How is the uterus assessed before embryo transfer? Learn when ultrasound, SIS, HSG and hysteroscopy are chosen, and what the evidence says about them.
Assessment of the uterus before embryo transfer mostly starts with ultrasound; ultrasound done with saline (SIS), the uterine X-ray (HSG) or hysteroscopy are added if there is a suspicious appearance on ultrasound or a reason in your history. The same methods are not applied to everyone, and it has not been shown that hysteroscopy done as a screening improves the outcome of IVF. The information below offers a general framework and does not replace a diagnosis or treatment recommendation specific to you.
Why is the uterus assessed before transfer?
After the embryo is placed in the uterine cavity, it tries to attach to the inner surface of the uterus. The shape of the cavity and the structure of its inner surface form an important ground for this process. For this reason, before the transfer it is checked whether there is an appearance needing attention in the area where the embryo will implant. The aim is to find an answer to this question with as few and as well-justified examinations as possible.
What is looked at in your uterus with ultrasound?
Transvaginal ultrasound is the first examination method in which the uterus and its lining are imaged. A current guideline prepared for unexplained infertility recommends ultrasound for the uterus, three-dimensional if possible, and does not see it as necessary to request an additional examination if the cavity looks regular on ultrasound. This recommendation is not directly adapted to IVF; even so, it explains why ultrasound is mostly the first step. A three-dimensional image can show the general shape of the uterine cavity in more detail than a two-dimensional image.
What is the difference between SIS and HSG?
SIS is an examination that combines saline given into the uterine cavity with ultrasound, and is chosen to clarify bulges or changes of shape on the inner surface of the cavity. HSG uses X-ray and contrast material; it is considered if the state of the tubes as well as the shape of the uterine cavity is in question. Both are aimed at diagnosis, and which is requested depends on the question the doctor is seeking an answer to.
In which situation is hysteroscopy chosen?
In hysteroscopy the inside of the uterus is watched directly with a thin camera. If a finding has been seen on ultrasound or another examination, it is chosen to clarify this finding or, if necessary, to intervene in the same procedure.
Is an additional method needed for everyone?
No; an additional method is chosen according to need. If there is no suspicious appearance on ultrasound and there is nothing in your history suggesting a problem related to the uterus, additional examination is mostly not required. According to current assessments, doing hysteroscopy as a screening in everyone before IVF is not recommended for routine use; no significant improvement in live birth has been shown in large studies. An unnecessary procedure can also bring its own risk and a delay in treatment. For this reason, the methods to be applied are determined by your doctor, who assesses your history, your ultrasound finding and your previous treatment results together.
Does the assessment change when transfers are unsuccessful?
When embryo transfers are unsuccessful one after another, your doctor can reconsider the scope of the uterine assessment while investigating the causes. The same current assessments state that hysteroscopy as a screening can be considered in recurrent implantation failure. Even so, the aim is not to have many tests done, but to carry out a limited assessment that has a justification.
What does it mean if the result is normal?
A normal image shows that, as far as the examined method can show, there is no striking structural finding in your uterine cavity. Every method has a limit to what it can see; a fine finding may be missed. A uterus that looks normal does not guarantee that the embryo will attach either, because implantation depends on other factors, such as the condition of the embryo. If an abnormal finding is detected, what is to be done is a separate decision; your doctor guides you according to the type of finding and the treatment plan.
Which complaints can be seen after the examination?
After SIS, HSG or hysteroscopy, mild cramp and light spotting may be seen; these are mostly expected complaints. Your doctor determines when the transfer will be done according to the finding and your recovery.
Frequently Asked Questions
What information should be given to the doctor before the uterine assessment?
The possibility of pregnancy and the date of your last period, the medicines you use, and any pelvic infection or operations you have had before are the main information you need to share with your doctor. Your doctor determines the details of the preparation, including medicine and dose, according to you.
What should I do if I have an allergy to contrast material or latex?
You should tell your doctor about these allergies before the procedure. Because the contrast material in HSG, and part of the material used in SIS, may contain latex, a different method may be chosen if you have a history of allergy.
Are these examinations done if there is a possibility of pregnancy?
HSG is not done when there is a possibility of pregnancy, because it involves exposure to X-rays. In SIS too, the procedure is postponed if there is a possibility of pregnancy or a sign of active pelvic infection.
At what time of the menstrual cycle is the examination planned?
The appointment is mostly arranged for the period after menstrual bleeding has ended, when the possibility of pregnancy is low. If the planned day is not suitable because of your bleeding, the date can be moved.
Does assessment of the uterus before transfer mostly start with ultrasound?
Yes. Transvaginal ultrasound is the first examination method. SIS, HSG or hysteroscopy is added according to the question being sought and your history.
Should everyone have hysteroscopy before transfer?
No. Applying it to everyone as a screening is not recommended routinely; no significant improvement in live birth has been shown in large studies.
If the ultrasound is normal, is an additional examination necessarily needed?
No. If there is no suspicious appearance on ultrasound and there is nothing in your history suggesting a uterine problem, additional examination is mostly not required.
Do SIS and HSG answer the same questions?
Both are aimed at diagnosis, but their methods differ. SIS can be chosen to clarify the inner surface of the uterine cavity; HSG is considered when it is wished to assess the state of the tubes as well.
When transfers are unsuccessful one after another, can the examinations be reconsidered?
Yes. The scope of the uterine assessment can be reconsidered and hysteroscopy can be considered. Even so, it is important that the examination has a justification.
Does a normal uterine examination show that the embryo will attach?
No. Every method has a limit to what it can see. Implantation also depends on other factors, such as the condition of the embryo.
If a finding is detected, is intervention needed straight away?
What is to be done is a separate decision. Your doctor guides you by assessing the type of finding and your treatment plan.
Can mild cramp and spotting be seen after the examination?
Yes. These complaints can be seen after SIS, HSG or hysteroscopy. The time of the transfer is determined according to the finding and your recovery.
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