Endometrial polyps and fertility: when to remove them

The endometrium, the inner lining of the womb, grows and sheds every cycle. Sometimes a part of it grows more and forms a small hanging overgrowth, a polyp, which can be a few millimetres or a few centimetres. Polyps are common at all reproductive ages, more common after the thirties, and are linked to the lining's sensitivity to oestrogen. The great majority are benign; a very small proportion can have changes that need attention, and this is why removed tissue is always analysed.

Many polyps give no symptoms and are found by chance. Others cause bleeding between periods, heavier periods or bleeding after intercourse. In women trying to conceive, they may give no sign at all and be found only during the fertility assessment.

A polyp can hinder implantation in several ways. It can occupy physical space in the cavity of the womb, alter the local environment of the lining through inflammation or molecular changes, and, when located near the entrance of the tubes, obstruct the passage of sperm or embryo. Studies, including those Dr. Göksu has reviewed, show that in women with infertility removing polyps is associated with improved chances of pregnancy, especially before insemination or embryo transfer.

This does not mean every polyp is the cause of infertility; often it is one factor among others. But it is one of the few factors that can be removed easily and safely, and that makes its assessment and treatment a reasonable step in the fertility plan.

The first step is usually a transvaginal ultrasound, which can show a localised thickening of the lining or a distinct structure within the cavity. When the diagnosis is unclear, sonohysterography, an ultrasound with a little fluid introduced into the womb, shows the cavity far more clearly and distinguishes polyps from fibroids or other thickenings. The timing of the ultrasound matters: early in the cycle, when the lining is thin, polyps are seen more easily.

Final confirmation is by hysteroscopy, where a thin camera looks directly inside the womb. The advantage is that hysteroscopy often allows the polyp to be removed at the same moment it is seen, so diagnosis and treatment are combined in a single procedure.

In women not trying to conceive and without symptoms, a small polyp may simply be monitored, because some disappear on their own. In women with irregular bleeding, or with large polyps, removal is recommended to relieve symptoms and analyse the tissue. In women with infertility, or before an IUI cycle or embryo transfer, removing the polyp is often reasonable even without symptoms, because it removes a possible obstacle with a small intervention.

The procedure itself, hysteroscopic polypectomy, is short, usually as a day case or a short stay, with recovery within a few days. The tissue is sent for analysis. After removal, most women can continue with the fertility plan after a cycle or two. As always, the decision is made individually, weighing size, location, symptoms and pregnancy plans.