Abstract
STUDY QUESTION
How should the findings of diagnostic hysteroscopy in women with reproductive disorders be reported?
SUMMARY ANSWER
This collaborative document by the European Society for Gynaecological Endoscopy (ESGE), the ESHRE, and the International Federation of Fertility Societies (IFFS) provides the first detailed structured reporting template for diagnostic hysteroscopy findings in women with reproductive disorders.
WHAT IS KNOWN ALREADY
Despite its widespread use in women with reproductive disorders, no standardized framework currently exists for reporting of hysteroscopic findings. This lack of uniformity may limit the utility of the procedure and contribute to substantial heterogeneity among operators and centers. As a result, the reproducibility of hysteroscopy is limited, making it difficult to conduct robust studies that define its prognostic value in specific patient subgroups.
STUDY DESIGN, SIZE, DURATION
A dedicated working group from ESGE, ESHRE, and IFFS collaborated to develop a consensus for comprehensive structured reporting of diagnostic hysteroscopy findings in women with reproductive problems.
PARTICIPANTS/MATERIALS, SETTING, METHODS
This consensus paper focuses on grouping diagnostic hysteroscopic findings, structuring their reporting, and adopting standardized terminology for women with reproductive disorders. The virtual Nominal Group Technique, a structured consensus-building method, was adopted to ensure equal contribution from all members in the development of the final consensus.
MAIN RESULTS AND THE ROLE OF CHANCE
The document provides a structured reporting of hysteroscopic findings into five sections, each systematically capturing patient characteristics, procedural findings, and pathological observations as follows: patient’s characteristics, and findings from the vagina, cervix, uterine cavity, endometrium, and tubal ostia.
LIMITATIONS, REASONS FOR CAUTION
The inclusion of a finding in this structured report is not a proof of its clinical significance, but it could be used as a validation tool for further research.
WIDER IMPLICATIONS OF THE FINDINGS
The standardized reporting of hysteroscopic findings promotes consistent data collection across centers and could help inform research and exchange of clinical experience, enhancing the value of hysteroscopy in fertility evaluation.
FUNDING
No external funding was received for the development of the consensus process or manuscript preparation.
DISCLOSURES
All authors declare that they have no competing interests.
TRIAL REGISTRATION NUMBER
N/A.
Keywords: consensus, hysteroscopy, infertility, reproduction, reproductive disorders, international consensus
Introduction
Hysteroscopy is widely recognized as the gold standard for the diagnosis and treatment of intrauterine pathologies (Gkrozou et al., 2015, 2020; Di Spiezio Sardo et al., 2016). Technological advancements, including smaller-diameter scopes with operative channels and the use of saline distension media, have greatly simplified hysteroscopy, making it more patient-friendly and enabling outpatient procedures without the need for cervical dilation or analgesia (Campo et al., 2005, 2018; Carugno et al., 2021).
As with other specialized diagnostic procedures, the use of hysteroscopy should be guided by specific clinical indications and diagnostic objectives. Reproductive disorders, such as infertility, recurrent pregnancy loss, late miscarriage, and repeated ART failures, represent common indications, requiring evaluation by operators with expertise in reproductive medicine. In patients with reproductive disorders, hysteroscopy provides valuable information on the vagina, cervix, cervical canal, uterine cavity, endometrium, and tubal ostia. It should be regarded not merely as an anatomical inspection, but as a comprehensive functional assessment of factors relevant to reproduction, as well as a tool that may improve the performance of ARTs (e.g. resolution of cervical canal stenosis, anatomical assessment for embryo transfer), specially in patients experiencing recurrent implantation failure (ESHRE Working Group on Recurrent Implantation Failure et al., 2023). Among its key advantages, the procedure enables detailed assessment of endometrial morphology and its concordance with the menstrual phase, while allowing the identification of common congenital and acquired uterine abnormalities, including uterine malformations, niches, fibroids, and intrauterine adhesions (IUAs). Hysteroscopy also permits a limited evaluation of tubal patency through indirect visualization of the morphological and dynamic characteristics of the tubal ostia, potentially revealing infertility-related factors that may escape detection by ultrasound. Overall, hysteroscopy represents a technically refined procedure with substantial diagnostic value.
Despite its widespread use in women with reproductive disorders, no standardized framework currently exists for reporting of hysteroscopic findings. This lack of uniformity may limit the utility of the procedure and contribute to substantial heterogeneity among operators and centers. As a result, the reproducibility of hysteroscopy is limited, making it difficult to conduct robust studies that define its prognostic value in specific patient subgroups.
In recent years, progress has been made toward harmonizing hysteroscopic terminology at the global level, based on expert consensus (Carugno et al., 2021). However, no comparable scientific efforts have been directed toward standardizing the execution and reporting of diagnostic hysteroscopy in women with reproductive disorders. Given its potential global value, there is an urgent need for a scientifically validated and universally accepted framework.
To address this gap, a joint working group was established, composed of representatives from the European Society for Gynaecological Endoscopy (ESGE), the ESHRE, and the International Federation of Fertility Societies (IFFS). The objective of the established working group was to develop a structured reporting of diagnostic hysteroscopy findings in women with reproductive disorders. The overarching objective was to standardize terminology and facilitate global adoption of this framework in both clinical practice and research settings. The present document represents the outcome of this collaborative effort.
Material and methods
Organizational framework and participants
This project was implemented as an international, multidisciplinary consensus initiative jointly endorsed by three leading organizations in the field of reproductive medicine and gynecological endoscopy: the ESGE, the ESHRE, and the IFFS.
A total of 17 experts were nominated by the three societies based on recognized expertise in hysteroscopy and reproductive medicine, as well as significant academic contributions to the field. To strengthen the global relevance of the consensus, experts were selected to ensure representation from diverse geographic regions.
