How Hysteroscopy Can Help Fertility in Selected Patients
Key Takeaways
Hysteroscopy can improve fertility-related outcomes when it identifies and treats a cavity lesion likely to affect implantation, such as an endometrial polyp, cavity-distorting fibroid, or scar tissue. The evidence is lesion-specific, and the effect of septum treatment on live birth in infertility remains uncertain. It is not required as routine screening before a first IVF cycle, but can be useful when symptoms, imaging, or a history of repeated unsuccessful transfers raises a specific concern about the cavity.
Key evidence: ASRM: Fertility Evaluation of Infertile Women (2026) ASRM: Evidence-Based Diagnosis and Treatment for Uterine Septum (2024) Cochrane: Screening Hysteroscopy in Subfertile Women and Women Undergoing Assisted Reproduction (2019)
Visualizing the Uterine Cavity
While fertilisation takes place inside the fallopian tube, the uterine cavity provides the specialised environment where an embryo must implant and grow. For implantation to occur smoothly, the endometrial lining must be receptive, well-vascularised, and free of structural distortions.
Hysteroscopy is an endoscopic procedure that allows a gynaecologist to inspect the interior of the uterus directly using a thin, lighted telescope passed through the cervix (ASRM, 2026). Because it uses the natural cervical canal, it requires no abdominal incisions and offers clear visual assessment of the endometrium.
Its practical value in reproductive medicine is the “see-and-treat” option: if a lesion is confirmed, it can often be treated in the same sitting.
When a diagnostic inspection confirms an intrauterine abnormality—such as an endometrial polyp, a small fibroid protruding into the lumen, or fine adhesions—micro-instruments can often correct the problem during the same procedure (ACOG, 2020).
What Hysteroscopy Can Diagnose and Treat
Hysteroscopy specifically addresses conditions that alter the contour of the uterine cavity or disrupt the receptive surface of the endometrium:
- Endometrial Polyps: Localised overgrowths of endometrial tissue that can act as physical obstacles or cause local biochemical changes that impair embryo implantation.
- Submucosal Fibroids (FIGO Types 0, 1, and 2): Benign muscular tumours originating in the uterine wall that bulge into the cavity, disrupting blood flow and mechanical receptivity.
- Intrauterine Adhesions (Asherman Syndrome): Fibrous scar bands connecting opposing uterine walls, typically arising after previous curettage, infection, or uterine surgery, which can reduce menstrual flow and compromise implantation.
- Uterine Septa: Congenital tissue partitions dividing the uterine cavity. While historically linked to recurrent pregnancy loss, current evidence is limited and guidelines emphasise careful shared decision-making regarding surgical division (ASRM, 2024; Cochrane, 2025).
- Suspected Chronic Endometritis: Visual signs such as micropolyps, focal strawberry-like hyperaemia, or stromal oedema can raise suspicion during hysteroscopy. Evaluation may include an endometrial biopsy with CD138 plasma-cell immunohistochemistry, but diagnostic thresholds vary between studies and the reproductive effects of antibiotic treatment remain uncertain (systematic review, 2020). In a 2026 meta-analysis, hysteroscopy had pooled sensitivity and specificity of about 80% against histological references (Pérez Milán et al., 2026).
By resecting or dividing these lesions, operative hysteroscopy helps restore a more regular cavity contour, supporting a healthier environment for embryo implantation and pregnancy development.
When Treating a Cavity Lesion May Help
This section focuses on treating a suspected or documented cavity lesion. The separate IVF decision guide explains when screening before a first cycle is usually unnecessary.
The clinical benefit of hysteroscopy depends on selecting the right patients. It is most effective when used to confirm and treat an identified or suspected intrauterine abnormality rather than used routinely in patients without a specific clinical indication.
Randomised evidence on removing small polyps or submucosal fibroids in infertility is still thin. The HELP Fertility trial closed early after recruiting 35 of 1,120 planned participants and could show neither benefit nor harm (Metwally et al., 2026). The 2026 ASRM opinion supports offering removal of polyps and submucosal fibroids while acknowledging the limited data.
1. Following Abnormal Non-Invasive Imaging
When routine transvaginal ultrasound, saline infusion sonography (SIS), or hysterosalpingography (HSG) reveals an irregular cavity shadow, filling defect, or suspected polyp, hysteroscopy is the reference test to confirm or treat that finding. Depending on the size and complexity of the lesion, treatment can be performed in an office setting or planned as an operative procedure.
2. Recurrent Implantation Failure (RIF)
After repeated unsuccessful IVF transfers with good-quality embryos, ESHRE says hysteroscopy may be considered, especially if intracavitary pathology is suspected (ESHRE, 2023). The 2026 ASRM committee opinion calls repeat evaluation of the cavity reasonable to offer, and notes that hysteroscopy can treat any lesion found. Whether to proceed is decided case by case (ASRM, 2026).
When a high-resolution 3D ultrasound is normal, routine screening hysteroscopy does not appear to add a clear advantage. The TROPHY trial (El-Toukhy et al., 2016) found no significant difference in live-birth rates (29% in both the hysteroscopy and control groups) among women with normal baseline scans.
3. Recurrent Pregnancy Loss (RPL) & Uterine Septum
Hysteroscopic division of a uterine septum or dense intrauterine adhesions is often considered in women with recurrent pregnancy loss. The ASRM guideline states that septum resection has been shown to improve outcomes in recurrent pregnancy loss. In infertility the benefit is less certain, and the guideline recommends shared decision-making after counselling (ASRM, 2024). The 2025 Cochrane update is more cautious: its one randomised trial (79 women) found little or no difference in live birth, and the observational data are of very low certainty (Joosse et al., 2025). The decision is therefore individual.
