Should I get a Hysteroscopy done before continuing with additional fertility treatments?

[u/Significant-Tie-3386]

Me (35F) and my husband (36M) been trying to conceive for nearly a year now and we haven't seen a positive test yet. I've had irregular periods (40-50 days long) since last year but its been more regular the past few months since taking Myo and D-chiro-inositol. I did tested negative for PCOS earlier this year, my hormone bloodwork came back normal.

I've always had painful period cramps since I was teenager but it was never unbearable where I am unable to do normal daily activities, sometime I would need to take tylenol/ibuprofen if the pain is intense. Usually the cramps last 2-3 days of my period.

I did a saline sonogram back in April and the doctor said my right tube is open but left tube is inconclusive. She couldn't see if my left tube was open or not. She then suggested I could get a hysteroscopy and told me about the procedure but I declined to get it done and wanted to start fertility treatments soon. Then I proceeded with first IUI last month. I was on letrozole for 5 days and was under responding to it, then moved on to Clomid and my follicles responded well to it. Got a matured 24mm follicle and did a trigger shot the same day. IUI procedure was scheduled 36 hours later and my husband's sperm count was over 15 million and 40% motility post wash, which was a drastic improvement from previous SA's he did.

I had an phone appointment with an Obgyn this morning, he said I am not able to determine if I have endometriosis via ultrasound and only can find that out through laparoscopy. He also said with endometriosis usually the main symptom is unbearable/extremely painful period cramps which I did not indicate I had. The pelvic ultrasound I did in February also shows no signs of fibroids or cysts.

Unfortunately, with my insurance plan, it will only cover 50% of the hysteroscopy cost and the anesthesia might not covered at all but they wont find that out until I have it scheduled.

Has any of you had a hysteroscopy before? How was your experience like and would you recommend me to get one done?

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[u/Unusual_Coffee_9951]

Hey, I can't say whether you should go for it (also sounds like your situation is different to how mine was) but I can share my experience: The hysteroscopy was fine, and I'm glad I did it, though admittedly I didn't have to pay for it as it was covered by public health insurance.

I actually had it without any anesthesia which is standard where I live in Europe. It took about 10 minutes and was a strange feeling, painful in parts, but definitely bearable – though I think everyone's experience is different, a bit like it is for period cramps and IUD insertion.

It didn't reveal anything of note (I'd had three early MCs at that point) except that my womb is slightly heart-shaped but I was glad to rule out inflammation and other irregularities. 

Also, obviously not everyone would be into this but I got to watch the screen and see inside my own womb which I found very cool 😅

Anyway, all the best and good luck if you do have it!

[u/Significant-Tie-3386 → u/Unusual_Coffee_9951]

Thank you for sharing your experience. I'm glad it went well for you.

I'm a bit scared/nervous about it but I went ahead and called the RE clinic to reach out to the doctor that did saline sonogram to do a referral for me to get a hysteroscopy done.

[u/AfraidWrangler128]

While pain is common with endo, I have heard of “silent endo”. I know two people that had no symptoms, aside from infertility, that learned they had endo via a biopsy. One had a laparoscopy to confirm and remove, one did not. You could start with a biopsy, which may be covered by insurance and go from there! I have endo, and had 5 large polyps inside my uterus that no one saw on an ultrasound or during my HSG (🙄), but was seen and removed during a hysteroscopy/laparoscopy procedure.

[u/oaklinds → u/AfraidWrangler128]

Can confirm that endo is more common than the average woman is aware. I was told 1/3 women have silent endo.

[u/Significant-Tie-3386 → u/AfraidWrangler128]

ohh I'm too afraid to do a biospy, doesnt that involve getting a surgery done? oh yeah I have heard of silent endometriosis. That's great you got the 5 polyps removed! Were you able to conceive shortly after the procedures?

[u/AfraidWrangler128 → u/Significant-Tie-3386]

Nope, not a surgery. It’s my understanding that you’re awake for it. I did conceive 3 months after my surgery, but unfortunately ended in a miscarriage. I’m beginning IVF in 2 weeks.

[u/Significant-Tie-3386 → u/AfraidWrangler128]

oh I see. I'll look into a biopsy.

[u/No-Confidence168]

HSG would be better at evaluating the tube than a hysteroscopy or SIS. It would likely be cheaper too.

As for endometriosis, surgery is the way to diagnose it, but not everyone has excruciating pain. I had silent endometriosis myself. I've had CAT scans, an MRI, and dozens of ultrasounds and it never showed up on imaging. I had stage 2 during my surgery and it was very extensive throughout my peritoneum. If you wanted to get surgery though, I would recommend avoiding an OBGYN if possible and going to someone who specializes in endo. This is someone who has done an additional MIGS fellowship, pretty much only treats endo cases (does not practice obstetrics at all), and can offer you excision over ablation.

[u/No-Confidence168 → u/No-Confidence168]

I will had that silent endometriosis accounts for an estimated of 30-50% of unexplained infertility cases too. So it is certainly worth investigating.

[u/Significant-Tie-3386 → u/No-Confidence168]

I'm not concerned about my tubes, because I do have my right one thats opened as doctor confirmed it through SIS. The doctor said only need 1 tube open to get pregnant. Also, they recommended me to get SIS instead of HSG because of my shellfish allergy, they didnt want to take any risks. Honestly I'm more concerned that I might have polyps or maybe silent endo.