Draft development and consensus methodology
A preliminary draft of a structured hysteroscopy recording template was prepared by a steering committee composed of three members (U.C., A.Vit., A.A.) and critically revised by one (G.G.). This draft was developed following a critical review of the current literature and existing recording systems in gynecology and served as the basis for the consensus process. The consensus process was completed in two virtual meetings and one final round of written feedback. The entire process was conducted between July 2025 and February 2026. After finalizing the reporting template, the manuscript was prepared by U.C. and G.G. and sent for comments and final approval by the members of the working group.
To refine and validate the draft template, we adopted the virtual Nominal Group Technique (vNGT), a structured consensus-building method designed to ensure equal contribution from all participants (Khurshid et al., 2023).
Step 1: Silent generation of comments
Each expert independently reviewed the draft template and documented its strengths, limitations, and potential modifications.
Step 2: Round-Robin sharing
During a moderated video conference, each participant in turn presented a proposed modification. All suggestions were recorded without immediate discussion until the full set of comments was collected.
Step 3: Structured discussion
Each proposed modification was then discussed by the group to ensure clarity, avoid redundancy, and consolidate overlapping proposals. The discussion was moderated to maintain focus and equitable participation.
Step 4: Voting and ranking
All participants subsequently rated each proposed modification anonymously using an electronic survey tool (five-point Likert scale: strongly disagree to strongly agree). A predefined threshold of ≥75% agreement (scores 4–5) was required for inclusion. Items with <50% agreement were excluded, whereas those with 50–74% agreement were revised and re-discussed before re-voting in the same session.
Step 5: Consolidation
The steering committee synthesized the voting outcomes, integrated approved modifications, and produced a revised version of the recording template. This version was circulated electronically among all 17 experts for final written comments. At this stage, only minor editorial adjustments were accepted, and no new items were introduced.
The final text was reviewed and approved by the ESGE Academic Faculty, ESHRE, and IFFS Executive Committees.
Ethical considerations
As this initiative did not involve patient recruitment or the collection of clinical data, formal ethical approval was not required. Nonetheless, the process was conducted in full compliance with the principles of transparency, inclusivity, and respect for intellectual contributions, following Good Consensus Practice recommendations for scientific societies (Brouwers et al., 2010).
Results
Development of the structured reporting template
To ensure a comprehensive and reproducible evaluation of uterine anatomy and pathology in women with reproductive disorders, a structured hysteroscopic reporting template was developed. The report is organized into five sections, each systematically capturing patient characteristics, procedural findings, and pathological observations.
A total of 35 items were reviewed (Supplementary Data File S1). Among these, 17 (48.6%) were approved unanimously, and 18 (51.4%) required modification following group discussion before final approval (Supplementary Data File S2).
Hysteroscopic report
The structured reporting template for hysteroscopic procedures in women with reproductive disorders (Fig. 1) includes the following.
Figure 1.
Final structured reporting template for diagnostic hysteroscopy in women with reproductive disorders.
Patient characteristics
The initial section records baseline demographic and reproductive data, including age, anthropometric parameters (height, weight), hormonal profile (anti-Müllerian hormone: AMH), (follicle-stimulating hormone: FSH), and menstrual history. It further includes previous hysteroscopic or uterine interventions (e.g. cesarean section, myomectomy, conization, uterine artery embolization) and possible previous infections (e.g. pelvic inflammatory disease—PID). Reproductive anamnesis, including infertility, previous implantation failures, gravidity, parity, miscarriages/abortions (with or without dilation and curettage), and preterm deliveries, are also reported. Indications for hysteroscopy (baseline assessment, failed ART attempts, and pregnancy losses) are specified, together with relevant imaging findings from ultrasound or MRI.
Hysteroscopic findings
Vagina, cervix, and cervical canal
The second section addresses the anatomical and pathological findings in the vagina, cervix, and cervical canal.
Potential vaginal anomalies are listed as: longitudinal non-obstructive or obstructive vaginal septum, transverse septum, others (Grimbizis et al., 2013).
Cervical morphology and orientation/course of the endocervical canal (anteverted, axial, retroverted) are documented, along with potential abnormalities such as congenital malformation (single cervix with cervical septum or double cervix) (Grimbizis et al., 2013; Catena et al., 2025a), intracervical synechiae, or stenosis of the internal or external uterine orifice. Cervical lesions, if present also should also be described.
Congenital anomalies of the vagina and the cervix follow the ESGE/ESHRE classification system (Grimbizis et al., 2013, 2016).
Uterine cavity
As a first step, the difficulty in accessing the uterine cavity should be reported; if the access to the uterine cavity is not possible, explanation of the reason why is required. Evaluation of the uterine cavity includes distension quality (optimal/non-optimal), wall irregularities, uterine orientation (anteverted, axial, retroverted), and overall uterine morphology. The presence of foreign bodies or fluid in the uterine cavity is also documented.
Regarding uterine morphology, the report may include a diagnostic suspicion of a dysmorphic uterus (T-shaped or Y-shaped), unicorporeal uterus, or other (e.g. I-shaped, infantilis) (Grimbizis et al., 2013, 2016; Pacheco et al., 2019, 2025). Further differential diagnoses (e.g. between septate uterus and bicorporeal uterus) cannot be made based solely on intrauterine hysteroscopic visualization (Grimbizis et al., 2016). In the hysteroscopic report, the description of the fundal indentation is also required following the ESHRE/ESGE classification system: partial (including also the indentation length) or complete. In case of fundal indentation, a 3D ultrasound examination is recommended, as only the combination of hysteroscopy and 3D ultrasonography ensures the highest diagnostic accuracy (Grimbizis et al., 2016; Campo et al., 2018).
