Management of endometrial polyps in subfertile women: a systematic review

Anesthesia-free In-office Hysteroscopic Morcellation for Endometrial Polyps: A Prospective Study

Objectives

The objective of the study was to evaluate the feasibility and quality of anesthesia-free in-office hysteroscopic morcellation for the treatment of endometrial polyps.

Materials and Methods

A prospective, single-center, open-label, single-arm clinical trial was conducted to evaluate the efficacy of hysteroscopic morcellation for endometrial polyps or retained products of conception. All surgical procedures were performed using the TruClear™ 5C system in the office setting without anesthesia. The primary endpoint was the success rate of surgery, defined as the completion of the operation. The secondary endpoints were operating time, fluid deficit, adverse events, pain evaluated by Visual Analog Scale (VAS) scores, and recurrence rate.

Results

Ninety-five patients underwent hysteroscopic morcellation without anesthesia and received the treatment. The success rate of surgery was 100% (95/95), and the mean operating time was 7.3 min. Adverse events occurred in only 2.1% (2/95), with vasovagal reflex. The mean VAS scores during the procedure ranged from 2.4 to 3.1, and the recurrence rate after 6 months was 2.1% (1/47), with a pregnancy rate of 33% (11/33). When comparing nulliparous and parous patients, the success rate and the operating time were equivalent, and the mean VAS scores during the procedure were both within tolerable levels but significantly higher in nulliparous patients (3.3-4.5 vs. 1.6-1.9, P < 0.001).

Conclusion

This study demonstrated that anesthesia-free in-office hysteroscopic morcellation for endometrial polyps can be safely performed with feasible quality and only tolerable pain. This less-invasive procedure is expected to become more widespread in future.

Guideline No. 447: Diagnosis and Management of Endometrial Polyps

OBJECTIVE

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps.

TARGET POPULATION

All patients with symptomatic or asymptomatic endometrial polyps.

OPTIONS

Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice.

OUTCOMES

Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows.

TWEETABLE ABSTRACT

Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Transcriptomic Analysis Reveals Intrinsic Abnormalities in Endometrial Polyps

Endometrial polyps (EPs) are benign overgrowths of the endometrial tissue lining the uterus, often causing abnormal bleeding or infertility. This study analyzed gene expression differences between EPs and adjacent endometrial tissue to elucidate intrinsic abnormalities promoting pathological overgrowth. RNA sequencing of 12 pairs of EPs and the surrounding endometrial tissue from infertile women revealed 322 differentially expressed genes. Protein-protein interaction network analysis revealed significant alterations in specific signaling pathways, notably Wnt signaling and vascular smooth muscle regulation, suggesting these pathways play critical roles in the pathophysiology of EPs. Wnt-related genes DKK1 and DKKL1 were upregulated, while GPC3, GREM1, RSPO3, SFRP5, and WNT10B were downregulated. Relevant genes for vascular smooth muscle contraction were nearly all downregulated in EPs, including ACTA2, ACTG2, KCNMB1, KCNMB2, MYL9, PPP1R12B, and TAGLN. Overall, the results indicate fundamental gene expression changes promote EP formation through unrestrained growth signaling and vascular defects. The intrinsic signaling abnormalities likely contribute to clinical symptoms of abnormal uterine bleeding and infertility common in EP patients. This analysis provides molecular insights into abnormal endometrial overgrowth to guide improved diagnostic and therapeutic approaches for this troublesome women's health condition. Confirmation of expanded cohorts and further investigations into implicated regulatory relationships are warranted.

Nonelectric shaving of endometrial polyp by hysteroscopy - A new technique to eliminate thermal damage

OBJECTIVE

To present a new technique for complete endometrial polypectomy, using the bipolar loop hysteroscope, but without the activation of electrical energy, and follow its efficiency and safety for the patient.

STUDY DESIGN

This is a prospective descriptive study conducted at a university hospital. Forty four patients were recruited to the study according to an intra uterine polyp diagnosed by transvaginal ultrasound (TVS). Out of them 25 really had an endometrial polyp which was inspected by hysteroscopy. Eighteen were at menopause age and seven in their reproductive age. The hysteroscopic removal of the endometrial polyp was performed using the operative loop resectoscope without using electricity, meaning by cold loop. We called this unique technique SHEPH: Shaving of Endometrial Polyp by Hysteroscopy.

