Hysteroscopic Polypectomy in IVF Patients
Perform hysteroscopic polypectomy before initiating IVF when an intrauterine polyp is detected on ultrasound, as polypectomy increases pregnancy rates four-fold in women undergoing assisted reproduction and should be completed at least one menstrual cycle before starting ovarian stimulation. 1
Indications for Hysteroscopic Polypectomy Before IVF
Remove all endometrial polyps detected on imaging before starting IVF treatment, regardless of size, because polyps negatively impact endometrial receptivity through multiple mechanisms including mechanical interference with implantation, altered gene expression, and chronic inflammation. 1
Polyps are found in 19.7% of patients with recurrent implantation failure (two or more failed IVF cycles), making them the most common intrauterine abnormality in this population. 2
Hysteroscopy detects unsuspected uterine pathology in 33.6% of women with prior IVF failure who had normal hysterosalpingography before their first IVF attempt, with polyps accounting for the majority of these findings. 2
After recurrent implantation failure (≥2 failed IVF cycles), perform diagnostic hysteroscopy with polypectomy if polyps are identified, as pregnancy rates after correction (24.6%) match those of patients with normal cavities (21.2%). 2
Timing of Polypectomy Relative to IVF Cycle
Schedule hysteroscopic polypectomy during the early proliferative phase (cycle days 5–10) and delay the IVF cycle by at least one complete menstrual cycle to allow endometrial healing and normalization of receptivity markers. 1, 3
Office hysteroscopic polypectomy is minimally invasive with negligible risk of intrauterine adhesion formation (less than 1%), making it safe to perform before IVF. 3
The mechanical trauma of hysteroscopy itself may improve subsequent embryo transfer by dilating the cervix and potentially increasing endometrial receptivity through controlled endometrial injury. 1
Technique and Approach
Perform office hysteroscopy with directed polypectomy using mechanical instruments (scissors or grasping forceps) rather than blind dilation and curettage, as D&C has unacceptably low accuracy for complete polyp removal and risks incomplete resection. 3
Office hysteroscopy demonstrates the highest diagnostic accuracy for detecting polyps in infertile patients and allows immediate treatment without general anesthesia. 3
Dilation and curettage should be avoided for polyp management because it frequently misses focal lesions and leaves residual polyp tissue. 3
Send all excised polyp tissue for histopathological analysis to exclude atypical hyperplasia or malignancy, as this is mandatory regardless of patient age or symptoms. 3
Special Considerations for Small Polyps
Do not adopt expectant management for polyps <10 mm in IVF candidates, even though small polyps may spontaneously regress in some cases, because the potential benefit of removal before expensive IVF treatment outweighs the minimal procedural risk. 4, 3
While some small polyps (<10 mm) regress spontaneously, the unpredictable nature of regression and the high cost of IVF justify prophylactic removal. 4
Cost-effectiveness analyses support performing office polypectomy in women desiring to conceive rather than proceeding directly to IVF with polyps in situ. 3
Evidence Strength and Nuances
The recommendation for polypectomy before IVF is based on strong observational evidence showing four-fold increases in pregnancy rates after polypectomy in women undergoing intrauterine insemination 1, combined with multiple studies demonstrating high rates of unsuspected polyps in IVF failure patients 2, 5. However, no randomized controlled trials have specifically addressed polypectomy immediately before first IVF cycles 1, 4, so the recommendation extrapolates from IUI data and recurrent failure populations.
The evidence is strongest for polypectomy after recurrent implantation failure (≥2 failed cycles), where hysteroscopy detects correctable pathology in one-third of patients. 2
For first-time IVF patients with incidentally detected polyps, the recommendation rests on biological plausibility (polyps impair receptivity) and minimal procedural risk rather than direct RCT evidence. 1
Common Pitfalls to Avoid
Never proceed with IVF when a polyp is visible on pre-treatment ultrasound, even if the polyp appears small or the patient is eager to avoid delay—the mechanical and inflammatory effects of polyps substantially reduce implantation rates. 1
Do not rely on transvaginal ultrasound alone for polyp diagnosis; when a polyp is suspected but not definitively visualized, perform saline infusion sonohysterography (sensitivity 96–100%) or diagnostic hysteroscopy before making treatment decisions. 6
Avoid scheduling polypectomy during the same cycle as planned ovarian stimulation—allow at least one full menstrual cycle between polypectomy and IVF start to ensure complete endometrial recovery. 3