See more, treat early, conceive sooner: Outpatient hysteroscopy in modern fertility care

Introduction

The introduction of hysteroscopy has revolutionized infertility practice and fundamentally changed the way in which gynecologists approach women with intrauterine pathology. ¹ It is currently considered the standard of care for diagnosing and treating intrauterine pathologies, including abnormal bleeding, endometrial and cervical polyps, fibroids, synechiae, placental remnants, intrauterine device malposition, adenomyosis, congenital malformations, and other uterine abnormalities.^2,3

Owing to the technical innovations and smaller instruments, the diagnosis and treatment of intrauterine pathologies can now be performed in the outpatient setting. ²

Up to 50% of women with recurrent implantation failure are diagnosed with intrauterine pathologies, which account for approximately 10%–15% of in vitro fertilization (IVF) failures. ⁴ Therefore, to identify and treat potential factors that could decrease the success of assisted reproductive techniques (ART), clinicians should perform a thorough evaluation of the uterine cavity prior to beginning ART. ⁵ In fact, women who are infertile or subfertile are more likely to have intrauterine diseases, making impaired fertility a major clinical challenge. ⁶

Although the real value of hysteroscopy in procreative testing remains the subject of debate, recent research suggests that hysteroscopic assessment prior to initiating ART may improve reproductive outcomes. ⁷ This is likely secondary to the frequency of intrauterine abnormalities in asymptomatic patients undergoing ART—ranging from 20% to 50%—depending on age, risk factors, and history of recurrent implantation failure. ⁸

See more

The principle “seeing is believing” reflects a crucial concept in precision medicine and fertility. The effectiveness of treatment and ultimately the success of ART depend on a clear and accurate image of the uterine cavity, which is crucial for fertility care as it influences the precision of diagnosis. In the past, the main indirect methods for evaluating uterine factors in infertility were saline infusion sonography, transvaginal ultrasonography, and hysterosalpingography (HSG).^9–11 The patient’s infertility journey may be prolonged if subtle and clinically significant abnormalities are overlooked, although these imaging techniques offer valuable first-level data. ¹²

Conversely, hysteroscopy provides direct, real-time visualization of the uterine cavity, representing a major advancement. ¹³ With the use of high-definition optics with 4K imaging systems, enhanced lighting sources, and increasingly compact instrumentation, modern hysteroscopy provides operators with unmatched clarity and precision in diagnosis and treatment while remaining a minimally invasive procedure. Its superior visualization enables the accurate identification of minute intrauterine pathologies, including micropolyps (<5 mm), stromal edema, hypervascularization of the endometrium, or localized inflammatory areas suggestive of chronic endometritis. Chronic endometritis is a subtle condition related to recurrent pregnancy loss and repeated implantation failure, often asymptomatic and not detectable via routine ultrasonography or standard infertility evaluations. ¹⁴ Moreover, subtle intrauterine adhesions and partial septae—conditions often overlooked or inadequately characterized by conventional imaging techniques—can be efficiently treated.

Hysteroscopic procedures have become increasingly patient-friendly over the past few decades. In the past, hysteroscopy entailed using a speculum to withdraw the vaginal walls, followed by the use of forceps or tenaculum to maintain the cervix in place and cervical dilatation using dilators. Next, using the external cervical os, the hysteroscope was inserted into the cervical canal under direct vision. As the hysteroscope could only be used during cervical dilatation, anesthesia was necessary, making the procedure painful and unsuitable to perform in an office setting.^15–17

The so-called “vaginoscopy no touch technique,” which does not require a vaginal speculum or tenaculum, is the current form of hysteroscopy performed in clinical practice due to technological advancements and the miniaturization of the hysteroscope. ¹⁷ This atraumatic method substantially reduces the discomfort caused by the tenaculum and speculum. The “no touch” technique is used to drive the instrument into the cervical canal after the hysteroscope has been placed into the vagina and the external cervical os has been identified. The vaginal introitus is manually closed when vaginal distension is necessary. Hysteroscopy is currently a viable and well-tolerated outpatient procedure that does not require preprocedural analgesia or anesthesia because of the widespread use of the vaginoscopic technique. ¹⁸