RESULTS

The range age was 21-77 years old. All patients with apparently endometrial polyp, underwent a complete removal of the polyp which could be directly seen through hysteroscopy. No bleeding was seen in all cases. The other nineteen patients had normal uterine cavity, so a biopsy was taken according to the indication. The specimen from all cases were sent to histological evaluation. An endometrial polyp was histologically confirmed in all cases who underwent the SHEPH technique, while fragments of an endometrial polyp was revealed by histology in six cases from the group that had normal uterine cavity. No complications were noted for the short and long periods.

CONCLUSIONS

Nonelectric Shaving of Endometrial Polyp by Hysteroscopy (SHEPH technique) is a safe and effective procedure which allows the surgeon to achieve a complete endometrial polypectomy but without using electrical energy within the body of the patient. The technique which is easy to learn, is new and unique by eliminate thermal damage in a very common gynecologic indication.

Color Doppler Imaging of Vascular Abnormalities of the Uterus

ABSTRACT

Many uterine abnormalities present clinically with bleeding encompassing a broad spectrum of patients from postmenopausal spotting to life-threatening hemorrhage. Color and spectral Doppler imaging of the pelvis is often the first crucial investigation used to quickly establish the correct etiology of the uterine bleeding and guide clinical decision making and patient management.

The effects of hysteroscopic morcellation of endometrial polyps on frozen embryo transfer outcomes

OBJECTIVE(S)

To determine if hysteroscopic removal of endometrial polyps, specifically via morcellation of polyps, affects implantation rate (IR), clinical pregnancy rate (CPR), spontaneous abortion (SAB) rate, and live birth rate (LBR) in first frozen embryo transfer (FET) cycles.

STUDY DESIGN

Retrospective chart review, with data abstracted from the charts of all first autologous oocyte frozen embryo transfer (FET) cases (n = 135) at a single fertility center from January 2018 through June 2020. Subjects were grouped into (A) hysteroscopic polypectomy prior to first FET (n = 25) or (B) no hysteroscopic polypectomy prior to first FET (n = 110). The primary outcome was live birth rate (LBR). Secondary outcomes were implantation rate (IR), clinical pregnancy rate (CPR), and spontaneous abortion (SAB) rate.

RESULTS

We found no difference between the groups in terms of the primary outcome (LBR) or the secondary outcomes IR, CPR, and SAB rate.

CONCLUSION(S)

The data analyzed here suggest that hysteroscopic morcellation of endometrial polyps has no adverse effect on IR, SAB rate, CPR, or LBR among first FET cases after this type of polypectomy.

Possible Roles of Calreticulin in Uterine Decidualization and Receptivity in Rats and Humans

Previous in vitro studies have suggested that calreticulin (CALR), which is responsible for the folding and quality control of glycoproteins, may be associated with decidualization. However, its precise role in regulating decidualization has not been explored in vivo. Here, we used pregnant rat models to examine endometrial CALR expression during the peri-implantation period. We also examined whether polypectomy, a procedure that could ameliorate infertility, alters the endometrial expression levels of CALR and several implantation factors in women diagnosed as infertile. In rats, uterine CALR was expressed at a high level at the implantation site, and a marked increase in CALR expression was observed in decidual cells of normal pregnancy. In addition, endometrial CALR expression was enhanced by either administration of estradiol-17β in the delayed implantation rat model or the artificial induction of decidualization in the pseudopregnant rat. In cultured stromal cells, siRNA-mediated silencing of CALR inhibited the decidual stimulus-induced expression of prolactin, decidual/trophoblast prolactin-related protein, and connexin 43. In humans, the endometrial expression levels of the mRNAs encoding CALR and the implantation-related factor insulin-like growth factor binding protein (IGFBP)-7 tended to increase after polypectomy. The strongest positive correlation between expression levels before polypectomy was observed for IGFBP-7 and CALR, and the strength of this correlation increased after the surgery. Thus, endometrial CALR may play a role in the formation of decidua, and the polypectomy of infertile patients may result in the co-operative expression of endometrial factors, including CALR, that could enhance endometrial receptivity.

Management of endometrial polyps in infertile women: A mini-review

Considerable disagreement exists regarding whether endometrial polyps should be removed before attempting natural pregnancy and before pregnancy via intrauterine insemination (IUI) or in vitro fertilization (IVF). Through a literature review, we obtained information on the impact of endometrial polyps and polypectomy on fertility outcomes. Several observational studies have suggested that women with unexplained infertility may benefit from endometrial polypectomy for a future natural pregnancy. A few studies reported benefits from endometrial polypectomy in infertile women who plan to undergo IUI. However, no strong evidence supports polypectomy as a way to improve the pregnancy rate in infertile women who plan to undergo IVF or polypectomy during controlled ovarian stimulation for IVF. Although no studies have defined criteria for the polyp size that should be removed in infertile women, clinicians should be aware that small endometrial polyps (<10 mm) sometimes regress spontaneously. Endometrial polypectomy is currently justified in patients with repeated IVF failure, but more studies are needed to verify that endometrial polypectomy itself will eventually increase the pregnancy rate. Although several mechanisms by which endometrial polyps exert a negative effect on fertility have emerged, there is no consensus about the proper management of endometrial polyps in infertile women. Therefore, the management of endometrial polyps should be individualized depending on the patient's situation and clinician’s preference.