Endometrial features
A dedicated section focuses on findings from endometrium.
It is recommended to describe whether the endometrium appears synchronous with the phase of the menstrual cycle or consistent with an ongoing hormonal therapy, if any.
The following abnormal findings, if present, should be described (Di Spiezio Sardo and Campo, 2021): hypotrophic endometrium; diffuse polypoid thickening; focal polypoid thickening; highly vascularized endometrium; easily bleeding areas; strawberry pattern; cystic dilations of the uterine glands; micropolyps; stromal edema; microcalcifications; ulcerated areas; crumbly consistency; haemorrhagic cysts; small opening on the surface; endometrial vascular dystrophia; endometrial compaction; and/or other.
This section additionally records intrauterine lesions. Polyps are described according to morphology (pedunculated, sessile), position on the uterine walls (anterior, posterior, lateral right, lateral left), location (fundus, corpus, isthmus), and dimensions.
Fibroids are classified following the FIGO system (Type 0 to Type 2) (Munro et al., 2011), with systematic documentation on wall involvement, (anterior, posterior, lateral right, lateral left), location (fundus, corpus, isthmus), and size. Suspicion of Type 3 lesions might also be reported.
Suspected malignant findings are categorized as focal or diffuse lesions, with quantification of cavity involvement (<50% vs >50%) and potential extension toward the myometrium or cervix (Di Spiezio Sardo and Campo, 2021).
IUAs are classified by site (central, lateral, cornua), extent (less than one third, more than one third, or more than two thirds, >1/3, >2/3 of the cavity), and consistency (filmy vs dense) (AAGL-ESGE, 2017).
Isthmocele is described according to its location from the internal uterine os (isthmus or cervix), classification (simple niche, simple niche with one branch, complex niche), and size (small, medium, large, extreme) (Min et al., 2024). Additional characteristics are fluid/blood retention and vascularization.
Other intrauterine pathologies, such as retained products of conception (RPOC) or foreign bodies, are also documented when present. The size and the location of RPOCs may be specified in the report (De Wilde et al., 2024).
Tubal ostia
The characteristics of right and left tubal ostia are reported, together with the presence of adhesions, polyps, or abnormal vascularization.
Discussion
The development of a structured template for reporting diagnostic hysteroscopy findings in women with reproductive disorders represents an important step toward standardization in the standardization of reproductive diagnostics. This initiative provides a consensus-based tool designed to improve consistency across centers, enhance communication among clinicians, and facilitate the design of robust scientific studies. In this section, we discuss the rationale and evidence supporting the inclusion of each section and item within the final report.
Patient characteristics
Accurate documentation of baseline characteristics is essential for stratifying patients and evaluation of hysteroscopic findings. Age, BMI, hormonal profile (AMH, FSH), and reproductive history have all been shown to impact endometrial receptivity and treatment outcomes (ESHRE Guideline Group on Ovarian Stimulation et al., 2026). Previous uterine surgery (e.g. myomectomy, cesarean section) or infections (e.g. PID) are relevant as they may predispose to IUAs or niche formation (Hooker et al., 2022). Although that information is usually included in the patient’s main records and inclusion in the hysteroscopy report might be a duplication, the working group considers that it is important to be included in the record due to their clinical significance, and as a way to avoid ignoring them.
Hysteroscopic findings
Vagina, cervix, and cervical canal
The evaluation of vaginal and cervical anomalies is necessary to identify congenital malformations or structural barriers that may hinder conception or IVF procedures. Cervical anomalies such as stenosis or synechiae can interfere with embryo transfer or sperm migration (Di Spiezio Sardo et al., 2016). Cervical duplications and septa may also indicate Müllerian anomalies (Grimbizis et al., 2013; Parodi et al., 2022).
Vaginal anomalies, although rare, may include longitudinal non-obstructive or obstructive septa and transverse vaginal septa. These anomalies can have significant implications for reproductive outcomes and may be associated with obstructive symptoms, hematocolpos, or dyspareunia. Importantly, their identification can suggest the presence of more complex Müllerian anomalies (Acién and Acién, 2016).
Differentiating between a single cervix with a cervical septum and true cervical duplication is crucial for accurate diagnosis and management planning (Smith et al., 2014). This distinction cannot be made solely by hysteroscopy but requires integration with clinical and imaging data (Miller et al., 2021). The combined use of hysteroscopy, transvaginal ultrasound, and 3-dimensional imaging enhances the diagnostic accuracy in distinguishing these conditions (Grimbizis et al., 2016; Pozzati et al., 2023; Catena et al., 2025a). In cases of a single cervix with a septum, hysteroscopy may reveal a central longitudinal ridge without duplication of cervical canals, whereas true duplication will typically present as two distinct cervical orifices, often associated with complete uterine septum or bicorporeal uterus.
Uterine cavity
Documenting any difficulties in accessing uterine cavity is important for procedures like embryo transfer (D’Angelo et al., 2022). Uterine cavity shape anomalies, such as T-shaped or Y-shaped uterus, were reported as potential factors impairing fertility and pregnancy outcomes; the need for more solid data makes their reporting useful for further research (Di Spiezio Sardo et al., 2020). Further subclassification of dysmorphic uteri, including T-shaped, Y-shaped, I-shaped, and uterus infantilis, has been proposed in recent years, with an increasing need for simultaneous hysteroscopic and ultrasound evaluation of the cavity (Pacheco et al., 2019, 2025; Ludwin et al., 2020). Furthermore, hysteroscopy alone cannot differentiate between septate bicorporeal uterus and/or bicorporeal septate uterus underlining the need of applying 3D ultrasound to improve diagnostic precision (Grimbizis et al., 2016; Ludwin et al., 2018). This combined approach is supported by the concept of the digital hysteroscopic clinic, where real-time hysteroscopy and 3-dimensional ultrasound are employed synergistically to enhance diagnostic accuracy (Campo et al., 2018).
