Understanding hysteroscopy’s role in improved fertility outcomes

Women experiencing fertility issues or gynaecological symptoms may be given a medical procedure called a hysteroscopy, which examines the inside of the womb.

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In the UK, around one in seven couples are affected by infertility.¹ “The medical definition of infertility isn’t
being able to achieve pregnancy after 12 months or more of regular unprotected sex,” notes Dr Mahshid NickkhoAmiry, Gynaecologist and Fertility Specialist. “There are different reasons why a woman may struggle to conceive, including uterine factors which affect the structure or function of the womb.” Dr Nickkho-Amiry explains that abnormalities in the womb’s cavity may change its nature and affect implantation (the stage where the fertilised egg attaches to the lining of the uterus). Benign muscular growths called fibroids, soft tissue growths called polyps or anomalies such as tissue scarring can all cause issues associated with infertility. Some women can be affected by fibroids and polyps yet experience no symptoms. Others may experience (in the case of polyps) light bleeding or discharge between periods; or, if fibroids are present, heavy bleeding and/or pelvic pressure or pain.

The benefit of a hysteroscopy is that clinicians can
target symptomatic tissue with high accuracy and then remove it

Understanding why a hysteroscopy may be necessary

If an investigation is deemed necessary, there are two ways to identify issues. The first is with an ultrasound scan or other form of imaging. The second — and the gold standard² — is with a hysteroscopy. A hysteroscopy is a procedure performed in a hospital or
outpatient setting, where a thin telescope is passed through the vagina and cervix and into the womb. Clinicians can then investigate the cavity of the womb in real time, and find out if any polyps, fibroids and/or scar tissue are present.

“There are two types of hysteroscopy,” says Dr NickkhoAmiry. “The first is a diagnostic hysteroscopy, which is used to examine the uterus and the cause of any symptoms. The second is an operative hysteroscopy, which is done to treat any cause of symptoms found during the diagnostic hysteroscopy. This can be done at the same time and is called a “see and treat” procedure, in which clinicians can look inside the womb and treat problems simultaneously.” Most of these procedures can be performed in the office
setting rather than in a conventional theatre. Some studies have associated polyp removal with improved fertility outcomes,^3,4,5 although patients experiencing fertility issues should note that a hysteroscopy isn’t routinely given before commencement of IVF or other fertility treatments.

Having the hysteroscopic treatment that’s best for you

Where a hysteroscopy is recommended, Dr Nickkho-Amiry stresses that women should choose the hysteroscopy that’s
right for them. “As clinicians, we’re often asked if a hysteroscopy is a painful procedure,” she reveals. “The answer is: the level
of discomfort can vary from person to person. That’s why patients have a choice of different types of anaesthetic and pain relief available.” For instance, a hysteroscopy can be carried out with the use of oral painkillers. It can also be performed under local anaesthetic, sedation or general anaesthetic, but patients should have the choice of all modalities.

The benefit of a hysteroscopy is that clinicians can target symptomatic tissue with high accuracy⁶ and then remove it with a mechanical hysteroscopic tissue removal device, without the use of electrical energy. This means it’s minimally traumatic to surrounding healthy tissue and therefore reduces the likelihood of further interventions.⁶ The procedure can also be used to manage miscarriage by removing Retained Products of Conception (RPOC), such as placental or foetal tissue that may be present in the uterus after a pregnancy has ended.⁷ Ultimately, Dr Nickkho-Amiry has a simple message for anyone experiencing gynaecological symptoms, or who’s struggling to conceive after a year of trying. “Don’t wait,” she says. “It’s important to see your doctor and get the right support.”

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[1] NHS UK. (2023). Infertility: Overview
[2] rgenoglu, AM et al. Can we rely on blind endometrial curettage for complete removal of focal intrauterine lesion? A prospective clinical study. J Gynecol Obstet Hum Reprod. 2020 Apr;49(4):101696
[3] PerezMedina, T et al. Fertility and Sterility, 2005
[4] Spiewankiewicz, B et al. Journal of Obstetrics and Gynaecology Research, 2003
[5] ESHRE & ASRM Guidance: Consensus Statements
[6] Hooker A, Aydin H, Brolmann H & Huirne J. Long-term complications and reproductive outcome after the management of retained products of conception: a systematic review. Fertil Steril. 2016;105:156–64
[7] Hamerlynck, T. W., Blikkendaal, M. D., Schoot, B. C., Hanstede, M. M., & Jansen, F. W. (2013). An alternative approach for removal of placental remnants: hysteroscopic morcellation. Journal of minimally invasive gynecology, 20(6), 796-802