Hysteroscopic visualization and resection of embryo in biochemical pregnancy loss

To demonstrate the feasibility and skills of hysteroscopic embryonic resection in biochemical pregnancy.

Video article.

Two patients with a history of recurrent biochemical pregnancy loss presented with plateauing human chorionic gonadotropin (hCG) levels and no ultrasound evidence of a gestational sac. Case 1 underwent hysteroscopy at 4⁺¹ weeks of gestation with a maximum hCG level of 76.8 IU/L, and case 2 underwent hysteroscopy at 5⁺⁴ weeks of gestation with a maximum hCG level of 276.5 IU/L. The patients included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (e.g., PubMed, ScienceDirect, and Scopus) and other applicable sites.

Noncontact office hysteroscopy was performed under a distension pressure of 80-100 mmHg using a 30° Bettocchi hysteroscope with a 5-mm outer sheath and a 5-Fr operating channel (Karl Storz, Tuttlingen, Germany). Immediately after the identification and resection, embryos were dissected and examined under stereoscope. This study was approved by the Ethics Committee of The First Affiliated Hospital, Zhejiang University School of Medicine (IIT2024-0505).

Site of the implantation manifested four characteristics under hysteroscopy: a yellowish prominence with or without circumferential bleeding; an unhealed crater-like epithelial defect overlying the implantation site; periembryonic dilated vessels; and blood-filled endometrial glands at the base of the embryo.

Cytogenetic analysis of the chorionic villi revealed a normal karyotype in case 1 and trisomy of chromosome 1 in case 2. Their histopathological findings were normal, and postoperative recovery was uneventful.

In patients with biochemical pregnancy loss, hysteroscopy may serve as a tool to diagnose and resect early intrauterine pregnancies undetectable by ultrasound. Direct visualization could help confirm an intrauterine implantation site, enable targeted retrieval of embryonic tissue for cytogenetic and histopathological analyses, and allow simultaneous diagnosis and treatment of intrauterine lesions. These advantages are difficult to achieve through expectant management, medication, or blind curettage. However, given the additional costs and surgical risks, hysteroscopy should be reserved for patients with strong indications and a desire for comprehensive diagnostic evaluation.