Congenital uterine anomalies are well-documented factors impairing reproductive outcome despite an existing debate for the need of their treatment (Venetis et al., 2014; Grimbizis et al., 2020; ESHRE Guideline Group on RPL et al., 2023; World Health Organisation Guideline Development Group for Infertility et al., 2026). Thus, the documentation of fundal indentation characteristics by hysteroscopy is extremely important in cases of women with infertility and/or impaired pregnancy outcomes (Grimbizis, 2019).
Endometrial features
A comprehensive description of endometrial appearance is a key feature in this consensus. Several hysteroscopic patterns have been associated with endometrial dysfunction, endometritis, or implantation failure. For example, the presence of micropolyps, stromal edema, or increased vascularity has been correlated with chronic endometritis (Bouet et al., 2016; Li et al., 2024). Glandular-cystic changes and irregular vascular patterns may indicate hormonal imbalance or underlying endometrial pathology. The recognition of endometrial post-ovulatory compaction has recently been proposed as a marker of receptivity (Gkrozou et al., 2020).
Endometrial polyps are associated with abnormal uterine bleeding and infertility, with evidence suggesting improved implantation and pregnancy rates following hysteroscopic polypectomy in selected patients (Spiewankiewicz et al., 2003; Pérez-Medina et al., 2005). Their systematic documentation by size, morphology (sessile or pedunculated), and location is fundamental for evaluation of their clinical impact and management.
Submucosal fibroids are linked to impaired implantation and increased miscarriage rates. Their classification using the FIGO system (Type 0 to Type 2 for submucosal types) allows reproducibility and better surgical planning (Munro et al., 2011). Studies have demonstrated improved reproductive outcomes following hysteroscopic myomectomy in women with symptomatic submucosal fibroids (Pritts et al., 2009, 2024; Roy et al., 2010). FIGO type 3 fibroids, which are entirely intramural but overlying the endometrium, are increasingly recognized as potentially relevant in the context of infertility (Favilli et al., 2023). Although they do not distort the endometrial cavity per se, some studies have suggested a possible detrimental effect on implantation due to their proximity to the endometrial–myometrial interface (Etrusco et al., 2023; Favilli et al., 2023). The management of Type 3 fibroids remains controversial, with ongoing debate regarding the indication for surgical removal in asymptomatic women seeking fertility treatment. Their potential documentation in hysteroscopic reports, as they are only partially visible by alterations in the overlying endometrium, is important for their management.
Although rare, the systematic recording of suspicious endometrial lesions is necessary to guide timely histological sampling and further oncological evaluation. Descriptors such as friability, ulceration, and abnormal vascularity are established warning signs of atypical hyperplasia or malignancy (De Angelis et al., 2013). Additional hysteroscopic features associated with endometrial neoplasia include irregular endometrial thickening, papillary excrescences, necrotic or hemorrhagic areas, and spontaneous bleeding upon touch. The presence of atypical vascular patterns, such as densely packed, irregular, or chaotic vessels, may further raise the index of suspicion (Di Spiezio Sardo and Campo, 2021), and when observed in the context of abnormal uterine bleeding, they have been correlated with an increased risk of endometrial cancer (Clark et al., 2002). Early recognition of these findings during hysteroscopy, followed by targeted biopsy, significantly improves the diagnostic accuracy and enables early oncological referral. Moreover, in selected cases of early-stage endometrial cancer, particularly in young women with reproductive desires, accurate hysteroscopic assessment, and standardized documentation of lesion characteristics may support timely decision-making for fertility-sparing treatment. Recent evidence underscores the importance of detailed endometrial evaluation to guide conservative management strategies (Rodolakis et al., 2023; Catena et al., 2025b).
IUAs, commonly resulting from infection or trauma (e.g. post-curettage), are a well-recognized cause of infertility, amenorrhea, and miscarriage, due to distortion of the uterine cavity and impairment of endometrial function (Grimbizis et al., 2021; Hanstede et al., 2021). Accurate description of IUA location, extent (<1/3, 1/3–2/3, >2/3 of the cavity), and consistency (filmy vs dense) is essential and reflects the parameters used in established classification systems such as those originally proposed by March and adopted by the American Society of Reproductive Medicine (March, 2011), and further supported by international guidelines (AAGL-ESGE, 2017).
Hysteroscopic adhesiolysis remains the gold standard for both diagnosis and treatment of IUA, allowing direct visualization and targeted lysis of adhesions under vision with restoration of cavity anatomy. Evidence consistently shows that hysteroscopic adhesiolysis can restore normal menstrual function and improve fertility outcomes, with conception rates reported to exceed 40% following effective treatment in infertility cohorts (Yu et al., 2008; Hanstede et al., 2021; Munro et al., 2025).
Recent retrospective analyses also report encouraging pregnancy and live birth rates following adhesiolysis in women with recurrent pregnancy loss and IUA (Hanstede et al., 2021; Qiao et al., 2025). The severity of adhesions significantly influences success, with mild disease having the most favorable reproductive prognosis (Grimbizis et al., 2021; Hanstede et al., 2021; Munro et al., 2025).
In addition to surgical technique, the use of mechanical barriers and anti-adhesion gels, as well as second-look hysteroscopy, has been advocated to reduce recurrence rates and improve reproductive outcomes (Grimbizis et al., 2021; Vitale et al., 2022).
