How is a uterine polyp that is preventing conception typically treated?

Treatment of Uterine Polyps Preventing Conception

Hysteroscopic polypectomy is the definitive treatment for uterine polyps preventing conception, with pregnancy rates of 61.4% and live birth rates of 54.2% in previously infertile women where polyps were the only identifiable cause of infertility. 1

Diagnostic Confirmation

Before proceeding with treatment, proper diagnosis is essential:

• 3D transvaginal ultrasound (TVUS) is the preferred initial imaging modality with 92% accuracy in detecting endometrial polyps 2
• MRI serves as the gold standard with 100% accuracy when diagnosis is uncertain 2
• In-office diagnostic hysteroscopy provides the highest diagnostic accuracy in infertile patients with suspected endometrial polyps and should be performed to confirm the diagnosis before therapeutic intervention 3
• Hysterosalpingography has poor accuracy (only 16.7%) and should be avoided for polyp characterization 2

Treatment Approach: Hysteroscopic Polypectomy

Indications for Removal

All endometrial polyps should be removed in women with infertility, regardless of size or number, as they alter endometrial receptivity and embryo implantation 1, 3:

• Polyps ≤1 cm: pregnancy rate 28% per embryo transfer after removal 4
• Polyps >1 cm: pregnancy rate 40% per embryo transfer after removal 4
• No statistical difference in fertility rates exists between small versus large or multiple polyps, meaning all should be removed 1

Surgical Technique

Resectoscopic polypectomy is the preferred technique over grasping forceps or microscissors 5:

• Resectoscope achieves 0% recurrence rate versus 15% with grasping forceps 5
• Can be performed safely in an outpatient setting under light sedation 4
• Complication rate is extremely low at 2.4%, with no major complications reported 1, 5

Timing Considerations

Critical timing principle: Allow adequate healing before embryo transfer

• Minimum 5-day interval required between polypectomy and embryo transfer for any chance of pregnancy 6
• Optimal interval appears to be longer, as the interval between polyp resection and embryo transfer is a significant predictor of live birth (odds ratio 1.2) 6
• If polyps <20mm are discovered during IVF stimulation, do NOT perform polypectomy during that cycle—instead, cancel the fresh transfer and proceed with frozen embryo transfer after proper healing 6

Expected Outcomes

Fertility Results

After hysteroscopic polypectomy in infertile women with polyps as the sole cause:

• Spontaneous pregnancy rate: 61.4% 1
• Live birth rate: 54.2% 1
• Cumulative pregnancy rate over long-term follow-up: 42.3% 5
• First trimester miscarriage rate: 6% (comparable to general population) 1

Menstrual Pattern Normalization

• 91.6% of patients experience normalized menstrual patterns after polypectomy 1
• 93.1% of those with abnormal uterine bleeding resume normal menstruation 5

Critical Pitfalls to Avoid

Never perform dilation and curettage (D&C) alone for polyp removal—it should be avoided due to inaccuracy for focal endometrial pathology and high incomplete removal rates 3:

• D&C has poor diagnostic and therapeutic accuracy
• Blind curettage frequently misses polyps entirely
• Hysteroscopic visualization with directed removal is mandatory 3

Do not attempt expectant management in symptomatic patients or those desiring fertility—the evidence clearly supports removal 3:

• Polyps impair endometrial receptivity
• Spontaneous resolution is uncommon
• Recurrence rate after proper hysteroscopic removal is only 4.9% 1

Histopathological Analysis

Mandatory histopathological examination of all removed polyps due to malignancy risk, particularly in postmenopausal women 3:

• Risk of premalignant or malignant changes exists
• If atypical hyperplasia or carcinoma is found, hysterectomy is recommended in postmenopausal patients 3

Cost-Effectiveness

Office-based hysteroscopic polypectomy is highly cost-effective in women desiring to conceive, with excellent benefit-to-risk ratio 3:

• Outpatient procedure under light sedation
• Minimal complications
• High success rates for fertility restoration
• Low recurrence when performed with resectoscope 5