Hysteroscopy: when it is needed before IVF
Hysteroscopy is a technique that lets the doctor look directly inside the uterus with a thin camera. A common question is: should every woman have a hysteroscopy before starting IVF?
The answer, based on the most recent randomized trials, is clear and perhaps surprising: routine hysteroscopy, when the uterine cavity appears normal on ultrasound, does not improve success rates.
What is hysteroscopy?
In hysteroscopy, a thin instrument with a camera (the hysteroscope) is inserted through the cervix into the uterus, giving a direct view of the endometrial cavity. It allows diagnosis and, when needed, correction of pathology in the same session.
Diagnostic hysteroscopy is often a simple procedure that can be done in an office setting. Operative hysteroscopy, to remove polyps, fibroids or a septum, is usually performed under light anaesthesia.
Does routine hysteroscopy improve success rates?
No, when the uterine cavity appears normal. Two large randomized trials — inSIGHT (before a first IVF) and TROPHY (after repeated failures) — showed that routine hysteroscopy does not increase the live-birth rate in women with a normal ultrasound.
On the basis of these data, guidelines do not recommend hysteroscopy as a routine test before IVF, provided the cavity has been adequately assessed with transvaginal ultrasound.
When, then, is it genuinely useful?
Hysteroscopy has a clear role when there is suspicion or a finding of intrauterine pathology: a polyp, a submucosal fibroid, intrauterine adhesions (Asherman syndrome) or a uterine septum. In these cases, correcting the problem can improve the chance of implantation.
It is also useful when the ultrasound leaves doubt or when there is unexplained abnormal bleeding. The goal is not to perform it in everyone, but in those who will benefit.
What about after repeated implantation failure?
Many couples believe that, after failed attempts, hysteroscopy will “find something” and solve the problem. The TROPHY trial, however, in women with previous failures and a normal cavity, showed no improvement in births with hysteroscopy.
This does not mean it is never needed in these situations — if a lesion is suspected, it is checked. But it does mean hysteroscopy should not be offered automatically as a “fix” for a normal uterus.
Is hysteroscopy dangerous?
Hysteroscopy is generally safe. Serious complications are rare and include infection, bleeding or, very rarely, perforation of the uterine wall. In its diagnostic form, discomfort is usually mild.
Even so, every invasive test carries some small risk and cost. That is a further reason not to perform it indiscriminately, but only when a genuine benefit is expected.
Summary
Hysteroscopy allows direct inspection and correction of the uterus. The randomized inSIGHT and TROPHY trials showed that, when the cavity is normal on ultrasound, routine hysteroscopy does not increase births — neither before a first IVF nor after repeated failures. It has a clear role when pathology is suspected (polyp, fibroid, adhesions, septum). The right rule: not in everyone, but in those who will benefit.
⚕ Medically reviewed by Prof. Stratis Kolibianakis · Thessaloniki Medical Association Reg. No. 16340
ARTICLE 17 · INFERTILITY & DIAGNOSIS
