Fertility Outcome after Outpatient Hysteroscopic Removal of Endometrial Polyps and Submucous Fibroids

We assessed the value of hysteroscopic removal of polyps and submucous fibroids from women requesting fertility treatment. Between December 1991 and June 1995 we recruited 146 women (age 28-44 yrs) with such lesions who were undergoing investigations for in vitro fertilization (IVF). In most of them, intrauterine pathology was not the sole cause of subfertility. In all women the lesions were diagnosed by hysterosalpingography or vaginal ultrasound examination with fluid instillation and subsequent hysteroscopy. In 122 patients the lesion was removed hysteroscopically with the resectoscope under light sedation in an outpatient setting. No complications occurred during or after surgery. The remaining 24 patients with polyps smaller than 2 cm underwent IVF treatment directly. In the 122 women who proceeded to treatment, further diagnostic office hysteroscopy was also performed. Group A consisted of 82 women with up to three polyps (65 <2 cm, 17 >2 cm); group B, 40 women with up to five fibroids smaller than 4 cm; and group C, 24 women with ultrasound diagnosis of polyps smaller than 2 cm for whom no treatment was carried out. In groups A and B the diagnosis was confirmed histologically. All these women subsequently underwent IVF. In group A (<2 cm polyps) the pregnancy rate was 28% per embryo transfer, and in the rest of group A (>2 cm) it was 40%. In group B the pregnancy rate was 46% and in group C 35%. We think that polyps less than 2 cm diameter do not require removal before IVF and do not affect the outcome of the subsequent pregnancy.

Comparison of Operative and Fertility Outcome Between Groups of Women with Intrauterine Adhesions after Adhesiolysis

We evaluated intraoperative difficulty and fertility outcome in women with intrauterine synechiae of different severity after hysteroscopic adhesiolysis. The 86 women were recruited before fertility treatment, during hysterosalpingogram (HSG) or diagnostic hysteroscopy, over 3 years. Fifty-eight women had a history of pregnancy terminations or miscarriages, and 28 had undergone myomectomy or correction of congenital uterine anomalies by conventional surgical procedures. Group A (11 women) had over 50% of the fundal cavity obliterated by fibrous tissue, and no tubal ostia could be seen; group B (26 women) had less than 50% of the fundal cavity obliterated by fibrous tissue, and one tubal ostium could be seen; group C (49 women) had a single adhesion thicker than 1 cm. Postoperative hemorrhage requiring treatment occurred in three women from group A and two from group B. All had subsequent HSGs, and three from group A (with previous myomectomies) required a second operation and still failed to achieve an adequate fundal cavity. All patients subsequently received in vitro fertilization. Three women from group A became pregnant. Ten in group B became pregnant, eight of whom delivered or have a continuing pregnancy. In group C, 17 became pregnant, of whom 13 delivered or have a continuing pregnancy. Adhesions after suturing the uterine cavity after open myomectomy or corrective surgery seem to cause maximum damage and yield poor results in both hysteroscopic correction and reproductive performance.