (6). However, some authors report that almost 90% of polyps can be adequately removed in an outpatient office setting ( 7, 8). In a 2002 study by Bettocchi (37) for instance bipolar electrodes were used for the removal of endometrial polyps and small submucosal myomas without significant complications, no recurrence at 3 months and no discomfort complained by most women.
• the myomectomy of small myomas submucosal G0 myomas < 1 cm in diameter: mechanical scissors such as scissors or electrified tips can be used to fragment the myoma and cut the fibres connecting it to the myometrium, subsequently extracting the fragments through the cervical canal with forceps, similar to myomas. Larger myomas are more complex to approach without sedation; a correct diagnostic picture, the surgeon's experience and the patient's characteristics allow the best therapeutic strategy to be chosen in this case (8)

• the lysis of intrauterine adhesions or synechiae: il successo di tale operazione in regime ambulatoriale è riportato fino al 90%dei casi; le indicazioni sono le alterazioni della fertilità e l’oligomenorrea; l’utilizzo di strumenti meccanici è preferibile rispetto a quello di strumenti elettrificati sia per evitare effetti gli effetti negativi di questi ultimi del tessuto endometriale e quindi  sulla ricerca di una successiva gravidanza, sia per ridurre il rischio di danno agli organi pelvici in caso di perforazione uterina, il cui rischio è riportato del 3-5% in pazienti con Sd di Asherman. Per prevenire il riformarsi delle adesioni alcuni autori suggeriscono l’utilizzo di terapie estroprogestiniche postoperatorie e l’esecuzione di una seconda isteroscopia di controllo ad alcune settimane dalla procedura, anche se non vi sono indicazioni univoche su questo in letteratura (8) 

• also the metroplasty of intrauterine septa can be performed using mechanical scissors or electrified instruments on an outpatient basis (8, 30)

The success rate of outpatient office hysteroscopy is reported to be between 44 and 99.5% (31). The right selection of patients and indications and the presence of experienced operators favour the best clinical outcome with a low complication rate. 

The failure of the procedure in most cases is due to stenosis of the cervical canal, which is more frequently found in nulliparous, postmenopausal women, women with previous cervical surgery or in the presence of malformations. Often the patient's pain proves to be a major component in the failure.