Endometrial polyps & adhesions
The uterine cavity is the space where the embryo will implant. Two common conditions that can disturb this space are endometrial polyps and intrauterine adhesions.
Both are identified and treated with hysteroscopy — a minimally invasive procedure through the vagina, without incisions. A proper assessment of the cavity is an important part of the fertility work-up.
What are endometrial polyps?
Polyps are benign outgrowths of the endometrium, the lining of the inside of the uterus. They may be single or multiple, small or larger, and often cause no symptoms at all.
They are usually discovered on ultrasound or at hysteroscopy during the infertility work-up. A polyp can act like a foreign body within the cavity, disrupting implantation, much as an intrauterine device prevents pregnancy.
Does polyp removal (polypectomy) help fertility?
For polyps found before fertility treatment, hysteroscopic removal is considered reasonable. A randomized trial in women with polyps who were about to undergo intrauterine insemination showed clearly higher pregnancy rates after polypectomy than without removal.
The procedure is simple, safe and done under light sedation or none at all. However, the routine removal of every small, incidentally found polyp in asymptomatic women does not have the same strong evidence; the decision is individualized.
What are intrauterine adhesions (Asherman syndrome)?
Intrauterine adhesions are scar-tissue bands that join the walls of the uterus to each other, partially or completely. When they cause symptoms — such as reduced or absent periods and infertility — the condition is called Asherman syndrome.
The commonest cause is injury to the endometrium, typically after curettage (chiefly following miscarriage or delivery), infection or previous uterine surgery. Adhesions reduce the space and the healthy tissue available for implantation.
How are adhesions treated?
The treatment is hysteroscopic division of the adhesions (adhesiolysis): under direct vision, the surgeon carefully separates the scars to restore a normal shape of the cavity.
The chance of conceiving after the operation depends greatly on the severity of the adhesions: women who regain a normal period and cavity have a clearly better prognosis than those with severe, extensive adhesions or recurrence of the damage.
Do adhesions come back after treatment?
Unfortunately, yes — especially in severe forms. Recurrence of adhesions is one of the main problems. Various methods are used to prevent it, such as mechanical barriers, hyaluronic-acid gels and, in selected cases, a second-look hysteroscopy a few weeks later.
No method eliminates the risk entirely. That is why the initial operation should be done carefully and by experienced hands, and avoiding unnecessary curettage remains the best prevention.
Should every woman have a hysteroscopy before IVF?
Not as a routine. In women with a normal ultrasound and no indications, universal hysteroscopy before every IVF cycle has not been shown to increase birth rates, and guidelines do not recommend it indiscriminately.
Hysteroscopy is indicated when a polyp, fibroid, adhesions or another cavity abnormality is suspected on ultrasound, or after repeated implantation failures. Targeted use, not routine.
Summary
Endometrial polyps and intrauterine adhesions (Asherman syndrome) disturb the cavity where the embryo implants. Hysteroscopic removal of a polyp before fertility treatment can increase pregnancy rates, as a randomized trial showed. Adhesions are treated with hysteroscopic division, with a prognosis depending on their severity and a risk of recurrence. Hysteroscopy is a targeted tool, not a routine test for every patient.
⚕ Medically reviewed by Prof. Stratis Kolibianakis · Thessaloniki Medical Association Reg. No. 16340
ARTICLE 24 · FEMALE CONDITIONS & FERTILITY
