Hysteroscopy Should Be A Routine Office Procedure, Says Okohue

In 2012 Over 1.25 Million Abortions Were Performed In Nigeria

The first global congress on Hysteroscopy, which recently took place in the city of Barcelona, Spain, brought together an array of gynaecological endoscopic experts from five different continents. Dr. Okohue Jude, an expert Obstetrician/gynaecologist, a minimal access surgeon and fertility expert was the West African sub-region representative at the conference. He shared with Theguardian, his experiences. Recently, you attended the first global congress on Hysteroscopy, in Barcelona, Spain. To start with, what is Hysteroscopy?

HYSTEROSCOPYIS one of the forms of gynaecological endoscopic surgeries or what we call minimal access surgery. It involves the visualization of the cavity of the womb, where babies grow, with a very small telescope, either rigid or flexible. It is the gold standard in the diagnosis and treatment of certain gynaecological conditions such as intrauterine adhesions (scarring of the womb); endometrial polyps; fibroids within the centre of the womb; congenital abnormalities of the womb; retrieval of a misplaced intrauterine contraceptive device (IUCD) from within the womb and even aiding in the diagnosis of abnormal uterine bleeding and endometrial cancer.

The procedure can be carried out in the theatre or as an office procedure and most times, the patients resume feeding, ambulate and usually are discharged home same day.

At the conference, where you gave a lecture, there were discussions and recommendations. What was the take home message?

It was quite an experience as this was the first time leading experts from all around the world would come together to brainstorm specifically on Hysteroscopy. Before now, we would converge to discuss endoscopy, which encompasses both Hysteroscopy and Laparoscopy, but for the first time the focus was solely on Hysteroscopy. The importance of Hysteroscopy in modern gynaecological practice was highlighted. It was suggested that it should be placed in the same pedestal as the stethoscope. In other words, Hysteroscopy should form part of the armamentarium of every Gynaecologist as important diagnosis and treatment including what we call the “See and treat” approach can be carried out even within the confines of your office. My main lecture centred on Asherman Syndrome. This is a situation that is quite common in Nigeria. By definition, it is the presence of scars within the uterine cavity in addition to symptoms such as menstrual problems, including scanty menses or the total absence of menses and infertility.

The number one factor responsible for Asherman syndrome is abortion, especially unsafe abortion. We all know that abortion is illegal in Nigeria but statistics show that in 2012 alone for example, over 1.25 million abortions were performed in Nigeria, majority of them unsafe. This causes injuries to the lining of the womb and following the normal healing process, the womb surfaces stick together thereby partially or totally occluding the womb space and therefore leading to menstrual problems, recurrent miscarriages and infertility. Another problem that I commonly see in my practice, which I equally discussed, is the presence of fetal bones arising from an incomplete abortion, retained within the cavity of the womb. The fetus is the growing baby in the womb and at a certain stage develops soft tissues and later, bones. These bones if left behind inadvertently act in a similar manner as an intrauterine contraceptive device (IUCD) or coil as it is called in local parlance, used by women to prevent pregnancies. As long as these bones remain in the cavity, the woman would not achieve conception. Unfortunately, the diagnosis of retained fetal bones is often missed as most ultrasound scans report it as a ‘metaplasia’, severe scarifications, etc. You need a high index of suspicion especially from the patient’s history to clinch the diagnosis and hysteroscopically and painstakingly retrieve each piece of bone in order to restore future fertility. Is Hysteroscopy readily available in Nigeria?

Hysteroscopy, just like Laparoscopy is available, albeit, in only a few centres in Nigeria. Steps are however being taken to improve the situation. We now have training centres in some parts of the country, where Gynaecologists are trained specifically on minimal access surgery. The practitioners in this field have recently decided to come together and for the first time hope to organise an international congress in the beautiful city of Abuja on the 20th of September 2017. At the conference, we hope to formally draw up a blueprint for the further development of gynaecological endoscopy in Nigeria. With the likes of Dr. Ibrahim Wada directly involved in organising the conference, we are expecting a seamless and memorable event.

You said you are a fertility expert, what has that got to do with Hysteroscopy?