Effectiveness of different methods for polypectomy in the menopause: a retrospective study

Introduction: Most endometrial polyps represent focal hyperplasia of the endometrium. Endometrial polyps can be diagnosed by ultrasound, hysterocontrast sonography, hysterosalpingography, endometrial biopsy, and uterine curettage, but diagnostic hysteroscopy is considered the gold-standard method, with the greatest sensitivity and specificity and also with the opportunity for treatment at the same time.Study design: A retrospective study was conducted on 424 patients between 2006 and 2018. The polyps were verified during diagnostic hysteroscopy and were removed by resectoscopy or curettage. All samples underwent histological examination. The effectivity of the type of resection and the recurrence rate were evaluated.Results: The average age of the patients was 60.2 ± 9.3 years. Polyps were excised in 62.97% by resectoscopic polypectomy and in 37.03% by curettage. Malignancy was confirmed in 4.24% of cases. Histological verification of polyps was 79.4% in the resectoscopy group and 69.04% in the curettage group; the difference was significant (p < 0.01). The recurrence rate was 20.47% after resectoscopy and 27.12% following curettage.Conclusion: Hysteroscopy remains the best option and the gold-standard method among diagnostic procedures of endometrial pathology. In this study, there was a significant difference in matching hysteroscopic and histological findings in the two methods of polypectomy. The recurrence rate is also lower following resectoscopy.

Fertility outcomes after hysteroscopic removal of intrauterine leiomyomas and polyps

INTRODUCTION

Thanks to the progress of science, it is now understood that a successful implantation not only depends on the quality of the embryo, but also on having a receptive endometrium. During the years, several authors have reviewed the important role of the uterine factor, ranging from the congenital anomalies, such as uterine septa and subsepta, and acquired conditions such as endometrial polyps and submucous myomas. Currently, hysteroscopy has proved to be a powerful and accurate tool for visualizing the uterine cavity and treating intrauterine pathologies.

EVIDENCE ACQUISITION

This review of the literature aims to report the current available data on the effects of the two most common endouterine pathologies (i.e. endometrial polyps and submucous myomas) and the impact of hysteroscopic removal on fertility outcomes.

EVIDENCE SYNTHESIS

To date, the low number of randomized controlled trials available does not yet make it possible to give a definitive answer on what are the reproductive outcomes following treatment of endometrial polyps and leiomyomas. Nevertheless, existing evidence points to a benefit of removal of this two pathologies in infertile women, mostly when they have a history of recurrent pregnancy loss.

CONCLUSIONS

Further studies are needed to demonstrate that surgical treatments of endometrial polyps and myomas could improve not only the morphology but also the function of the uterine cavity before undergoing any assisted fertility treatment.

The Potential Relationship Between Different Human Female Reproductive Disorders and Sperm Quality in Female Genital Tract

Spermatozoa should travel throughout the female reproductive tract to reach its ultimate goal, fertilization of the oocyte. At the ejaculation moment, millions of sperm within a few milliliters of the ejaculate are deposited at the cranial segment of vagina and make their journey to the fertilization site. This is done by means of various factors, such as sperm motility, the uterine and fallopian tubes contractility, and the ciliary movement of the lining cells. During this migration, spermatozoa interact with the female microenvironment both physically and molecularly. In this regard, the quality of the environmental conditions may affect this interaction. Therefore, some alterations in women's genital tract microenvironment, such as conditions that occur in female reproductive disorders, may have detrimental effects on sperm reproductive function. In this review, human sperm migration through the female tract is described, and the potential effects of different reproductive disorders at reproductive organs, such as vagina, uterine cervix, uterus, fallopian tubes, and ovary on sperm survival and quality, are also argued. The understanding of those conditions that may impair sperm fertility in the female genital tract can provide a more accurate diagnosis of the causes of infertility in couples. This can ultimately lead to the discovery of effective treatment approaches.

Hysteroscopy Findings after Two Previous Failed In vitro Fertilisation Cycles: A Case for Routine Hysteroscopy before In vitro Fertilisation?

