Hysteroscopy before IVF versus no hysteroscopy – Real Patient Cases

Unexplained infertility is one of the most difficult challenges couples face, particularly when routine tests show no obvious problems and the woman is still in her reproductive prime. This was the situation for a 35-year-old woman and her 40-year-old husband, who arrived at EmbryoClinic after five years of unsuccessful attempts to conceive.

Their journey had already included three years of trying naturally, followed by several rounds of IUI and a full IVF cycle at another clinic. Although the IVF treatment produced viable embryos of acceptable quality, none of the transfers resulted in pregnancy. The repeated failures, despite the woman’s young age and good ovarian reserve, raised questions that standard investigations had not answered.

At this point, the couple sought the expertise of the EmbryoClinic team. What followed was a careful and detailed diagnostic process that went beyond the usual fertility work-up. A key step was diagnostic hysteroscopy, which allowed direct visualisation of the uterine cavity and the collection of endometrial biopsies for precise testing. This investigation ultimately revealed an underlying uterine condition that had been silently preventing implantation. Once treated, it transformed the couple’s chances, leading to a healthy pregnancy and live birth.

In this article, we will examine three real patient cases, where the role of hysteroscopy was crucial in explaining repeated IVF failure and optimising the chances of success.

Patient Case Study no. 1

Patient background

A 35-year-old woman and her 40-year-old husband came to our clinic after five years of unexplained infertility. Both partners were in good general health. The woman had been diagnosed with hypothyroidism, which was under control via medication. The husband was overweight (BMI: 28.6) and smoked occasionally; however, his latest semen analysis was normal. They had attempted spontaneous conception for three years before visiting another clinic to undergo assisted reproduction treatment. They attempted three IUI cycles, which were all negative and subsequently pursued IVF as a reproductive treatment option. They underwent a single IVF cycle, which resulted in three viable embryos. Unfortunately, all attempts failed, despite the embryos being considered to be of acceptable or good quality. After that, they first attended our Clinic. The presence of repeated failures, despite favourable female age and embryo quality, prompted a thorough investigation prior to any attempts.

Diagnostic findings

The patient was advised to undergo a full hormonal assessment and evaluation of oocyte reserve, which were both normal. Subsequently, in order to investigate the uterine cavity, a diagnostic hysteroscopy was recommended and performed within our Clinic. Visual inspection of the endometrial cavity revealed a hyperemic endometrial surface, which raised suspicion of endometritis. Therefore, biopsies were collected and sent for histopathological assessment, along with endometritis examination (CD138 immunohistochemical staining of the endometrium) and microbiome assessment. The examinations confirmed the presence of chronic endometritis in addition to endometrial dysbiosis.

Protocols and procedures

The findings of the diagnostic tests prompted medical treatment with a targeted course of oral antibiotics (Doxycycline) for 14 days, along with a two-month regimen of endometrium-specific pre- and probiotics. Subsequent assessment with pipelle biopsy confirmed resolution of endometritis and restoration of normal endometrial flora. Subsequently, the patient underwent a standard stimulation cycle (short antagonist protocol).

Before the embryo transfer

At the end of the stimulation, seven oocytes were collected, five of which were mature and proceeded with fertilisation. Of the fertilised oocytes, four managed to reach day five of development, when a single fresh embryo transfer was performed. The remaining three embryos were evaluated with the Gardner scale as 4AA, 4AB and 3BB and were frozen for subsequent attempts.

The Embryo transfer

Fresh embryo transfer was performed, approximately 8 months after the couple’s initial visit to our clinic. A single, 4AA blastocyst was transferred.

After the embryo transfer

Twelve days after embryo transfer, the patient had a positive beta-hCG result (358 IU/L), and a viable intrauterine pregnancy was confirmed by transvaginal ultrasound at 6 weeks. The pregnancy proceeded without complication, and she delivered a healthy baby at 39 weeks of gestation through vaginal delivery.