Treat early

Time is a critical resource in reproductive medicine. The difference between a failed cycle and a positive pregnancy test may depend on the ability to treat immediately. ¹⁹

In addition to accurate diagnosis, prompt and efficient therapeutic interventions are essential to maximize fertility outcomes. Outpatient hysteroscopy provides the opportunity to address uterine abnormalities and intracavitary pathologies immediately.^20,21

In the past, diagnosing uterine diseases required a sequential procedure involving imaging, diagnostic hysteroscopy, referral for anesthesia-assisted surgery, and finally re-evaluation. This fragmented approach frequently resulted in delays lasting weeks or months. Conversely, see-and-treat hysteroscopy eliminates the need for hospitalization or general anesthesia by enabling diagnosis and treatment in a single session. This simplified procedure significantly shortens the interval between diagnosis and treatment, which is critical for women preparing for ART or approaching the end of their reproductive window. ¹⁴

Crucially, early treatment with outpatient hysteroscopy minimizes time loss both biologically and psychologically. One of the most distressing parts of the infertility journey for many patients is the uncertainty regarding the extended interval between diagnostic tests and treatment. ²² Performing procedures in the outpatient setting is simpler than scheduling resections in the operating room. Clarity, feasibility, and precision—an immediate action plan that empowers the patient and the clinician—are provided by a one-session see-and-treat strategy. Accordingly, it should be emphasized that the advantage of the outpatient setting does not lie in the intrinsic speed of the hysteroscopic procedure itself, but in the overall simplification of the clinical pathway. Unlike day surgery or operating room scheduling, outpatient hysteroscopy avoids preoperative anesthesiology consultations, laboratory or radiological workup, and anesthetic preparation. Therefore, care continuity is improved by the promptness of hysteroscopic intervention. Clinicians can address uterine-related inflammatory or mechanical barriers to fertility within minutes of diagnosing a patient, avoiding surgical waiting lists and maintaining or even speeding up ART timelines.^2,7 In high-stakes situations, such as those involving women who are in their late reproductive age or who have few viable embryos left, this has a particularly significant effect.

Importantly, outpatient hysteroscopy can safely and effectively treat various uterine lesions that affect fertility. Bipolar, laser, mechanical, or even hysteroscopic tissue removal devices can be used to remove endometrial polyps, including those larger than 2 cm—which can interfere with implantation and are linked to lower pregnancy rates.^23–25 It is also possible to completely remove submucosal fibroids (type 0, 1, or 2), which occupy or distort the endometrial cavity and are associated with pregnancy loss and implantation failure, using a single- or two-step approach. ²⁶ T-shaped uteri, partial or complete uterine septa, and other Müllerian abnormalities that affect embryo implantation and increase the risk of pregnancy loss can be corrected on the same day as the sonographic diagnosis. ²⁷

It is possible to safely manage the retained products of conception, decidual remnants after an abortion, or spontaneous pregnancy loss, which, if ignored, could lead to intrauterine adhesions and unsuccessful pregnancy attempts. ²⁸ Without interfering with the reproductive schedule, the ability to treat these conditions promptly maintains or restores normal endometrial receptivity. Hysteroscopy may cause changes in the immune system and gene expression that could improve endometrial receptivity and implantation, according to another theory that supports intracavitary assessment as both diagnostic and therapeutic. ²⁹ Patients with repeated implantation failure exhibit distinct patterns of cytokine concentrations and different activity levels of matrix metalloproteinase in the lavage fluid collected after hysteroscopy. Irrigation of cytokines and components related to immunity may theoretically help reverse this pattern. ³⁰

Conceive sooner

Infertility is not only a critical issue but also a time-sensitive challenge. For many couples, each lost cycle represents not only a biological setback but also an emotional strain and often a financial burden. In this context, outpatient hysteroscopy emerges not only as a diagnostic or therapeutic tool but also as a means to accelerate conception through timely, targeted, and minimally invasive management of uterine pathology.