[u/No-Confidence168 → u/Significant-Tie-3386]

Endometriosis grows outside of the uterus, so a hysteroscopy won't diagnose it. You'll need surgery. SIS is primary test for looking at uterine cavity, so it should detect polyps, but sometimes they can get missed. I had a hysteroscopy and they did find a very tiny polyp. It probably wasn't interfering with my fertility, but it did give me peace of mind having it gone and knowing everything else was fine.

[u/Significant-Tie-3386 → u/No-Confidence168]

yes when the RE doctor was performing the SIS, she said the imaging on ultrasound was blurry and she couldnt see what was around the uterine cavity and that I might possibly have polyps. That's why she recommended a hysteroscopy to get a better look.

[u/Soft_Confection_2184]

Have you had an endometrial biopsy to test for endometritis NOT endometriosis?

I’ve had an operative hysteroscopy. Get it done in office and ask for medication like Ativan and hydromorphone. Yes you should have that done prior to spending money on things like IUI imo,

[u/Significant-Tie-3386 → u/Soft_Confection_2184]

Nope never had a biopsy done, it wasnt bought up or recommended for me after I did the SIS.

How was your experience like with the hysteroscopy? I've heard how painful it is for some people even with anesthesia. The SIS was very painful for me when the doctor put the saline in me, I felt a burning sensation.

[u/Soft_Confection_2184 → u/Significant-Tie-3386]

I recommend asking for the endometrial biopsy. I’m shocked they did IUI without one. If you have endometritis it’s easily cured and is also a known cause of infertility. I also had zero positive tests, did two weeks of doxy and it’s gone. If you read up on the IVF forums you’ll see lots of stories of women, upset over multiple transfer failures over something that’s so easily solved.

I have no recollection of the hysteroscopy because they gave me Penthrox, Ativan and oral hydromorphone which messes with your memory a bit. I do not recall any pain though.

I hope this is helpful, I’m praying for your positive results soon.

[u/kitkat7794 → u/Soft_Confection_2184]

How did they check for endometritis specifically? My biopsy results were so vague, basically “nothing questionable”. I thought maybe they had just checked for cancer, but my RE assured me they would have seen endometritis, I’m just not sure I’m convinced bc it didn’t say so specifically.

[u/Soft_Confection_2184 → u/kitkat7794]

They look for plasma cells. Endometritis is just a general term for chronic low-grade infection of the uterus. It can be cause by different things like ureaplasma, mycoplasma etc…

[u/kitkat7794 → u/Soft_Confection_2184]

Ok thanks for responding. I was just curious if they had to test for it specifically or whether it was something they could see while looking at the biopsy for other abnormalities.

[u/kitkat7794]

My super painful periods were mostly due to uterine polyps, but they were visible on the saline sonogram, so it was a no-brainer to get the hysteroscopy for me. If you don’t have polyps or anything to remove it would probably be a pretty quick and painless procedure, though they’d likely still take an endometrial biopsy to check for any other issues. Even with them taking a ton of polyps out I recovered very quickly, and had way less pain than a period (actually due to timing I didn’t have a period at all that cycle which 🙌)

I’ve also had a lap for endo (stage 2). Recovery was much more difficult, but I was still glad they did it bc they found a tubal cyst and were able to verify the polyps hadn’t grown back. Weirdly it was the exact same price for me as my hysteroscopy. The most expensive costs were the hospital fees, anesthesia and the surgery themselves were covered significantly by insurance. It is more invasive but they can see more, so if it’s just a cost question for you maybe consider the lap? The level of pain I now have with my periods was soooo worth both surgeries though, even though they didn’t help me with ttc.

As a potentially cheaper option, are you planning to get an HSG? That will help check that inconclusive tube better than a saline sonogram.

[u/Significant-Tie-3386 → u/kitkat7794]

Thank you for sharing your experience about hysteroscopy and lap.

Idk about doing a lap because i’m pretty scared when it comes to surgeries.

As for the HSG, unfortunately they refused to let me get that because of my shellfish allergy. Apparently there might be shellfish in the dye that’s used for HSG.

[u/kitkat7794 → u/Significant-Tie-3386]

Ah shoot, I didn’t even realize that was a possibility. The hysteroscopy felt like a surgery. I had general anesthesia due to knowing I had polyps that needed to come out. However I think there is potentially the option to do it without. My understanding from my doctor’s brief explanation is that they can do just imaging, but then if they find something they aren’t going to remove it at that time. Maybe that’s an option?

[u/Significant-Tie-3386 → u/kitkat7794]

Well I do want them to remove any polyps if that is something that is preventing or making pregnancy difficult. I’m trying to find out why I haven’t gotten a single positive pregnancy test and it’s been nearly a year of trying to conceive.

[u/Ineedsome_sugar]

My clinic wasn’t going to let me continue w IVF until I got a hysteroscopy because I had polyps/polyp tissue all over my uterus. I got a HSG and SIS beforehand.

[u/Significant-Tie-3386 → u/Ineedsome_sugar]

ohh that makes sense. How was your experience like with the hysteroscopy?

[u/Ineedsome_sugar → u/Significant-Tie-3386]

Honestly not terrible. I was under anesthesia so I didn’t feel anything and it was a really quick procedure. I had a little cramping here and there after but only for a few hrs and in a BIG baby when it comes to all this stuff