Background:

The success rates of in vitro fertilisation (IVF) cycles have remained low. The condition of the uterus plays a significant role in the IVF treatment outcome. Unfortunately, some uterine pathologies are missed on routine ultrasound scans performed before IVF.

Objective:

To document the hysteroscopy findings following normal ultrasound scan endometrial assessments in women with two previous failed IVF cycles, seen at a private fertility unit.

Materials and Methods:

This is a retrospective descriptive study. The electronic medical records were retrieved for patients who underwent hysteroscopy after two consecutive failed IVF cycles despite normal ultrasound scan findings between April 1, 2010, and March 31, 2017. Data, including age, findings at hysteroscopy, and IVF/intracytoplasmic sperm injection treatment outcomes following hysteroscopy, were documented. The results are presented as frequency distribution tables.

Results:

A total of 77 patients had normal ultrasound scan findings after two previous failed IVF cycles, requiring a hysteroscopy during the study period. This represented 7.7% of the 1,002 hysteroscopies performed during the same period. The age range was 25–54 years, with a mean age of 37 ± 4.3 years. A majority of the women (59, 76.6%) had no pathology on hysteroscopy, while 14 (18.2%) had intrauterine adhesions. Three patients (3.9%) had endometrial polyps, and one patient (1.3%) had a subseptate uterus. Following hysteroscopy, 24 patients (31.2%) became pregnant, 29 patients (37.6%) had failed IVF cycles, while the remaining 24 patients (31.2%) were lost to follow up.

Conclusion:

This study has added to the body of evidence that suggests that routine hysteroscopy before IVF is capable of picking up missed pathologies that might otherwise negatively impart IVF success rates. More RCT are, however, needed to determine the effect of routine hysteroscopy on IVF treatment outcomes.

Multiple endometrial polyps is associated with higher risk of chronic endometritis in reproductive-aged women

AIM

To determine whether single endometrial polyp (EP) or multiple EP (polyp number ≥ 6) are associated with chronic endometritis (CE).

METHODS

From June 2017 to December 2018, this study enrolled a total of 277 patients, including 92 patients with multiple EP, 82 patients with a single EP and 103 patients without polyps who underwent hysteroscopic examination and polypectomy. Polyps and endometrium samples were obtained and subjected to immunohistochemistry for CD138 to identify plasma cells and CE was diagnosed as CD138-positive plasma cells greater than or equal to 5/high power field. The prevalence of CE was compared and analyzed using the logistic regression model.

RESULTS

All baseline parameters were comparable among the three groups except that the prevalence of abnormal uterine bleeding (AUB) was much higher in both polyp groups than the non-polyp control. The prevalence of CE was significantly higher in the multiple EP group than in the single EP group (58.7% vs 28.0%, P < 0.001). There was no difference on the prevalence of CE between the single EP and the non-polyp groups (28.0% vs 29.1%, P = 0.872). Multivariable analysis revealed that AUB (adjusted OR 2.81, 95% CI 1.35-5.87) and multiple EP (adjusted OR 2.58, 95% CI 1.38-4.82) were independently associated with CE, while the single EP did not increase the odds of CE compared to the non-polyp group (adjusted OR 0.74, 95% CI 0.38-1.45).

CONCLUSION

Multiple EP were positively associated with CE among reproductive-aged women, suggesting a possible hidden etiopathogenetic link between chronic inflammation and multiple EP.

Does a hyperechogenic endometrial mass in the uterus during controlled ovarian stimulation affect assisted reproductive technology cycle outcomes?

OBJECTIVES

Healthy embryos and endometrial receptivity are keys to the success of in-vitro fertilization and embryo transfer (IVF-ET). Abnormal transvaginal ultrasonography (TVU) findings in the endometrium are a concern during assisted reproductive technology (ART) treatments. Observation of a hyperechogenic endometrial mass (HEM) during controlled ovarian stimulation (COS) in an IVF or intracytoplasmic sperm injection (ICSI) cycle is a dilemma. Here we investigated whether an HEM would affect ART cycle outcomes.

STUDY DESIGN

We analyzed all data from patients who underwent IVF or ICSI treatment cycles from January 1, 2009 to December 31, 2016 at our institution. Patients diagnosed with an HEM were included. Each woman was matched with two control subjects of similar age (± 1 year), in terms of the number of cycles, type of infertility (primary or secondary), protocol used for COS, but with no HEM identified by TVU. Baseline characteristics, COS response, and pregnancy outcomes after ET were compared.