The growing recognition of isthmocele (uterine niche at the site of cesarean section scar) and its impact on implantation failure, abnormal bleeding, and miscarriage risk justifies its detailed inclusion in hysteroscopic reports. Recent evidence has emphasized its role in reproductive failure and outlined classification systems based on size, residual myometrial thickness, and anatomical complexity (Gubbini et al., 2011; Tower and Frishman, 2013; Klein Meuleman et al., 2023; Min et al., 2024). Hysteroscopic evaluation allows visualization of the defect, associated fluid retention, and vascular abnormalities, which may interfere with embryo implantation or favor endometritis (Dokras et al., 2025).
Tubal ostia
Though hysteroscopy does not directly assess tubal patency, the evaluation of the ostia and surrounding areas can reveal signs of prior salpingitis, occlusion, or peritubal adhesions. Recent studies have proposed that tubal ostial abnormalities may correlate with tubal infertility and reduced IVF success (Pérez-Milán et al., 2025).
Strengths and limitations
A major strength of this consensus-based template is its ability to bridge the gap between clinical practice and research. By promoting standardized data collection, the structured report enhances not only diagnostic reproducibility but also facilitates the creation of multicenter registries and prospective studies exploring correlations between hysteroscopic findings and reproductive outcomes.
The proposed record may also play a pivotal role in training and certification of hysteroscopists, enabling objective evaluation of procedural completeness and reporting accuracy. Furthermore, its adoption may help reduce inter-operator variability, a known limitation in the interpretation of hysteroscopic images and terminology (Carugno et al., 2021).
However, several limitations should be acknowledged. First, although the template is grounded in available literature and expert consensus, the clinical significance, and prognostic impact of all recorded hysteroscopic findings have not been conclusively established. Some abnormalities included in the structured report, particularly subtle endometrial patterns or minor morphological variations, may not yet have robust evidence demonstrating a direct causal relationship with infertility or adverse reproductive outcomes. Therefore, the inclusion of these items should be interpreted as a comprehensive documentation strategy rather than as confirmation of proven clinical relevance.
Second, the consensus reflects expert opinion and structured discussion rather than prospective validation studies. The ultimate value of the reporting system will depend on its application in real-world settings and on future research assessing interobserver agreement, feasibility, and correlation between specific hysteroscopic findings and reproductive prognosis, particularly in IVF cycles.
Future research should focus on validating the predictive value of individual items, determining which findings carry independent prognostic significance, and refining the template accordingly based on outcome-driven evidence.
Conclusions
This international consensus developed by ESGE, ESHRE, and IFFS provides the first structured framework for reporting diagnostic hysteroscopy in women with reproductive disorders. The final template includes comprehensive clinical, anatomical, and pathological parameters based on literature and expert validation.
The standardized approach promotes consistent data collection across centers to enhance the value of hysteroscopy in fertility evaluation. It represents a pragmatic tool for clinical care, research, and educational purposes, with the potential to inform predictive models and digital health integration. Its adoption is recommended in both routine clinical settings and IVF programs.
Future work will focus on the implementation of the structured report across diverse healthcare systems, translation into additional languages, and validation through prospective outcome studies.
Supplementary Material
Contributor Information
U Catena, Gynaecology Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
G Grimbizis, 1st Department of Obstetrics and Gynecology, Medical Faculty, Aristotle University of Thessaloniki, Thessaloniki, Greece.
A Arena, Division of Gynecology and Human Reproduction Physiopathology, IRCCS S.Orsola Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
R Campo, Life Expert Centre, Leuven, Belgium.
C De Angelis, Department of Maternal and Child Health and Urological Sciences, “Sapienza” University of Rome, Rome, Italy.
A Di Spiezio Sardo, Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy.
A Feki, Department of Obstetrics and Gynecology, HFR Fribourg—Hôpital cantonal, Fribourg, Switzerland.
H Fernandez, University Paris-Saclay, Paris, France.
M Horton, Pregna Medicina Reproductiva, Buenos Aires, Argentina.
E Mocanu, Department of Reproductive Medicine, Rotunda Hospital and RCSI, Dublin, Ireland.
L A Pacheco, Obstetrics and Gynecology Department, Reproductive Surgery Unit, Hospital Quirón, Malaga, Spain.
G Pados, 1st Department of Obstetrics and Gynecology, Medical Faculty, Aristotle University of Thessaloniki, Thessaloniki, Greece.
A Vereczkey, Versys Clinics-Human Reproduction Institute, Budapest, Hungary.
S Saravelos, Hammersmith Hospital, Imperial College, London, UK.
A Vitagliano, Unit of Obstetrics and Gynaecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, Bari, Italy.
M Acién, Obstetrics and Gynecology Service, San Juan University Hospital, Division of Gynecology, Miguel Hernández University, Alicante, Spain.
L Gianaroli, International Institute of Reproductive Medicine—IIRM—Lugano, Lugano, Switzerland; Interdisciplinary Institute of Reproductive Medicine—IIRM—Bologna, Bologna, Italy.
International Hysteroscopy Working Group of ESGE, ESHRE and IFFS:
U Catena, G Grimbizis, A Arena, R Campo, C De Angelis, A Di Spiezio Sardo, A Feki, H Fernandez, M Horton, E Mocanu, L A Pacheco, G Pados, A Vereczkey, S Saravelos, A Vitagliano, M Acién, and L Gianaroli
Data availability
All materials relevant to the structured reporting template are included within the manuscript and its supplementary files.
Authors’ roles
U.C. and G.G. conceived and designed the project. U.C., A.Vit., and A.A. developed the initial draft of the structured reporting template. All 17 expert members of the working group participated in the consensus process, including structured discussion, voting, and revision of the template. U.C. prepared the first draft of the manuscript, which was critically revised by G.G. All authors critically revised the manuscript for intellectual content, approved the final version for publication, and agree to be accountable for all aspects of the work. The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported, that no important aspects of the work have been omitted, and that any discrepancies from the study as originally planned have been explained.