It is well known that hysteroscopy increases the possibility of live births in patients who have experienced at least one unsuccessful ART cycle. ⁷ A significant number of patients undergoing IVF are likely to benefit from hysteroscopy, as up to two-thirds of initial transfers may not necessarily lead to implantation (depending on patient prognosis and usage of preimplantation genetic testing for aneuploidy). ⁴ Furthermore, given the severe financial outcomes of a failed embryo transfer, we could argue that the expense of performing a diagnostic outpatient hysteroscopic operation is more than justified. ³¹

Reproductive outcomes can be greatly enhanced by treating intrauterine abnormalities, even if they are mild or asymptomatic. Increased clinical pregnancy and live birth rates have been linked to hysteroscopic correction of endometrial polyps, submucosal fibroids, uterine septa, or synechiae in women undergoing ART.^13,32 For instance, it has been demonstrated that removing endometrial polyps before embryo transfer almost doubles the likelihood of implantation. ³³ Similarly, hysteroscopic metroplasty significantly lowers miscarriage rates and shortens time to pregnancy in women with dysmorphic or septate uteri. ³⁴

Additionally, improving endometrial receptivity, a crucial factor in implantation success, is another benefit of hysteroscopy. ³⁵ A more favorable environment for embryo implantation is produced by hysteroscopic intervention, which restores the endometrial cavity’s normal architecture, eliminates localized inflammation, and optimizes vascular patterns.^36,37 Combining hysteroscopic biopsy with targeted treatments can substantially increase live birth rates in women with suspected endometrial dysfunction or chronic endometritis, especially after multiple failed implantation attempts. ³⁷

Implementing outpatient hysteroscopy as a routine step in infertility care may significantly shorten time to pregnancy, both spontaneous and assisted, compared with traditional stepwise approaches, according to recent data from cohort studies and meta-analyses. ³⁸ Crucially, these advantages are not exclusive to environments with abundant resources; even in settings with limited resources, the use of outpatient hysteroscopy has been linked to increased accessibility and cost-effectiveness of fertility-preserving care. ³⁹

Limitations and challenges

Access to adequate equipment and efficient logistics is critical to the efficacy and safety of outpatient hysteroscopy. Disposable instruments or dependable sterilization systems for reusable devices are two approaches for instrument management. ⁴⁰ The first approach may reduce long-term costs but requires additional staff and infrastructure. Although the second approach streamlines the processes, it creates financial barriers and poses greater environmental challenges. One of the major obstacles to broader adoption is the cost of establishing a specialized ambulatory clinic, which includes purchasing optical towers, light sources, fluid management systems, and sterilizing platforms. ³⁹ Disposable hysteroscopes and accessories could mitigate such issues but may reduce sustainability, especially in underfunded healthcare systems, where cost is frequently the main barrier. To address this, low-cost models have been proposed. ³⁹

However, the long-term advantages of establishing an outpatient hysteroscopy service can outweigh the upfront expenses. This strategy is not only a therapeutic innovation but also a cost-effective treatment model as it may save numerous resources by avoiding general anesthesia, cutting down on operating room preparation time, eliminating waiting lists, and limiting hospital stays.^31,41,42 However, adequate institutional support and well-designed health policies are essential for its long-term viability.

Another important factor that determines success is the operator’s skills and competence. Specialized training in vaginoscopic approach, pain management techniques, and analysis of unexpected intrauterine findings is a key requirement for outpatient hysteroscopy.^43,44 Although pain and discomfort are significant issues in more complicated situations, the surgery is generally well-tolerated by the patients. However, the operator’s ability to smoothly perform the procedure is a crucial factor, which involves minimizing time losses, avoiding unnecessary maneuvers, and providing efficient counseling and consistent analgesic procedures when needed.^17,40 Finally, it is important to acknowledge the technological limits. Large submucosal fibroids or severe adhesions often render ambulatory operations impractical, necessitating conversion to operating room procedures. ¹

Innovative perspectives

The real innovation of outpatient hysteroscopy lies in its ability to go beyond merely reproducing operations that were previously performed in an operating room in an outpatient environment. Instead, it represents a paradigm shift in infertility treatment, providing a novel approach to diagnosing and treating intrauterine diseases in women.^24,35 This innovation’s first and well-established pillar is the see-and-treat strategy, which overcomes the rigid diagnostic imaging sequence, subsequent surgical hysteroscopy, and postponed therapy. ⁶ The see-and-treat approach avoids needless anesthetic exposure, cuts down on waiting periods, and, most importantly, shortens the time to conception for women who are racing against their biological clock by combining both procedures into a single, instantaneous office-based session.

