Is Fertility Improved After Hysteroscopy for Uterine Cavity Abnormalities?

Hysteroscopic removal of polyps in women with unexplained infertility may increase their chances of becoming pregnant, concludes an intervention review conducted by the Cochrane Menstrual Disorders and Subfertility Group.¹
   
Abnormalities in the uterine cavity, such as endometrial polyps, submucous fibroids, uterine septum, and intrauterine adhesions, may disrupt the process of implantation of a fertilized egg into the inner layer of the cavity of the uterus. In subfertile women with a uterine cavity abnormality, removal of these abnormalities using hysteroscopy may be recommended to help increase the odds of pregnancy. Although the practice is theoretically sound, it is unknown whether hysteroscopic removal of uterine cavity abnormalities results in a definitive increase in pregnancy and live birth rates.
   
To better understand the effects of hysteroscopic removal of uterine cavity abnormalities in women with otherwise unexplained subfertility or before commencing assisted reproductive technology, such as intrauterine insemination (IUI), in vitro fertilization, or intracytoplasmic sperm injection, researchers reviewed and analyzed available relevant studies. Live birth and hysteroscopy complications were primary outcomes, and pregnancy and miscarriage were secondary outcomes.
   
Two studies were included in this analysis, and neither provided information about the primary outcomes of live birth and hysteroscopy-related complications. The first study involved 94 women with otherwise unexplained subfertility and submucous fibroids. According to the researchers, hysteroscopic myomectomy might have some benefit over regular fertility-oriented intercourse over a 12-month period for clinical pregnancy rates (odds ratio, 2.4; P=0.06) or miscarriage rates (OR, 1.5; P=0.47), but the small sample size and the low number of pregnancies (30 total) led to statistically insignificant results. In addition, the researchers reported that the quality of the study was very low.
   
The second study involved 204 women with various fertility problems who also had polyps. The results of the analysis showed that hysteroscopic removal of polyps before IUI, compared with diagnostic hysteroscopy and biopsy, significantly increased the odds of clinical pregnancy (63% vs 28%, respectively; P<0.00001). The researchers deemed the quality of this study to be high. Although this analysis showed an important increase in pregnancy rates, additional studies are needed to confirm the results.
   
The real clinical value of hysteroscopic removal of uterine cavity abnormalities to increase fertility rates in subfertile women remains unknown. The limited evidence shows that hysteroscopy may improve the odds of a clinical pregnancy. However, more studies are needed before hysteroscopy can be recommended as a fertility-enhancing procedure, concluded the researchers.

Pertinent Points:
- Removing polyps and other uterine cavity abnormalities via hysteroscopy in women with unexplained infertility may increase their chances of becoming pregnant.
- The analysis shows the practice is associated with important increases in pregnancy rates or at least a benefit trending toward increased fertility, but the evidence is limited and additional, larger studies are needed.
 

References:

1. Bosteels J, Kasius J, Weyers S, et al. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev. 2013;1:CD009461. doi: 10.1002/14651858.CD009461.pub2.