Funding
No external funding was received for the development of the consensus process or manuscript preparation.
Disclosures
All authors declare that they have no competing interests.
References
- Acién P, Acién M. The presentation and management of complex female genital malformations. Hum Reprod Update 2016;22:48–69. [DOI] [PubMed] [Google Scholar]
- AAGL-ESGE. AAGL practice report: practice guidelines on intrauterine adhesions developed in collaboration with the European Society of Gynaecological Endoscopy (ESGE). Gynecol Surg 2017;14:6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bouet PE, El Hachem H, Monceau E, Gariépy G, Kadoch IJ, Sylvestre C. Chronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure: prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis. Fertil Steril 2016;105:106–110. [DOI] [PubMed] [Google Scholar]
- Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE et al. ; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839–E842. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Campo R, Molinas CR, Rombauts L, Mestdagh G, Lauwers M, Braekmans P, Brosens I, Van Belle Y, Gordts S. Prospective multicentre randomized controlled trial to evaluate factors influencing the success rate of office diagnostic hysteroscopy. Hum Reprod 2005;1:258–263. [DOI] [PubMed] [Google Scholar]
- Campo R, Santangelo F, Gordts S, Di Cesare C, Van Kerrebroeck H, De Angelis MC, Di Spiezio Sardo A. Outpatient hysteroscopy. Facts Views Vis Obgyn 2018;10:115–122. [PMC free article] [PubMed] [Google Scholar]
- Carugno J, Grimbizis G, Franchini M, Alonso L, Bradley L, Campo R, Catena U, De Angelis C, Di Spiezio Sardo A, Farrugia M et al. International Consensus Statement for recommended terminology describing hysteroscopic procedures. Facts Views Vis Obgyn 2021;13:287–294. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Catena U, Bernardini F, La Fera E, Fedele C, Bonetti E, Pozzati F, Scambia G, Grimbizis GF. Complete uterine septum, cervical septum and longitudinal vaginal septum: a challenging differential diagnosis with double cervix. Facts Views Vis Obgyn 2025a;17:84–89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Catena U, Macklon KLT, Rodolakis A, Scambia G. A practical guideline on the fertility-sparing treatment of patients with endometrial carcinoma and atypical endometrial hyperplasia. Int J Gynaecol Obstet 2025b;169:453–455. [DOI] [PubMed] [Google Scholar]
- Clark TJ, Voit D, Gupta JK, Hyde C, Song F, Khan KS. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA 2002;288:1610–1621. [DOI] [PubMed] [Google Scholar]
- D’Angelo A, Panayotidis C, Alteri A, Mcheik S, Veleva Z. Evidence and consensus on technical aspects of embryo transfer. Hum Reprod Open 2022;2022:hoac038. [DOI] [PMC free article] [PubMed] [Google Scholar]
- De Angelis C, Carnevale A, Santoro G, Nofroni I, Spinelli M, Guida M, Mencaglia L, Di Spiezio Sardo A. Hysteroscopic findings in women with menorrhagia. J Minim Invasive Gynecol 2013;20:209–214. [DOI] [PubMed] [Google Scholar]
- De Wilde K, Groszmann Y, Van Schoubroeck D, Grewal K, Huirne J, de Leeuw R, Bourne T, Timmerman D, Van den Bosch T. Enhanced myometrial vascularity secondary to retained pregnancy tissue: time to stop misusing the term arteriovenous malformation. Ultrasound Obstet Gynecol 2024;63:5–8. [DOI] [PubMed] [Google Scholar]
- Di Spiezio Sardo A, Campo R (editors). State-of-the-Art Hysteroscopic Approaches to Pathologies of the Genital Tract, 2nd revised and expanded edition. Germany: Endo: Press. GmbH, 2021. [Google Scholar]
- Di Spiezio Sardo A, Campo R, Zizolfi B, Santangelo F, Meier Furst R, Di Cesare C, Bettocchi S, Vitagliano A, Ombelet W. Long-term reproductive outcomes after hysteroscopic treatment of dysmorphic uteri in women with reproductive failure: an European multicenter study. J Minim Invasive Gynecol 2020;27:755–762. [DOI] [PubMed] [Google Scholar]
- Di Spiezio Sardo A, Di Carlo C, Minozzi S, Spinelli M, Pistotti V, Alviggi C, De Placido G, Nappi C, Bifulco G. Efficacy of hysteroscopy in improving reproductive outcomes of infertile couples: a systematic review and meta-analysis. Hum Reprod Update 2016;4:479–496. [DOI] [PubMed] [Google Scholar]
- Dokras A, Somigliana E, Donnez O, Humphries LA, Shah DK, Christianson MS, de Ziegler D. Isthmocele-fix it or observe, an ongoing dilemma. Fertil Steril 2025;123:981–988. [DOI] [PubMed] [Google Scholar]
