It is the responsibility of physicians in gatherings such as ours to set the tone and speak forthrightly about accomplishments and limitations. The fundamentals of diagnostic hysteroscopy are well known and now is the time for us to push forward to ascertain whether this endoscopic approach, in selected patients, is more innocuous than the conventional laparotomy. I have tried to indicate the clinician's dilemma in the search for the proper approach to several types of uterine abnormalities. As enthusiastic hysteroscopists, we must continue to analyze and document our findings, with careful concern so as to avoid poorly substantiated claims.
PIP: Some of the problems of therapeutic hysteroscopy are addressed with focus on methods and interpretations of results. At this time, intrauterine adhesions seem to be the best indication for therapeutic hysteroscopy. When one reviews the many reports on this topic, it becomes evident that results are difficult to compare due to a lack of classification of intrauterine adhesions. There seems to be no standard operative technique for their removal. Preoperative regimens differ, and the contemporary use of an IUD seems paradoxical. The restoration of menses in a patient who previously has had amenorrhea or hypomenorrhea is considered favorable, but reports of the percentage of pregnant patients postoperatively can be misleading in women whose problem was mostly repeated abortion. The end result of an uncomplicated term pregnancy should be regarded as the ultimate measure of success. Most likely the initial indication for therapeutic hysteroscopy was for the removal of the occult intrauterine IUD. Presently, the hysteroscope is infrequently used for this purpose. A uterine sound can be introduced to feel for the device, and in most instances the IUD can be removed easily with a uterine packing forceps. The findings on the hysterogram give the initial clue to the discovery of a congenital uterine abnormality, but the radiographic findings cannot predict which patients will be amenable to hysteroscopic metroplasty. The final decision depends upon both the laparoscopic and hysteroscopic results. The hysteroscopic procedure offers the patient a shorter hospitalization, a lower rate of complications, avoids postoperative intraabdominal adhesions, and, if successful, obviates the need for a later cesarean delivery. Amin and Neuwirth published results of hysteroscopic myomectomy performed on 32 patients. 75% of these patients experienced no recurrent abnormal bleeding during a followup of 4 years. Submucous myomas have been resected, morcellated, and removed during therapeutic hysteroscopy under laparoscopic control. Several authors have reported cannulating tubes, but this author is unaware of successful pregnancies from previous tubal cannulation of proximally obstructed tubes. The possibility of sterilization qualifies as a therapeutic use of the hysteroscope, but it would require an entire symposium to cover the subject adequately. To date, hysteroscopic sterilization techniques still must be considered experimental.