Hysteroscopy in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS (DIAGNOSTIC HYSTEROSCOPY):

• Women with abnormal uterine bleeding (AUB) unresponsive to medical management, classified under the FIGO PALM-COEIN system

• Patients with suspected endometrial polyps or submucosal fibroids identified on transvaginal ultrasound (TVUS) or saline infusion sonohysterography (SIS)

• Women with recurrent implantation failure (RIF) undergoing IVF — defined as ≥2–3 failed embryo transfer cycles with good-quality embryos

• Investigation of recurrent miscarriage (≥2 pregnancy losses) to exclude uterine anatomical anomalies

• Evaluation of postmenopausal bleeding (PMB) to rule out endometrial hyperplasia or carcinoma

• Assessment of a thickened endometrium (>4 mm postmenopause or >14 mm premenopause on TVUS)

• Suspected uterine septum, bicornuate uterus (differentiable only via hysteroscopy + laparoscopy or 3D ultrasound), or congenital Müllerian anomalies

• ELIGIBLE PATIENTS (OPERATIVE HYSTEROSCOPY):

• Confirmed FIGO Type 0, 1, or 2 submucosal fibroids ≤5 cm in diameter (larger fibroids may require staged or combined laparoscopic approach)

• Endometrial polyps confirmed on TVUS or SIS

• Intrauterine adhesions (AFS Grade I–IV) — Asherman's syndrome

• Uterine septum causing reproductive failure

• Retained products of conception (RPOC) or displaced intrauterine devices (IUD)

• Targeted endometrial ablation for menorrhagia in women who have completed childbearing

• REQUIRED PRE-PROCEDURE DIAGNOSTICS:

• Transvaginal ultrasound (TVUS) — baseline uterine mapping

• Saline infusion sonohysterography (SIS/SHG) — superior sensitivity for polyps and fibroids

• 3D pelvic ultrasound or MRI pelvis — for Müllerian anomaly characterisation and fibroid mapping

• Full blood count (FBC), coagulation profile (PT/aPTT/INR), blood group and Rh typing

• Endocervical and high vaginal swabs — to exclude active pelvic infection (procedure contraindicated if positive)

• Serum beta-hCG — to exclude pregnancy

• ECG and anaesthesia fitness assessment for patients requiring general or regional anaesthesia

• Pap smear (cervical cytology) if not current

• ABSOLUTE CONTRAINDICATIONS:

• Active pelvic inflammatory disease (PID) or cervicitis

• Confirmed or suspected intrauterine pregnancy

• Cervical malignancy

• Severe medical comorbidities precluding safe anaesthesia

• RELATIVE CONTRAINDICATIONS:

• Cervical stenosis (can often be managed with pre-procedural cervical priming using misoprostol or osmotic dilators)

• Recent uterine perforation

• Known coagulopathy without haematological optimisation

DIAGNOSTIC HYSTEROSCOPY (Office / Outpatient):

Modern 'no-touch' or 'vaginoscopic' hysteroscopy using a 2.9–3.5 mm hysteroscope with a continuous-flow sheath and normal saline distension medium is performed without speculum, tenaculum, or cervical dilation in the majority of nulliparous and parous patients. This approach, validated in multiple RCTs, significantly reduces procedure-related pain (VAS scores reduced by 30–40%) and allows truly office-based diagnosis with targeted biopsy using 5 Fr flexible biopsy forceps under direct vision. Success rates for office hysteroscopy exceed 95% in experienced hands.

OPERATIVE HYSTEROSCOPY — STANDARD RESECTOSCOPY (Operating Room):

The classic 26–28 Fr continuous-flow resectoscope with monopolar or bipolar loop electrodes allows electrosurgical resection of fibroids, polyps, and uterine septum. Bipolar resectoscopy (using normal saline distension at 60–80 mmHg pressure) has largely replaced monopolar systems (glycine/sorbitol media) due to superior safety profile — eliminating hyponatraemic fluid overload syndrome. Technique-specific considerations include:

• Submucous myomectomy: Two-stage resection technique for Type 1–2 fibroids to minimise uterine wall perforation risk; the use of preoperative GnRH agonists (e.g., leuprolide acetate) for 2–3 months to reduce fibroid vascularity and facilitate resection

• Endometrial ablation: Second-generation global endometrial ablation (GEA) devices — NovaSure impedance-controlled radiofrequency ablation, Thermachoice balloon thermal ablation, and Minerva endometrial ablation system — offer single-application 90-second procedures for menorrhagia with amenorrhoea rates of 40–50% and satisfaction rates >85%

• Uterine septum resection (hysteroscopic metroplasty): Cold scissors technique (preferred for fertility preservation) or bipolar needle electrode resection under simultaneous laparoscopic guidance to monitor serosal integrity

HYSTEROSCOPIC MORCELLATION (Advanced Platform):

Intrauterine morcellators — specifically the MyoSure Lite (for polyps), MyoSure XL (for fibroids), and TruClear Elite — use high-speed oscillating blades with simultaneous suction to resect and aspirate tissue in a single step, without the need for repeated instrument exchanges. Compared to conventional resectoscopy, morcellation reduces operative time by 25–35%, minimises fluid deficit risk, and is increasingly preferred for hysteroscopic polypectomy — particularly in an office setting under local anaesthesia. The technology is available at leading centres in both India and the UAE.