- ESHRE Guideline Group on Ovarian Stimulation; Ata B, Bosch E, Broer S, Griesinger G, Grynberg M, Kolibianakis E, Kunicki M, La Marca A, Lainas G, Le Clef N et al. ESHRE guideline: ovarian stimulation for IVF/ICSI: an update in 2025. Hum Reprod 2026;41:deag018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- ESHRE Guideline Group on RPL; Atik RB, Christiansen OB, Elson J, Kolte AM, Lewis S, Middeldorp S, Mcheik S, Peramo B, Quenby S, Nielsen HS et al. ESHRE guideline: recurrent pregnancy loss: an update in 2022. Hum Reprod Open 2023;2023:hoad002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- ESHRE Working Group on Recurrent Implantation Failure; Cimadomo D, de Los Santos MJ, Griesinger G, Lainas G, Le Clef N, McLernon DJ, Montjean D, Toth B, Vermeulen N, Macklon N. ESHRE good practice recommendations on recurrent implantation failure. Hum Reprod Open 2023;2023:hoad023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Etrusco A, Laganà AS, Chiantera V, Vitagliano A, Cicinelli E, Mikuš M, Šprem Goldštajn M, Ferrari F, Uccella S, Garzon S et al. Feasibility and surgical outcomes of hysteroscopic myomectomy of FIGO type 3 myoma: a systematic review. J Clin Med 2023;12:4953. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Favilli A, Etrusco A, Chiantera V, Laganà AS, Cicinelli E, Gerli S, Vitagliano A. Impact of FIGO type 3 uterine fibroids on in vitro fertilization outcomes: a systematic review and meta-analysis. Int J Gynaecol Obstet 2023;163:528–539. [DOI] [PubMed] [Google Scholar]
- Gkrozou F, Dimakopoulos G, Vrekoussis T, Lavasidis L, Koutlas A, Navrozoglou I, Stefos T, Paschopoulos M. Hysteroscopy in women with abnormal uterine bleeding: a meta-analysis on four major endometrial pathologies. Arch Gynecol Obstet 2015;291:1347–1354. [DOI] [PubMed] [Google Scholar]
- Gkrozou F, Tsonis O, Dimitriou E, Paschopoulos M. In women with chronic or subclinical endometritis is hysteroscopy suitable for setting the diagnosis? A systematic review. J Obstet Gynaecol Res 2020;46:1639–1650. [DOI] [PubMed] [Google Scholar]
- Grimbizis GF. The pathophysiology of septate uterus. BJOG 2019;126:1200. [DOI] [PubMed] [Google Scholar]
- Grimbizis GF, Di Spiezio Sardo A, Campo R. Pregnancy-related intrauterine adhesion treatment: new insights. Fertil Steril 2021;116:1188. [DOI] [PubMed] [Google Scholar]
- Grimbizis GF, Di Spiezio Sardo A, Saravelos SH, Gordts S, Exacoustos C, Van Schoubroeck D, Bermejo C, Amso NN, Nargund G, Timmerman T et al. The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies. Hum Reprod 2016;31:2–7. [DOI] [PubMed] [Google Scholar]
- Grimbizis GF, Gordts S, Di Spiezio Sardo A, Brucker S, De Angelis C, Gergolet M, Li TC, Tanos V, Brölmann H, Gianaroli L et al. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod 2013;28:2032–2044. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Grimbizis G, Saridogan E, Di Spiezio Sardo A, Campo R. No need for septum incision: really? Facts Views Vis Obgyn 2020;12:153–154. [PMC free article] [PubMed] [Google Scholar]
- Gubbini G, Centini G, Nascetti D, Marra E, Moncini I, Bruni L, Petraglia F, Florio P. Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: prospective study. J Minim Invasive Gynecol 2011;18:234–237. [DOI] [PubMed] [Google Scholar]
- Hanstede MMF, van der Meij E, Veersema S, Emanuel MH. Live births after Asherman syndrome treatment. Fertil Steril 2021;116:1181–1187. [DOI] [PubMed] [Google Scholar]
- Hooker AB, de Leeuw RA, Emanuel MH, Mijatovic V, Brolmann HAM, Huirne JAF. The link between intrauterine adhesions and impaired reproductive performance: a systematic review of the literature. BMC Pregnancy Childbirth 2022;22:837. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Klein Meuleman SJM, Murji A, van den Bosch T, Donnez O, Grimbizis G, Saridogan E, Chantraine F, Bourne T, Timmerman D, Huirne JAF et al. ; CSDi Study Group. Definition and criteria for diagnosing cesarean scar disorder. JAMA Netw Open 2023;6:e235321. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Khurshid F, O’Connor E, Thompson R, Hegazi I. Twelve tips for adopting the virtual Nominal Group Technique (vNGT) in medical education research. MedEdPublish (2016) 2023;13:18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Li J, Wei J, Chen S, Wang X, Chen J, Zeng D, Fan L. Prevalence and risk factors for chronic endometritis in patients with adenomyosis and infertility: a retrospective cohort study. BMC Womens Health 2024;24:403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ludwin A, Martins WP, Nastri CO, Ludwin I, Coelho Neto MA, Leitão VM, Acién M, Alcazar JL, Benacerraf B, Condous G et al. Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus? Ultrasound Obstet Gynecol 2018;51:101–109. [DOI] [PubMed] [Google Scholar]
- Ludwin A, Coelho Neto MA, Ludwin I, Nastri CO, Costa W, Acién M, Alcazar JL, Benacerraf B, Condous G, DeCherney A et al. Congenital Uterine Malformation by Experts (CUME): diagnostic criteria for T-shaped uterus. Ultrasound Obstet Gynecol 2020;55:815–829. [DOI] [PubMed] [Google Scholar]
- March CM. Management of Asherman’s syndrome. Reprod Biomed Online 2011;23:63–76. [DOI] [PubMed] [Google Scholar]
- Miller CM, Shenoy CC, Khan Z. Three degrees of separation: complete uterine and cervical septa. Fertil Steril 2021;116:915–916. [DOI] [PubMed] [Google Scholar]
- Min N, de Leeuw RA, van der Voet LF, Di Spiezio Sardo A, Barri-Soldevila PN, Dueholm M, Donnez O, Saridogan E, Clark TJ, Brolmann HAM et al. Structured hysteroscopic examination of uterine niches: a modified Delphi procedure. Facts Views Vis Obgyn 2024;16:253–262. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011;113:3–13. [DOI] [PubMed] [Google Scholar]