RESULTS

In all, 1088 patients were diagnosed with an HEM. Of these, 426 met the inclusion criteria and were matched with 852 controls. Baseline characteristics showed no significant differences between the groups. The peak endometrial thickness was significantly greater in the experimental group than in the control group (1.15 ± 0.18 cm vs. 1.08 ± 0.21 cm, p < 0.001). The live birth rates were 43.7% vs 46.2% in the experimental and control groups, respectively. There were no significant between-group differences in the rates of biochemical or clinical pregnancy or abortions at any stage.

CONCLUSIONS

Newly diagnosed HEMs < 18 mm in diameter monitored by TVU did not impair the outcomes of ART following COS in this study. If other conditions are suitable, completion of ART cycles should be the appropriate approach in such cases.

KEY MESSAGE

Newly diagnosed hyperechogenic endometrial masses measuring <18 mm in diameter monitored by TVU during COS did not adversely affect the outcomes of these IVF/ICSI-ET cycles.

Endometrial polyps: Pathogenesis, sequelae and treatment

Endometrial polyps are overgrowths of endometrial glands that typically protrude into the uterine cavity. Endometrial polyps are benign in nature and affect both reproductive age and postmenopausal women. Although endometrial polyps are relatively common and may be accompanied by abnormally heavy bleeding at menstruation. In asymptomatic women, endometrial polyps may regress spontaneously, in symptomatic women endometrial polyps can be treated safely and efficiently with hysteroscopic excision.

The effect of localization and histological verification of endometrial polyps on infertility

Aim

Our purpose is to investigate if transcervical resection of endometrial polyps improves the fertility in ovulatory infertile women, and whether polyp histology, intrauterine location, and the technique of polypectomy have any influence on the pregnancy rates.

Methods

In this retrospective study, clinical data of 87 ovulatory infertile women who underwent hysteroscopy and polypectomy, and their 12-month follow-up have been analyzed. Subgroups according to the method of polyp removal (resectoscope or curettage), the polyp localization (utero-tubal, anterior, posterior, lateral, multiple) and the histological result were interpreted.

Results

Mean age of patients was 33.99 ± 4.24 years. There were no differences in the BMI and basal FSH levels between the subgroups. Pregnancy was recorded in 30 (34.5%) within the next 12 months without any difference between the subgroups of polypectomy method applied. Posterior wall polyp resection increased the pregnancy chance (OR 5.02), but no other differences were observed in 1-year pregnancy rates to other localizations. Removal of polyps which had normal endometrial histology had lower pregnancy rates as compared to that of polyps with hyperplasia or endometrial polyp histology results (OR 0.25).

Conclusions

Polypectomy improved the conception rate in the subsequent year regardless of the intrauterine localization and the method of its surgical removal. Therefore, we can conclude that polypectomy should be considered in infertile women.

Intraoperative and Postoperative Clinical Evaluation of the Hysteroscopic Morcellator System for Endometrial Polypectomy: A Prospective, Randomized, Single-blind, Parallel Group Comparison Study

Objective:

To evaluate the TRUCLEAR™ system (Smith and Nephew Inc., London, UK), a hysteroscopic system that morcellates and aspirates masses, in terms of the operating time, surgeon's convenience, and effect on patients compared with conventional electrosurgical resection.

Methods:

Patients undergoing hysteroscopic resection of endometrial polyps were randomly allocated to undergo hysteroscopic morcellation or electrosurgical resection (UMIN-CTR identifier: UMIN000019649). The primary outcome was the operating time. Secondary outcomes were the removal success, fluid deficit, convenience with the technique, insertion time, number of insertions during the operation, visibility of the operative field, recurrence of the patient's chief complaint, and adverse events.

Results:

Sixty-seven women were randomly allocated to the morcellation arm (n = 34) or electrosurgical resection arm (n = 33) from November 2015 to November 2016. The polyps were completely removed, and no adverse events were observed in all 67 patients. The average operating time (8.3 min vs. 12.0 min, P = 0.014), insertion time (5.0 min vs. 9.0 min, P < 0.001), and number of insertions (1.0 vs. 8.2, P < 0.001) were significantly lower in the morcellation arm than in the electrosurgical resection arm. Surgeons' subjective evaluation measured on a 10-cm visual analog scale was higher in the morcellation arm than in the electrosurgical resection arm in terms of easiness of removal (8.4 vs. 6.5, P < 0.001) and visibility of the operative field (7.8 vs. 6.4, P < 0.001).

Conclusion:

Surgeons gave the hysteroscopic morcellator system a better evaluation compared than electrosurgical resection, and the system shortened the operating time.

