Hysteroscopy in Female Infertility: Indications, Procedures, and Clinical Evidence

Key Takeaways

Ultrasound remains the starting test. Hysteroscopy is the reference examination when a cavity lesion is suspected, when bleeding is unexplained, or when reduced flow after uterine instrumentation raises concern for adhesions. It is not used routinely before a first transfer if there are no symptoms and imaging is normal.

Key evidence: ACOG Committee Opinion on Hysteroscopy and Intrauterine Pathology · ASRM Committee Opinion on Evaluation of Infertile Women · ASRM Committee Opinion on Recurrent Implantation Failure

On this page

• What is Hysteroscopy?
• Video: Clinical Insights from Dr. Senai Aksoy
• Diagnostic vs. Operative Hysteroscopy
• Which Uterine Conditions Can Be Identified and Treated?
• Hysteroscopy Compared to Ultrasound, SIS, and HSG
• When is Hysteroscopy Recommended in Infertility?
• Procedure Steps, Comfort, and Recovery
• FAQ
• Sources

What is Hysteroscopy?

Hysteroscopy is a minimally invasive endoscopic procedure that allows direct, magnified visualisation of the endocervical canal and the uterine cavity.

By passing a slender optical instrument (a hysteroscope) through the natural opening of the cervix, clinicians can examine the endometrium in real time without making abdominal incisions.

A structural or lining defect in the cavity can hinder embryo implantation, impair placental blood supply or raise the risk of early pregnancy loss. Because these defects can be seen directly, hysteroscopy is a key reference test when imaging is inconclusive.

Dr. Aksoy’s Approach

A normal ultrasound does not fully exclude intrauterine adhesions. For Dr. Aksoy, the history that most changes the decision is reduced menstrual flow, or amenorrhoea, after curettage, a postpartum procedure or infection. In that setting, hysteroscopy confirms the diagnosis and allows treatment in the same session. The cavity may also be reassessed after repeated unsuccessful transfers of euploid or good-quality embryos. Routine hysteroscopy is not used before a first transfer when the patient has no symptoms and imaging is normal. The selective approach is consistent with the 2026 ASRM committee opinion, which describes repeat cavity evaluation in recurrent implantation failure as reasonable to offer, not routine.

Video: Clinical Insights from Dr. Senai Aksoy

The video is in French. Subtitle and audio availability depends on the options currently provided by YouTube.

Diagnostic vs. Operative Hysteroscopy

Hysteroscopy serves two primary functions, often combined into a single outpatient visit:

1. Diagnostic hysteroscopy: Inspects the shape of the cavity, the endometrium and the tubal openings. Small-calibre scopes and a vaginoscopic approach (without a speculum) can reduce discomfort, although individual experience varies.
2. Operative hysteroscopy: Passes micro-instruments, bipolar electrodes or mechanical morcellators through the channel of the hysteroscope to remove or repair a lesion while it is in direct view.

Which Uterine Conditions Can Be Identified and Treated?

Hysteroscopy is the reference method for diagnosing and treating many intrauterine abnormalities (ACOG Committee Opinion No. 800):

• Endometrial polyps: Localised growths of the uterine lining. Their relevance depends on size, location, symptoms and treatment context; evidence that removal improves IVF outcomes remains limited. The one randomised trial of removing small polyps and fibroids in infertility (HELP Fertility) closed early with 35 of 1,120 planned participants (Metwally et al., 2026).
• Submucosal fibroids (FIGO types 0, 1 and 2): Fibroids that project into or distort the cavity. Hysteroscopic myomectomy can restore the cavity, but the expected fertility benefit depends on the lesion and the patient’s wider clinical picture.
• Intrauterine Adhesions (Asherman Syndrome): Fibrous scar bands formed following curettage, infection, or postpartum procedures. Hysteroscopic adhesiolysis restores cavity volume and functional endometrial surface area.
• Uterine septum: Hysteroscopic incision may be offered after recurrent miscarriage through shared decision-making. In infertility alone, the effect on live birth remains uncertain; the 2025 Cochrane update found little or no difference in live birth in its one randomised trial (Joosse et al., 2025; ASRM uterine septum guideline, 2024).
• Chronic endometritis: Hysteroscopic appearances may raise suspicion, and pooled sensitivity and specificity are about 80% in a 2026 meta-analysis (Pérez Milán et al., 2026), but diagnosis generally still relies on endometrial sampling and pathology.

Hysteroscopy Compared to Ultrasound, SIS, and HSG

Evaluating the uterine cavity typically involves several complementary diagnostic tools (ASRM Committee Opinion, 2026):

When is Hysteroscopy Recommended in Infertility?

Hysteroscopy is most useful when targeted to a specific clinical question (ESHRE RIF recommendations, 2023; ASRM 2026):

• Suspicion of intracavitary pathology identified during transvaginal 2D/3D ultrasound or SIS.
• Repeated unsuccessful embryo transfers, when the history and previous assessment leave a meaningful concern about the cavity. There is no universal transfer-count threshold that automatically requires hysteroscopy. ESHRE’s add-ons recommendations say screening hysteroscopy can be considered in recurrent implantation failure but is not for routine use (ESHRE add-ons, 2023).
• Recurrent pregnancy loss (RPL) to look for a septum or a cavity-distorting fibroid. Cervical insufficiency is assessed separately; hysteroscopy does not diagnose it.
• History of uterine instrumentation, postpartum curettage, or severe pelvic inflammatory disease with hypomenorrhea (suggesting Asherman syndrome).
• Unexplained abnormal uterine bleeding (AUB) or persistent intermenstrual spotting during fertility evaluation.