- Munro MG, Salazar CA, Bhagavath B, Emanuel MH, Huddleston HG, Sobti D, Jaiswal AK, Gamburg R, Kumar J, Martin C et al. ; Women’s Health Research Collaborative’s Endometrial Trauma Group. The epidemiology, clinical burden, and prevention of intrauterine adhesions (IUAs) related to surgically induced endometrial trauma: a systematic literature review and selective meta-analyses. Hum Reprod Update 2025;31:588–625. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pacheco LA, Carugno J, Alcázar JL, Caballero M, Roig MC, Mereu L, Domínguez JA, Moratalla E, Saponara S, Vitale SG et al. Infantile uterus and uterine hypoplasia: a comprehensive overview to explore possible managements amidst limited scientific certainties. Facts Views Vis Obgyn 2025;17:5–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pacheco LA, Laganà AS, Ghezzi F, Haimovich S, Azumendi Gómez P, Carugno J. Subtypes of T-shaped uterus. Fertil Steril 2019;112:399–400. [DOI] [PubMed] [Google Scholar]
- Parodi L, Hoxhaj I, Dinoi G, Mirandola M, Pozzati F, Topouzova G, Testa AC, Scambia G, Catena U. Complete uterine septum, double cervix and vaginal septum (U2b C2 V1): hysteroscopic management and fertility outcomes—a systematic review. J Clin Med 2022;12:189. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pérez-Medina T, Bajo-Arenas J, Salazar F, Redondo T, Sanfrutos L, Alvarez P, Engels V. Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination: a prospective, randomized study. Hum Reprod 2005;20:1632–1635. [DOI] [PubMed] [Google Scholar]
- Pérez-Milán F, Caballero-Campo M, Carrera-Roig M, Moratalla-Bartolomé E, Domínguez-Arroyo JA, Alcázar-Zambrano JL, Alonso-Pacheco L, Carugno JA; Spanish Fertility Society Special Interest Group on Organic Reproductive Disorders. Hydrosalpinx treatment before in-vitro fertilization: systematic review and network meta-analysis. Ultrasound Obstet Gynecol 2025;65:414–426. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pozzati F, Mirandola M, Topozouva G, Parodi L, Carla Testa A, Scambia G, Catena U. Complete uterine septum, double cervix, and longitudinal vaginal septum: an integrated approach for one-stop diagnosis and ultrasound-guided endoscopic treatment. Facts Views Vis Obgyn 2023;15:167–170. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pritts TL, Ogden M, Parker W, Ratcliffe J, Pritts EA. Intramural leiomyomas and fertility: a systematic review and meta-analysis. Obstet Gynecol 2024;144:171–179. [DOI] [PubMed] [Google Scholar]
- Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009;91:1215–1223. [DOI] [PubMed] [Google Scholar]
- Qiao X, Liu D, Liu C, Pei T, Ouyang Y. Reproductive outcomes after hysteroscopic adhesiolysis in patients experiencing recurrent pregnancy loss and intrauterine adhesions. J Minim Invasive Gynecol 2025;32:57–63. [DOI] [PubMed] [Google Scholar]
- Rodolakis A, Scambia G, Planchamp F, Acién M, Di Spiezio Sardo A, Farrugia M, Grynberg M, Pakiž M, Pavlakis K, Vermeulen N et al. ESGO/ESHRE/ESGE guidelines for the fertility-sparing treatment of patients with endometrial carcinoma. Facts Views Vis Obgyn 2023;15:3–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Roy KK, Singla S, Baruah J, Sharma JB, Kumar S, Singh N. Reproductive outcome following hysteroscopic myomectomy in patients with infertility and recurrent abortions. Arch Gynecol Obstet 2010;282:553–560. [DOI] [PubMed] [Google Scholar]
- Smith BC, Brown DL, Carter RE, Famuyide AO. Double cervix: clarifying a diagnostic dilemma. Am J Obstet Gynecol 2014;211:26.e1–26.e5. [DOI] [PubMed] [Google Scholar]
- Spiewankiewicz B, Stelmachów J, Sawicki W, Cendrowski K, Wypych P, Swiderska K. The effectiveness of hysteroscopic polypectomy in cases of female infertility. Clin Exp Obstet Gynecol 2003;30:23–25. [PubMed] [Google Scholar]
- Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol 2013;20:562–572. [DOI] [PubMed] [Google Scholar]
- Venetis CA, Papadopoulos SP, Campo R, Gordts S, Tarlatzis BC, Grimbizis GF. Clinical implications of congenital uterine anomalies: a meta-analysis of comparative studies. Reprod Biomed Online 2014;29:665–683. [DOI] [PubMed] [Google Scholar]
- Vitale SG, Riemma G, Carugno J, Perez-Medina T, Alonso Pacheco L, Haimovich S, Parry JP, Di Spiezio Sardo A, De Franciscis P. Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials. Am J Obstet Gynecol 2022;226:487–498.e8. [DOI] [PubMed] [Google Scholar]
- Yu D, Wong YM, Cheong Y, Xia E, Li TC. Asherman syndrome—one century later. Fertil Steril 2008;89:759–779. [DOI] [PubMed] [Google Scholar]
- World Health Organisation Guideline Development Group for Infertility; Mburu G, Santesso N, Brignardello-Petersen R, Kennedy R, Farquhar C, Boivin J, Pennings G, Giudice LC, Rebar RW, Gianaroli L et al. Recommendations from the WHO guideline for the prevention, diagnosis, and treatment of infertility. Hum Reprod 2026;41:25–38. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All materials relevant to the structured reporting template are included within the manuscript and its supplementary files.