Hysteroscopy for treating suspected abnormalities of the cavity of the womb in women having difficulty becoming pregnant

Cochrane: Human life starts when a fertilised egg has successfully implanted in the inner layer of the cavity of the womb. It is believed that abnormalities originating from this site, such as polyps, fibroids, septa or adhesions, may disturb this important event. The removal of these abnormalities by doing a hysteroscopy using a very small diameter inspecting device might therefore increase the chance of becoming pregnant either spontaneously or after specialised fertility treatment, such as insemination or in vitro fertilisation.


Study characteristics
We found only two studies in 309 women. The first study compared the removal of fibroids versus no removal in 94 women wishing to become pregnant from January 1998 until April 2005. The second study compared the removal of polyps versus simple hysteroscopy only in 215 women before insemination with husband's sperm from January 2000 to February 2004. The evidence is current to September 2014. No study reported funding sources.
 

Key results
None of the studies reported live birth.
The study on the removal of fibroids in women with unexplained infertility suggests does not exclude a higher chance of conceiving after surgery compared to regular sexual intercourse for 12 months. However uncertainty remains because the number of women (94) and the number of pregnancies (30) are too small for any differences between both comparison groups to reach statistical significance. If 21% of women with fibroids achieve a pregnancy having timed intercourse only, the evidence suggests that between 21% to 58% of women will achieve a successful outcome following the hysteroscopic removal of the fibroids.
The second study on the hysteroscopic removal of polyps supports a benefit with the hysteroscopic removal of polyps. If 28% of women become pregnant in the control group, the evidence suggests that between 50% to 76% of women will become pregnant after the removal of the endometrial polyps
No study reported data on adverse procedure related events.
More studies are needed before hysteroscopy can be proposed as a fertility-enhancing procedure in the general population of women having difficulty becoming pregnant.
 

Quality of the evidence
The quality of the evidence on fibroids is very low: there was only one poorly conducted study lacking sufficient data.
The quality of the evidence on polyps is moderate: there were issues with selective reporting of outcomes.

 

 

Authors' conclusions: 

A large benefit with the hysteroscopic removal of submucous fibroids for improving the chance of clinical pregnancy in women with otherwise unexplained subfertility cannot be excluded. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may increase the clinical pregnancy rate. More randomised studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions in women with unexplained subfertility or prior to IUI, IVF or ICSI.