Equally innovative is the technological revolution accompanying the miniaturization of instruments. Modern 4K optics and digital platforms enable visualization of even the smallest lesions that were previously undetectable with standard ultrasound or hysterosalpingography. ⁴⁰ In the future, augmented reality overlays, 3D reconstructions, and artificial intelligence (AI) algorithms are expected to enhance diagnostic accuracy while also paving the way for automated lesion mapping, real-time decision support, and image recognition of subtle and unclear hysteroscopic patterns. ⁴⁵ These advancements will usher in a new era of precision hysteroscopy. AI in hysteroscopy is evolving from proof-of-concept studies to early translational phases. The actual reproducible features include real-time identification of localized lesions during the process and computer-aided diagnosis on static frames or short clips to identify endometrial disease. ⁴⁶ Regarding categorization, recent studies have shown that convolutional neural networks could significantly outperform gynecologists in interpreting the same hysteroscopic images, indicating that AI can standardize preliminary visual assessments before histological confirmation.^47,48

The biological impact of hysteroscopy is an additional benefit. Once considered strictly a mechanical remedy for intrauterine anomalies, new research suggests that endometrial irrigation and specific hysteroscopy procedures can influence the molecular environment by modifying cytokine patterns, immune cell activity, and implantation-related gene expression.^36,37 This perspective could fundamentally alter our approach to recurrent implantation failure by redefining hysteroscopy as a possible biological modulator of endometrial receptivity in addition to being a structural intervention.

Therefore, outpatient hysteroscopy embodies an integrated, transformative, future-oriented model of fertility medicine, combining technological progress, biological insights, organizational efficiency, and patient-centered care, offering a valid support for the reproductive medicine specialist.

Conclusions

Outpatient hysteroscopy plays a crucial role in the workup of infertile patients in the era of minimally invasive surgery, particularly prior to starting ART and in situations where there has been a history of unsuccessful ART cycles. To date, there is insufficient high-quality information to support the widespread use of hysteroscopy as a screening method to improve the reproductive outcomes of subfertile or infertile women with a normal uterine cavity on ultrasonography or HSG in the initial fertility workup. This practice will probably change, particularly as outpatient hysteroscopy becomes increasingly feasible and affordable. Similarly, it serves as a critical diagnostic method for identifying endometrial subtle lesions and chronic endometritis that are not detectable with standard ultrasound evaluation. In the era when time for reproduction is frequently scarce, the see-and-treat approach is not only a practical substitute but also promotes fertility. Removing a subtle lesion, lysing thin adhesions, treating chronic endometritis, and correcting a minor uterine malformation are a few examples of how early interventions can be favorable for implantation, pregnancy, and motherhood. Clinicians, researchers, and policymakers should recognize the strategic role of outpatient hysteroscopy not only as a diagnostic or surgical tool but also as a core component of modern fertility care.

Improving the broader implementation of hysteroscopy through training, infrastructure, and guideline integration can lead to faster, safer, and more successful reproductive workups. This is because early intervention in reproductive medicine is extremely crucial. Therefore, “See more, treat early, conceive sooner” is more than a clinical motto; it is a fundamental standard for patient-centered, fertility-focused gynecology care.

CRediT authorship contribution statement

Gaetano Riemma, Salvatore Giovanni Vitale, Pasquale De Franciscis: conceptualization, writing—original draft, review and editing.

Data availability statement

Not required for Editorials.

Declaration of generative AI in scientific writing

No generative AI was utilized in writing this manuscript.

Declaration of conflicting interests

There is no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.