Hysteroscopic polypectomy prior to infertility treatment: A cost analysis and systematic review

The cost of fertility treatment is expensive and interventions that reduce cost can lead to greater efficiency and fewer embryos transferred. Endometrial polyps contribute to infertility and are frequently removed prior to infertility treatment. It is unclear whether polypectomy reduces fertility treatment cost and if so, the magnitude of cost reduction afforded by the procedure. The aim of this study was to determine whether performing office or operative hysteroscopic polypectomy prior to infertility treatment would be cost-effective. PubMed, Embase, and Cochrane libraries were used to identify publications reporting pregnancy rates after hysteroscopic polypectomy. Studies were required to have a polypectomy treatment group and control group of patients with polyps that were not resected. The charges of infertility treatments and polypectomy were obtained through infertility organizations and a private healthcare cost reporting website. These charges were applied to a decision tree model over the range of pregnancy rates observed in the representative studies to calculate an average cost per clinical or ongoing pregnancy. A sensitivity analysis was conducted to assess cost savings of polypectomy over a range of pregnancy rates and polypectomy costs. Pre-treatment office or operative hysteroscopic polypectomy ultimately saved €6658 ($7480) and €728 ($818), respectively, of the average cost per clinical pregnancy in women treated with four cycles of intrauterine insemination. Polypectomy prior to intrauterine insemination was cost-effective for clinical pregnancy rates greater than 30.2% for office polypectomy and 52.6% for operative polypectomy and for polypectomy price <€4414 ($4959). Office polypectomy or operative polypectomy saved €15,854 ($17,813) and €6644 ($7465), respectively, from the average cost per ongoing pregnancy for in vitro fertilization/intracytoplasmic sperm injection treated women and was cost-effective for ongoing pregnancy rates greater than 26.4% (office polypectomy) and 31.7% (operative polypectomy) and polypectomy price <€6376 ($7164). These findings suggested that office or operative hysteroscopic polypectomy was cost-effective when performed prior to both intrauterine insemination and in vitro fertilization over a range of plausible pregnancy rates and procedural costs.

Pregnancy complications in spontaneous and assisted conceptions of women with infertility and subfertility factors. A comprehensive review

In the literature, there is growing evidence that assisted reproductive techniques increase the risk of pregnancy complications in subfertile couples. Moreover, many concomitant preconception risk factors for subfertility are frequently present in the same subject and increase the risk of pregnancy complications. This review aimed to summarize in a systematic fashion the best current evidence regarding the effects of preconception maternal factors on maternal and neonatal outcomes. A literature search up to March 2016 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science and Google Scholar. An evidence-based hierarchy was used to determine which articles to include and analyse. Available data show that the risk of pregnancy complications in spontaneous and assisted conceptions is likely multifactorial, and the magnitude of this risk is probably very different according specific subgroups of patients. Notwithstanding the only moderate level and quality of the available evidence, available data suggest that the presence and the treatment of specific preconception cofactors of subfertility should be always taken into account both in clinical practice and for scientific purposes.

Progesterone administration for luteal phase deficiency in human reproduction: an old or new issue?

Luteal phase deficiency (LPD) is described as a condition of insufficient progesterone exposure to maintain a regular secretory endometrium and allow for normal embryo implantation and growth. Recently, scientific focus is turning to understand the physiology of implantation, in particular the several molecular markers of endometrial competence, through the recent transcriptomic approaches and microarray technology. In spite of the wide availability of clinical and instrumental methods for assessing endometrial competence, reproducible and reliable diagnostic tests for LPD are currently lacking, so no type-IA evidence has been proposed by the main scientific societies for assessing endometrial competence in infertile couples. Nevertheless, LPD is a very common condition that may occur during a series of clinical conditions, and during controlled ovarian stimulation (COS) and hyperstimulation (COH) programs. In many cases, the correct approach to treat LPD is the identification and correction of any underlying condition while, in case of no underlying dysfunction, the treatment becomes empiric. To date, no direct data is available regarding the efficacy of luteal phase support for improving fertility in spontaneous cycles or in non-gonadotropin induced ovulatory cycles. On the contrary, in gonadotropin in vitro fertilization (IVF) and non-IVF cycles, LPD is always present and progesterone exerts a significant positive effect on reproductive outcomes. The scientific debate still remains open regarding progesterone administration protocols, specially on routes of administration, dose and timing and the potential association with other drugs, and further research is still needed.