Fertility practice, including In Vitro Fertilization (IVF) and Intracytoplasmic Sperm Injection (ICSI) can be said to be intimately related to endoscopy especially hysteroscopy. It will be extremely difficult to carry out IVF/ICSI without an endoscopy unit. Endoscopy complements IVF/ICSI. In some fertility centres, Hysteroscopy is carried out as a routine before any IVF/ICSI procedure, with the aim of having a firsthand view of the cavity of the womb before placing the embryos for possible implantation and pregnancy. Some of the conditions we have already enumerated including adhesions, polyps, fibroids can have negative effects on pregnancy rates after IVF/ICSI. These are therefore addressed hysteroscopically without subjecting the woman to the traditional open surgery with its myriad of problems. A few centres are even now transferring embryos following IVF/ICSI, under direct vision with the aid of a Hysteroscope. A woman with an accumulation of “dirty” fluids within her fallopian tubes (hydrosalpinx) has a significantly reduced chance of being pregnant through IVF/ICSI and might therefore require endoscopic procedures to either remove the tubes or occlude it, so there is no communication between the fallopian tubes, and hence the “dirty” fluid with the womb.

Still talking infertility, I read somewhere that one in four Nigerian couples encounter infertility challenges and that half of those would be male factor related, is this true?

It is indeed true that one in four couples or 25 per cent of Nigerian couples have challenges achieving pregnancy compared to the worldwide figures of 10-15 per cent. It is important to remember that in a normal situation, for a woman to achieve pregnancy, both the sperm and egg that united to give rise to the baby must be normal. There are millions of sperms per ejaculate and thousands of eggs, albeit, one egg is usually released at a time during ovulation. We as human beings have no control over which sperm would fertilize which egg. If the uniting egg or sperm is abnormal, the “body” rejects the resultant “baby”, either very early (the couple not aware there was a pregnancy) or as a miscarriage, most often within the first three months of conception. I tell my patients it is akin to ingesting a contaminated food item; you end up with diarrhea and or vomiting as you try to extricate yourself from the offending agent. The chance of a perfect union between a normal sperm and an equally normal egg in young healthy couples is about 20-25 per cent and this forms the basis for the explanation as to why some couples might have to wait for up to a year or even longer to achieve conception. If you consider the fact that more unsafe abortions, which can cause infertility, are performed in Nigeria compared to many other countries of the world coupled with our poor health-seeking habit, you would understand why we have higher infertility figures. Many people with sexually transmitted infections for example, would rather engage in self- medications or patronise quacks with its attendant consequences of causing infertility.

The scenario above has to do majorly with women. In what way do men contribute to infertility?

With respect to the contribution of the male partner to infertility, it is true that up to half of cases are caused by the man and that is why it is wrong for society, especially ours, to heap all the blame on the woman. There are numerous reasons why a man could be infertile. By far the commonest cause is sexually transmitted infections caused by gonorrhea or Chlamydia (DEFINITELY NOT STAPHYLOCCOCUS). Other causes include issues with ejaculation such as retrograde ejaculation (semen flowing into the bladder during ejaculation rather than externally). If a woman constantly fails to observe semen flowing out of her genital tract after intercourse, her husband should probably see a doctor as it could be retrograde ejaculation. Undescended testes, if not discovered and managed early in life can cause infertility. This is the reason why as a routine we examine for the testes following every male child delivery before the baby goes home with the mother. Congenital causes, chromosomal abnormalities, certain drugs, previous surgeries (especially groin surgeries), excessive alcohol intake, smoking and environmental factors such as excess heat in the scrotal area, exposure to toxins, are some of the other causative factors

Do we have enough expertise in endoscopy in the Nigerian medical field?

I would say for now, no but will quickly add that the future looks very bright indeed. I have a very strong conviction that things will significantly improve within the next couple of years. Minimal access surgery or endoscopy is the future of gynaecological surgery and we have no choice but to follow the global trend. Of course, not all patients are suitable candidates for this form of surgery but for those who meet the criteria for Hysteroscopy/laparoscopy, the advantages far outweigh the risks involved especially in experienced hands.