Procedure Steps, Comfort, and Recovery

• Timing: When the patient is menstruating, hysteroscopy is commonly scheduled after bleeding has ended and before ovulation, when the lining is relatively thin. Timing is individualised for irregular cycles, urgent bleeding or hormonal treatment.
• Anaesthesia and setting: Diagnostic procedures and minor operative treatments (for example a small polypectomy) are often done in the office using vaginoscopy without general anaesthesia. Complex myomectomies or extensive adhesiolysis are done under sedation or general anaesthesia.
• Recovery: Most women experience mild menstrual-like cramping and minimal spotting for 24 to 48 hours and resume normal daily activities within 24 hours.

Frequently Asked Questions for Dr. Aksoy

Can hysteroscopy be done during a period, or should I wait until bleeding has stopped?

I usually prefer to wait until menstrual bleeding has stopped before hysteroscopy. That is not because the procedure is dangerous during a period. It is because we can see the inside of the uterus more clearly.

In hysteroscopy we look at the uterine cavity with a thin camera. If bleeding is still going on, especially if it is heavy, small polyps, adhesions or other changes inside the uterus can be harder to see.

So in women with regular periods I usually plan the procedure for the days after bleeding has ended and before ovulation. The lining is thinner then, which also makes the assessment easier.

If you have light bleeding on the day of the appointment, does the procedure always have to be cancelled? No. Light spotting is sometimes not a problem. If the bleeding is heavy, it is often better to postpone.

In women with irregular cycles, or when a specific treatment protocol is being used, we can plan the timing differently. In every case we also need to exclude the possibility of pregnancy.

In short, hysteroscopy during a period is not always forbidden. Waiting until bleeding has stopped is, however, usually the better choice for a clearer examination.

FAQ

Is hysteroscopy always painful?

Experience varies. Some patients report mild cramping, while others find office hysteroscopy painful. The team should discuss pain-control options in advance; medication is not appropriate for everyone.

How soon after hysteroscopy can I attempt pregnancy or start IVF?

After an uncomplicated diagnostic procedure, treatment can often continue without a long delay. The interval after polypectomy, myomectomy, adhesiolysis or septum surgery depends on the extent of treatment and the clinician’s review of healing.

Does removing a polyp improve IVF success rates?

Not with certainty. Removing a clinically relevant polyp may be reasonable, but evidence for improved IVF outcomes is limited. The clearest randomised evidence concerns pregnancy before intrauterine insemination rather than IVF (Cochrane review).

Can hysteroscopy diagnose blocked fallopian tubes?

Hysteroscopy shows the tubal openings (ostia) inside the uterus, but it does not assess the full length of the tubes or whether their far ends are open. Tubal patency is evaluated via HSG or laparoscopy with chromopertubation.

Related Reading

• Hysteroscopy Before IVF: Necessity and Clinical Recommendations
• Who Needs Hysteroscopy? Clinical Indications and Candidate Profiles
• Chronic Endometritis and IVF: Diagnosis, Impact, and Treatment
• Hysteroscopic Cytoreductive Surgery for Adenomyosis

Sources

• American College of Obstetricians and Gynecologists (ACOG). The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion No. 800. Obstet Gynecol. 2020;135(3):e138-e148.
• Practice Committee of the American Society for Reproductive Medicine. Fertility evaluation of infertile women: a committee opinion. Fertil Steril. 2026. doi:10.1016/j.fertnstert.2026.08.686.
• Practice Committee of the American Society for Reproductive Medicine. Evidence-based diagnosis and treatment for uterine septum: a guideline. Fertil Steril. 2024;122:251-265.
• ESHRE Working Group on Recurrent Implantation Failure. Good practice recommendations on recurrent implantation failure. Hum Reprod Open. 2023;2023(3):hoad023.
• ESHRE Add-ons Working Group. Good practice recommendations on add-ons in reproductive medicine. Hum Reprod. 2023;38(11):2062-2104.
• Practice Committee of the American Society for Reproductive Medicine. American Society for Reproductive Medicine recurrent implantation failure: a committee opinion. Fertil Steril. 2026;126:277-293.
• Joosse MI, Kostova EB, Rikken JF, et al. Septum resection for women of reproductive age with a septate uterus. Cochrane Database Syst Rev. 2025;11:CD008576.
• Metwally M, McKendrick K, Ridsdale K, et al. Removal of small fibroids and polyps in patients with infertility and recurrent miscarriage: the HELP Fertility? RCT. Health Technol Assess. 2026;30(62):85-120.
• Pérez Milán F, Caballero Campo M, Domínguez Arroyo JA, et al. Diagnostic accuracy of hysteroscopy for chronic endometritis in reproductive-age and infertile women: a systematic review and latent class meta-analysis. J Minim Invasive Gynecol. 2026;33:898-912.

Dr. Senai Aksoy

Dr. Senai Aksoy studied and trained in France before returning to Turkey, where he was a member of the ICSI team at Sevgi Hospital, Ankara — the country's first ICSI centre (1994-95) — and a co-author on the first Turkish ICSI publications produced in collaboration with the Brussels Van Steirteghem group (Human Reproduction, 1996; PMID 8671323). He helped build the IVF programme at the American Hospital Istanbul and has been running his own fertility practice since 1998.

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The content has been created by Dr. Senai Aksoy and medically approved.