Surgical Management of Endometrial Polyps in Infertile Women: A Comprehensive Review

Endometrial polyps are benign localized lesions of the endometrium, which are commonly seen in women of reproductive age. Observational studies have suggested a detrimental effect of endometrial polyps on fertility. The natural course of endometrial polyps remains unclear. Expectant management of small and asymptomatic polyps is reasonable in many cases. However, surgical resection of endometrial polyps is recommended in infertile patients prior to treatment in order to increase natural conception or assisted reproductive pregnancy rates. There is mixed evidence regarding the resection of newly diagnosed endometrial polyps during ovarian stimulation to improve the outcomes of fresh in vitro fertilization cycles. Hysteroscopy polypectomy remains the gold standard for surgical treatment. Evidence regarding the cost and efficacy of different methods for hysteroscopic resection of endometrial polyps in the office and outpatient surgical settings has begun to emerge.

Evaluation of sonohysterography in detecting endometrial polyps - 241 cases followed with office hysteroscopies combined with histopathological examination

Introduction

Hysteroscopy is considered the ‘gold standard’ procedure in assessing uterine pathology however it is more expensive and invasive method than ultrasonography. An alternative to the diagnostic hysteroscopy is sonohysterography.

Aim

To evaluate the usefulness of sonohysterography in detecting endometrial polyps in female patients diagnosed with infertility.

Material and methods

We compared the results of sonohysterographic examinations with hysteroscopy combined with histopathological findings.

Results

All the 241 sonohysterography examinations were performed successfully. No complications were observed. Forty-three hysteroscopies (17.8%) and six sonohysterography examinations (2.5%) were performed in short total intravenous anesthesia because of a low pain threshold of the patients. After hysteroscopic resection polyps were diagnosed in 74 (30.7%) patients. In 72 cases both saline infusion sonography (sonohysterography, SIS) examination and hysteroscopy confirmed the occurrence of an endometrial polyp. In 7 examinations (4.2%) the diagnosed polyp was not confirmed in sonohysterography (false-positive results). Two SIS procedures (2.7%) did not confirm the occurrence of the polyp (false-negative results). Sensitivity, specificity accuracy and error of sonohysterography in detecting endometrial polyps were 97.3%, 95.8% 96.2% and 3.7%, respectively. Positive and negative predictive values were 91.1% (PPV) and 98.7% (NPV). The agreement between SIS and hysteroscopy combined with histopathological examination was very high (K = 0.91).

Conclusions

Sonohysterography is a safe and highly sensitive and specific method used in diagnostics of endometrial polyps. Its results closely correspond to those obtained in a hysteroscopic examination and histopathological analysis.

Application of office hysteroscopy in gynaecological practice

Introduction: Nowadays minimally invasive techniques are a leading factors in medicine. According to this trend, hysteroscopy has been used in gynecology more and more frequently. Office hysteroscopy gives opportunity for a faster examination with less costs and strain for the patient. Aim: The aim of this work was to get familiar with the novel method. The author examined the level of pain during hysteroscopy performed for different indications with different types of instruments. In addition, the novel method invented for evaluating tubal patency was compared to the gold standard laparoscopy in 70 tubes. Method: Office hysteroscopy was performed in 400 cases for indications according to the traditional method. All examinations were performed in University of Debrecen, Department of Obstetrics and Gynecology in an outpatient setting. A 2.7 mm diameter optic with diagnostic or operative sheet was used. Hysteroscopies were scheduled between the 4th and 11th cycle day. For recording pain level VAS was used in 70 cases. Comparison of hysteroscopic evaluation of tubal patency to the laparoscopic method was studies in 70 cases. Results: It was found that office hysteroscopy can be performed in an outpatient setting, without anesthesia. Pain level showed no difference among subgroups (nulliparous, non-nulliparous, postmenopausal, diagnostic, operative) (mean±SD, 3.5±1.01; p=0.34). For the evaluation of tubal patency, office hysteroscopy showed 92.06% accuracy when compared to laparoscopy. Conclusions: Office hysteroscopy has several advantages over traditional method. This procedure is fast, it has less strain for the patient. The novel method, rather than traditional hysteroscopy, should be used in the work-up of infertility as well. Orv. Hetil., 2014, 155(40), 1589–1597.

Surgical intervention versus expectant management for endometrial polyps in subfertile women

BACKGROUND

Endometrial polyps, which are benign growths of the endometrium, may be a factor in female subfertility. Possible mechanisms include physical interference with gamete transport, alteration of the endometrial milieu and unresponsiveness to the cyclical global endometrial changes. As such polyps remain mostly asymptomatic, their diagnosis is often incidental during routine investigations prior to embarking on assisted reproductive treatment. Transvaginal sonography, hysterosalpingography and saline infusion sonography are the diagnostic tools most commonly employed. However, hysteroscopy remains the gold standard for diagnosis, as well as for treatment. Due to the possible effect of endometrial polyps on fertility, their removal prior to any subfertility treatment is widely practiced.

