Transvaginal hydrolaparoscopy (THL) was evaluated in comparison with the already established chromolaparoscopy in the detection of tubal factors, adhesions as well as endometriosis. 43 infertile patients without previous pelvic operations and with an inconspicuous clinical examination were included in a prospective comparative study of THL and chromolaparoscopy. THL succeeded in 40 patients (93.0%). Both methods showed 100% agreement with regard to tubal factors and adhesions. However, only 72/80 tubes (90.0%) could be portrayed by THL. In contrast to this, THL failed to identify 8 of 10 laparoscopically verified endometrioses (isolated endometriosis of the bladder peritoneum in 2). No complications occurred with THL. THL could be the method of choice for the clarification of mechanical infertility factors in symptom-free patients with no suspicion of pelvic pathologies. Tubal pathologies and/or adhesions (visible during THL) should be indications for laparoscopy. In the case of inconspicuous genitals during THL and a still unfulfilled desire for offspring postoperatively, laparoscopy should be considered in order to exclude the possibility of unidentified endometriosis. Retroflexio uteri should at least be a relative contraindication for THL. Further studies are necessary to evaluate the role of THL in the diagnostic concept of infertility in the future.

Hysteroscopic surgery is widely used for the treatment of patients suffering from menorrhagia. In different studies, pretreatment of the endometrium with GnRH analogues (GnRH-a) prior to endometrial ablation has been reported to increase the success rate, as well as to reduce the menstrual blood flow, accounting for a significantly higher postoperative amenorrhea rate (42% in pretreated patients vs. 24% in those receiving no pretreatment). The aim of pretreatment is not only to obtain a thin endometrium but also to reduce the size and vascularization of myomas being treated. In our study, GnRH-a administration prior to endometrial ablation was shown to have the following advantages: improved hysteroscopic view, reduced blood loss, absorption of uterine distending fluid and higher postoperative amenorrhea rates. Prior to hysteroscopic myoma resection, pretreatment with GnRH-a may be particularly indicated for all myomas with a diameter of more than 3 cm and/or with an intramural portion, or for patients suffering from secondary anemia. GnRH-a pretreatment is thus indicated before endometrial ablation, and in most cases, before hysteroscopic resection of submucous myomas, and combined medical and surgical therapy has clear benefits in the treatment of bleeding disorders.

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The hysteroscopic metroplasty demonstrates a low intra- and postoperative rate of complication. Particularly the indication of a lower rate of miscarriages, possibly of an increase in the pregnancy rates, should, in our opinion, give reason to proceeding with a diagnostic hysteroscopy, especially prior to extensive sterility therapies. Where suspicion exists of a septum > 1.0 cm, this should be corrected by means of an operative hysteroscopy.

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