Clinic’s experience with this kind of case

Unexplained infertility in young couples is quite a common occurrence in the field of Assisted Reproduction. Usually, these cases are not caused by oocyte reserve issues and are mostly due to other factors, such as male factor, tubal factor or uterine factor. In the present case, the presence of endometritis and endometrial flora imbalance could not have been diagnosed via ultrasound and necessitated thorough assessment via hysteroscopy.

Doctor’s perspective

Dr Elias Tsakos, EmbryoClinic’s Medical Director:

“This case shows how important it is to look beyond the embryo. Even a perfect embryo cannot implant in an unfavourable endometrial environment. Furthermore, this case highlights the utility of hysteroscopy as a diagnostic test, as it allows for both direct visual assessment of the endometrial cavity, which led to the initial suspicion of endometritis, in addition to the collection of endometrial biopsies and further, precise assessment of the endometrial environment with highly specialised tests. Once we identified and treated the underlying endometrial conditions, the uterus became receptive—and that changed everything.”

Patient Case Study no. 2

Patient background

A 48-year-old woman and her 50-year-old husband visited our clinic, seeking IVF treatment, following a lengthy and emotionally challenging journey through infertility. They had been trying to conceive for 7 years, with multiple IVF attempts in the past. No apparent causes of infertility. In particular, the first three IVF cycles were performed using the female partner’s own oocytes. During the first cycle, five oocytes were retrieved, three of which fertilised. One Day-3 embryo of fair quality was transferred, but implantation did not occur. In the second cycle, four oocytes were retrieved, with two fertilising. One blastocyst (graded BB) developed and was transferred, but no pregnancy resulted. In the third attempt, only three oocytes were collected, and just one was fertilised, which, however, failed to develop into a viable embryo.

Due to age-related diminished ovarian reserve and consistently poor outcomes, the couple transitioned to donor oocyte IVF. An oocyte donation programme was initiated at our clinic, which resulted in 4 viable embryos. Their next attempt involved the transfer of one good-quality blastocyst (Grade 3AA), but the result was negative. At this point, hysteroscopy was recommended in order to assess potential factors related to the endometrium, given the repeated failed attempts; however, the couple opted to continue their attempts.

The next embryo transfer resulted in a biochemical pregnancy after transferring a single top-quality (5AA-grade) donor blastocyst, but it did not progress. The sixth attempt also failed to lead to pregnancy, despite transferring another high-quality blastocyst (Grade 4AB). At that time, one viable embryo (grade 3AB) remained available. The repeated implantation failures, even in the context of donor oocytes and well-prepared endometrial cycles, raised concern about possible uterine factors that had not yet been investigated.

Diagnostic findings

A thorough investigation of both partners was performed. Andrological assessment with semen analysis revealed asthenoteratospermia for the husband, and assessment of the DNA fragmentation index revealed elevated DFI. Regarding investigations for the wife, a full hormonal assessment was performed, and the uterus was assessed via ultrasound. However, given the history of repeated implantation failures, hysteroscopy was recommended as a means of directly assessing the endometrial cavity.

Protocols and procedures

Diagnostic hysteroscopy was performed. Visual inspection of the uterine cavity revealed no apparent abnormalities. Biopsies were collected, and mild endometrial scratching was performed. The woman recovered swiftly and was instructed to wait for her next menstrual period to make one final attempt at embryo transfer.
Before the embryo transfer

One 3AB embryo, resulting from a donated oocyte, was available for transfer at our Clinic’s laboratory.

The Embryo transfer

The transfer occurred in the cycle after hysteroscopy, approximately two and a half years after the couple’s initial presentation to the clinic. The available 3AB embryo was transferred after thawing.

After the embryo transfer

Rising beta-hCG levels indicated successful implantation, and a prenatal ultrasound scan confirmed the presence of a gestational sac with normal heart function. At the time of writing, the patient has delivered a healthy baby girl (Birth weight 3400 g) via caesarean section at 39 weeks of gestation. The baby is healthy and is developing normally.

