Abstract
<h3>Study Objective</h3> Demonstrate clinical consideration, operative setup and techniques for safe hysteroscopic navigation through the complex uterine isthmus. <h3>Design</h3> Video. <h3>Setting</h3> Operative hysteroscopy under general anesthesia with simultaneous ultrasound and hysteroscopic guidance. <h3>Patients or Participants</h3> 33-year-old G1P1 with history of cesarean delivery, chorioamnionitis, multiple D&C, endometriosis presents for management of secondary infertility with cervical stenosis and isthmocele obstructing embryo transfer. <h3>Interventions</h3> Ultrasound-guided hysteroscopic cervical dilation. <h3>Measurements and Main Results</h3> Despite simultaneous stenosis and isthmocele, cervical dilation and access to the uterine cavity was obtained safely without perforation, permitting planned embryo transfer. <h3>Conclusion</h3> Advanced hysteroscopy requires care pre- and intraoperative planning, use of simultaneous multi-modal imaging and knowledge of safety parameters of all available instrumentation.
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