FERTILITY-PRESERVING ADHESIOLYSIS (Asherman's Syndrome):

Hysteroscopic adhesiolysis using micro-scissors, cold-loop resection, or bipolar needle under direct vision — guided by AFS/ESGE adhesion grading — is combined with post-operative intrauterine balloon stenting (Foley catheter or dedicated IUA prevention devices such as the Seprafilm-coated balloon), high-dose oestrogen therapy (conjugated equine oestrogen 2.5 mg twice daily for 60 days with cyclical progestogen), and repeated second-look hysteroscopy at 4–8 weeks to assess cavity restoration. Reproductive outcomes post-adhesiolysis correlate directly with adhesion grade: live birth rates of 60–80% for mild disease versus 20–40% for severe pansynechiae.

COMBINED HYSTEROSCOPIC + LAPAROSCOPIC APPROACH:

Indicated for complex Müllerian anomalies, large or multiple fibroids, deep uterine septum with suspected extrauterine component, and endometriosis-associated intrauterine pathology. Simultaneous laparoscopy provides real-time transillumination and serosal monitoring during hysteroscopic metroplasty, reducing uterine perforation rates from ~1.5% to <0.3%.

PRE-OPERATIVE PHASE (4–6 Weeks Before Procedure):

• Remote consultation with GAF Healthcare's partner gynaecologist via teleconsultation — medical records, TVUS/MRI/SIS reports, and prior surgical history reviewed

• Personalised treatment plan issued; procedure type (diagnostic vs. operative), anaesthesia approach (local, conscious sedation, or general), and hospital tier confirmed

• GAF Healthcare initiates e-Medical Visa application for India (typically approved in 3–5 business days) or coordinates UAE entry requirements

• Patient completes pre-operative blood work, ECG, and anaesthesia fitness evaluation — reports submitted digitally for review by the surgical team

• Cervical priming with vaginal misoprostol 400 mcg administered 6–8 hours before procedure if cervical stenosis is anticipated (particularly postmenopausal patients or nulliparous women)

• Pre-operative GnRH agonist therapy initiated (if indicated for large submucosal fibroids) — this phase may begin 6–8 weeks before travel

ARRIVAL & ADMISSION (Day 0):

• GAF Healthcare dedicated patient coordinator meets the patient at the airport with private transfer to hotel or hospital-affiliated accommodation

• Hospital admission and consultant team introduction; written informed consent obtained with interpretation support if required

• Day-of-procedure fasting (6 hours for solids, 2 hours for clear fluids per ASA/ESRA guidelines)

• Pre-operative checklist: IV access established, beta-hCG confirmed negative, antibiotic prophylaxis administered (single-dose doxycycline 100 mg or co-amoxiclav per hospital protocol)

PROCEDURE DAY (Day 1):

• Transfer to operating suite or procedure room

• Anaesthesia administered: local para-cervical block ± IV conscious sedation (e.g., midazolam + fentanyl) for diagnostic/simple operative cases; laryngeal mask airway (LMA) general anaesthesia for complex operative hysteroscopy

• Vaginoscopic or speculum-assisted hysteroscope insertion; uterine cavity systematically inspected from internal os to tubal ostia in a clockwise pattern

• Operative intervention performed (polypectomy, myomectomy, adhesiolysis, septum resection, ablation) with continuous fluid deficit monitoring (maximum allowable deficit: 1,000–1,500 mL saline for bipolar systems per AAGL guidelines)

• Total operative time: 10–20 minutes (diagnostic/polypectomy); 30–75 minutes (operative — fibroid resection, adhesiolysis)

• Patient transferred to recovery room; vital signs and fluid balance monitored for 1–2 hours

• Same-day discharge (day-care) for uncomplicated diagnostic and simple operative cases; overnight admission for complex operative hysteroscopy or patients with anaesthetic concerns

IMMEDIATE POST-OPERATIVE PHASE (Days 1–5):

• Mild-to-moderate uterine cramping managed with NSAIDs (ibuprofen 400 mg TDS or naproxen 500 mg BD) — opioid analgesia rarely required

• Light vaginal spotting or watery discharge expected for 3–7 days post-procedure — this is physiologically normal

• Oral antibiotics prescribed if post-operative infection risk elevated (e.g., post-adhesiolysis)

• Post-operative oestrogen therapy commenced immediately for Asherman's syndrome cases

• Patient ambulates within 2–4 hours of procedure; hotel-based recovery with daily check-in from GAF Healthcare coordinator

• Avoid intercourse, tampons, and swimming for a minimum of 2 weeks

FIT-TO-FLY ASSESSMENT (Days 7–14):

• Post-operative consultant review (in-person or teleconsultation) at Day 5–7

• Clinical assessment: cessation of significant bleeding, absence of fever or signs of infection, satisfactory pain control

• Short-haul flights (<4 hours): typically cleared at Day 5–7

• Long-haul international flights: cleared at Day 10–14 with a formal fit-to-fly certificate issued by the treating surgeon

• Discharge summary, operative report, histopathology results, and follow-up instructions provided in a digital patient file

LONG-TERM RECOVERY & FOLLOW-UP (4–8 Weeks Post-Procedure):

• Return of menstrual cycle: typically 4–6 weeks post-operative (may vary with endometrial ablation — oligomenorrhoea or amenorrhoea is the intended outcome)

• Second-look hysteroscopy at 4–8 weeks recommended for Asherman's syndrome cases to confirm adhesion resolution

• Fertility patients: IVF embryo transfer cycle can typically be planned 1–2 menstrual cycles after operative hysteroscopy (6–8 weeks)

• Remote teleconsultation with GAF Healthcare's partner specialist at 4-week and 8-week milestones included in the care package