Clinic’s experience with this kind of case

Women over 45 years of age represent a rising percentage of IVF patients worldwide, with a similar trend being present in our clinic as well. While some patients have managed to conceive using their own genetic material, they are the exception, and most women will eventually undergo oocyte or embryo donation. While highly successful, a small proportion of patients may not conceive right away, even with the use of donated genetic material, such as in the present case. In these cases, hysteroscopy can help assess and optimise the endometrial cavity, leading to improved outcomes in this patient group.

Doctor’s perspective

Dr Elias Tsakos, EmbryoClinic’s Medical Director:

“Donation programmes are highly successful at our clinic, with cumulative pregnancy rates over 90%, without the need for additional intervention. However, a proportion of patients, such as the present case, are likely affected by multiple factors that contribute to infertility. Once oocyte and male factors have been addressed, the uterus constitutes the most common final factor that may affect the chances of success. Hysteroscopy is the most effective way of both assessing and treating endometrial conditions and, even in the absence of any obvious anomaly, such as in the present case, to improve the chances of implantation.”

Patient Case Study no. 3

Patient background

A 40-year-old woman and her 42-year-old husband visited our clinic from abroad after experiencing multiple failed IVF attempts at various other Fertility centres. In particular, the couple had been trying to conceive for 7 years and had had 8 failed embryo transfer attempts (three stimulation cycles, three fresh attempts and five frozen-thawed attempts).

Three attempts resulted in biochemical pregnancy, four in implantation failure, and one resulted in pregnancy, which, however, ended up as an incomplete miscarriage in the 9th week of gestation, and the woman underwent a dilation and curettage procedure to remove all retained products of conception. Furthermore, from her medical history, she had another curettage procedure in the past for benign endometrial hyperplasia. The male partner was healthy, but obese (BMI 32.4) and had oligospermia.

Diagnostic findings

Baseline hormonal assessment and ultrasound scan were performed, which indicated a satisfactory ovarian reserve. However, examination of the uterus revealed a thin endometrium with deviations from its expected ultrasonographic appearance. This finding, combined with the patient’s history of endometrial interventions, led to elevated clinical suspicion of endometrial adhesions and prompted our Medical Team to recommend hysteroscopy to the patient, both as a means of assessing her uterine cavity and confirming the diagnosis, but also as a treatment modality for optimising her chances of success in her upcoming attempt.

Protocols and procedures

The woman underwent hysteroscopy at a Tertiary Female Healthcare Centre, partnered with our Clinic. Inspection of the endometrial cavity revealed numerous adhesions, and the diagnosis of Asherman’s Syndrome was made. Hysteroscopic adhesiolysis was performed, and the uterine cavity was restored to its normal, proper form. Two months following hysteroscopy, the woman underwent ovarian stimulation, using a standard short protocol.

Before the embryo transfer

Ultimately, 4 oocytes were collected and all of them were successfully fertilised. Fresh transfer of a 4AA blastocyst was performed, and the rest were cryopreserved (3AA, 3AB, 3AB).

The Embryo transfer

Embryo transfer occurred 4 months after the couple’s initial visit to our clinic. Single, fresh embryo transfer of a 4AA blastocyst was performed.

After the embryo transfer

Subsequent laboratory testing revealed positive beta-hCG, with a viable intrauterine pregnancy confirmed at 6 weeks. At the time of writing, pregnancy is ongoing, uneventful and entering the third trimester.

Clinic’s experience with this kind of case

At EmbryoClinic, patients with a history of endometrial curettage and other endometrial interventions are frequently encountered and are at increased risk for intrauterine adhesions and scarring, even when their menstrual cycles appear normal. These adhesions can impair implantation by disrupting the architecture and vascularity of the endometrial lining. Among women experiencing multiple IVF failures and with a history of prior uterine surgery, intrauterine pathology is detected in up to 30–40% of cases during hysteroscopy.

Doctor’s perspective

Dr Elias Tsakos, EmbryoClinic’s Medical Director:

“This case highlights a common but often overlooked issue—silent intrauterine adhesions in women with a surgical history. Even with genetically normal embryos, implantation cannot occur if the endometrial environment is compromised. Hysteroscopy remains an essential tool not just diagnostically, but therapeutically in such cases and sometimes the only available option to ensure optimal outcomes.”