OBJECTIVES

To determine the effectiveness and safety of removal of endometrial polyps in subfertile women.

SEARCH METHODS

Electronic databases were searched, including the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL and trial registers. The reference lists of identified articles were checked. The last search was performed on 30 July 2014.

SELECTION CRITERIA

Only randomised controlled trials, reporting pregnancy or live birth rates and complication rates as primary or secondary outcomes, in which polyps were removed surgically prior to treatment of subfertility were eligible for inclusion. The diagnosis of endometrial polyps was required to be made by transvaginal ultrasound, hysterosalpingography, saline infusion, sono-hysterography or hysteroscopy. Any surgical technique of polyp removal was acceptable, with no intervention in the control groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles, abstracts and full articles to assess their suitability for inclusion in this review. Quality assessment was attempted independently by two authors with discrepancies being settled by consensus or consultation with a third review author.No data extraction was performed due to the absence of useable data in the one eligible study. If there had been data to include, two review authors would have independently extracted the data from the studies using a data extraction form designed and pilot tested by the authors. Any disagreements would have been resolved by discussion or by a third review author.

MAIN RESULTS

Only one randomised controlled trial of endometrial polypectomy was identified for inclusion. However, a single set of data could not be extracted from this study due to internal inconsistencies of the results reported. Attempts to contact the authors to resolve the issue were unsuccessful, by phone, post and e-mail.

AUTHORS' CONCLUSIONS

Removal of endometrial polyps in subfertile women is commonly being performed in many countries with an aim to improve the reproductive outcome. We did not identify any analysable randomised trials which would allow us to reach any sound scientific conclusions on the efficacy of endometrial polypectomy in subfertile women. Well designed, methodologically sound, randomised controlled trials are urgently needed.

New opportunities for the evaluation of infertility

Incidence of infertility increased in the past years and it affects 15% of couples. Female and male factors are responsible in 40% and 40% of the cases, respectively, while factors present in both females and males can be found in 20% of cases. Female factors can be further divided into organic and functional ones. Function of the female organs can be evaluated in an outpatient setting by well-developed laboratory techniques but evaluation of the uterine cavity and inspection of the tubal patency have been traditionally carried out in one-day surgery. However, the latter can be performed under ambulatory setting with the use of office hysteroscopy, so that the use of operating theatre and staff costs can be saved. Using selective pertubation for the evaluation of tubal patency via office hysteroscopy can reduce cost further. The new methods in infertility workup which can be performed in ambulatory setting have several advantages for the patients. Orv. Hetil., 2013, 154, 1287–1290.

Endometrial polyps and subfertility

Endometrial polyps are a relatively common finding in infertility patients. They can distort the endometrial cavity, may have a detrimental effect on endometrial receptivity and increase the risk of implantation failure. Although treatment seems to be safe and easy, this may not always be the case if endometrial polyps are diagnosed after starting an in vitro fertilization cycle. This paper reviews the medical literature to provide an evidence-based approach for management of endometrial polyps in subfertile women.

Redefining reproductive surgery

With the availability of and improvements in in vitro fertilization (IVF), the role of reproductive surgery has been questioned. Yet, the scope of reproductive surgery today is much larger than in the past. Hysteroscopic correction of intrauterine disease is an important endoscopic procedure in women with infertility. Evidence suggests that correction of intrauterine disease is often followed by spontaneous pregnancy and improved IVF outcome. Hysteroscopic examination should be considered after 1 failed IVF. Today, it is clear that removal of the hydrosalpinx leads to a higher IVF-related live birth rate. The procedure should be performed thoroughly without compromising the ovarian blood supply. The IVF pregnancy rate is not affected by the presence of ovarian endometriomas, and small endometriomas need not be removed; however, large and symptomatic endometriomas that interfere with oocyte retrieval should be excised. When excision of the cyst wall is difficult, fenestration and ablation should be considered. This might lead to an increased recurrence rate, but is associated with less interference of the ovarian reserve. Although the role of reproductive surgery as primary treatment for tuboperitoneal infertility is limited, it has an important role in enhancing the outcome of IVF treatment and in preservation of fertility. Surgical preservation of fertility consists of ovarian suspension, ovarian excision for cryopreservation, and ovarian tissue transplantation.