4. Unexplained Abnormal Uterine Bleeding
Intermenstrual spotting, post-coital bleeding, or sudden changes in menstrual volume often indicate focal endometrial pathology that warrants direct inspection.
Why Routine Screening Before a First IVF Cycle Is Not Standard
For asymptomatic women with a normal pelvic ultrasound, the two low-risk-of-bias trials in the Kamath Cochrane review (2019) showed no increase in live birth with routine screening hysteroscopy before a first IVF cycle. The pooled result of all trials leaned towards a benefit, but it rests on low-quality evidence, so guidelines favour a selective, indication-driven approach rather than screening everyone. For the first-cycle decision in more detail, see the IVF guide.
What Hysteroscopy Cannot Evaluate
Understanding the diagnostic limits of hysteroscopy helps set realistic expectations:
- Deep Intramural Adenomyosis: Hysteroscopy evaluates the superficial lining of the uterine cavity. Adenomyosis situated deep within the muscular wall requires high-resolution transvaginal ultrasound or pelvic MRI for accurate diagnosis.
- Subserosal and Deep Intramural Fibroids: Fibroids located on the outer surface of the uterus or embedded entirely within the muscle layer without cavity distortion cannot be treated hysteroscopically and may require laparoscopic management if clinically indicated.
- Fallopian Tube Patency: Although the tubal openings (ostia) inside the cavity are visualised, hysteroscopy alone cannot determine whether the fallopian tubes are open along their entire length. Tubal patency is assessed using HSG, HyFoSy, or laparoscopy.
- Pelvic Endometriosis: Endometriotic lesions on the ovaries, pelvic peritoneum, or bowel lie outside the uterine cavity and are evaluated through clinical assessment, specialised ultrasound, MRI, and laparoscopy rather than hysteroscopy.
Procedure Steps, Timing, and Recovery
Hysteroscopy is usually scheduled after menstrual bleeding has ended and before ovulation (often around days 6 to 11 of the cycle), when the endometrial lining is thin and visibility is clearer. Waiting is not because the procedure is unsafe during a period; heavy bleeding makes small polyps and adhesions harder to see, while light spotting does not always mean cancellation. Any possibility of pregnancy should also be assessed with the clinical history and testing appropriate to the patient before the procedure.
Office vs. Operating Room Setting
- Diagnostic / Office Hysteroscopy: Performed using miniature hysteroscopes (often under 3.5 mm) without general anaesthesia or cervical dilation. Most patients experience mild to moderate, transient menstrual-like cramping.
- Operative Hysteroscopy: When larger lesions, dense fibroids, or broad septa require operative intervention, the procedure is typically performed with intravenous sedation or light anaesthesia in a day-surgery setting to manage discomfort effectively during the procedure.
Safety and Post-Procedure Care
Hysteroscopy is generally safe, but the risk of complications depends on whether the procedure is diagnostic or operative and on the complexity of the treatment (ACOG, 2020). Light vaginal spotting and mild uterine cramping for 24 to 48 hours are common. Most patients return to their regular daily activities the next day.
Dr. Aksoy’s Clinical Perspective
In fertility practice, Dr. Senai Aksoy emphasises that hysteroscopy is a valuable therapeutic tool when properly indicated, but should not be used routinely without a clear clinical indication:
- Normal Baseline Imaging: When high-resolution 3D transvaginal ultrasound is genuinely normal, routine hysteroscopy is not necessary before a first embryo transfer.
- Specific Clinical Indications: A history of traumatic curettage with hypomenorrhea (suspected Asherman syndrome), persistent intermenstrual spotting, subtle endometrial irregularity during cycle monitoring, or a suspected polyp, fibroid or adhesions on imaging warrant direct evaluation.
- Repeated Unsuccessful Transfers: Dr. Aksoy finds it reasonable to reassess the cavity, but not automatically with hysteroscopy. Previous scans, the embryos and the transfer technique are reviewed first, and three-dimensional or saline-infusion ultrasound may give enough information.
Related Reading
- Who May Need Hysteroscopy and When It Is Most Useful
- Hysteroscopy Before IVF: When It Helps and When It Is Usually Unnecessary
- Fibroids and IVF: When Fibroids Matter and When They Do Not
- Chronic Endometritis and IVF: Diagnosis, Impact, and Management
Frequently Asked Questions for Dr. Aksoy
What is hysteroscopy used for in infertility?
Hysteroscopy lets us see inside the uterus directly with a thin camera. It can be very useful when we suspect a problem inside the uterus that could make it harder to become pregnant.
For example, we use it when the ultrasound shows a polyp in the uterus, when we suspect a fibroid growing into the cavity, or when we think there may be adhesions from a previous curettage or operation.
The good thing about this method is that it is not limited to diagnosis. In suitable cases, during the same procedure, we can remove a polyp, open adhesions or treat some fibroids that distort the cavity.
But not every infertility patient needs hysteroscopy. I want to stress this. If the cavity looks normal on ultrasound and there is no other suspicious finding, routine hysteroscopy done only to increase the chance of pregnancy has not been shown to help.
After repeated unsuccessful embryo transfers, I find it reasonable to reassess the cavity. But that does not necessarily mean doing a hysteroscopy. In some patients a three-dimensional ultrasound, or an ultrasound with saline given into the uterus, can give enough information.
I do not see hysteroscopy as a method that treats infertility on its own. I use it to find a problem inside the uterus that could prevent pregnancy and, where possible, to correct it. When there is no such problem, I prefer to avoid an unnecessary procedure.
Frequently Asked Questions
Does hysteroscopy automatically improve pregnancy rates for everyone?
Not automatically. Hysteroscopy may help when it identifies and treats a cavity lesion that is likely to affect implantation, such as a polyp, submucosal fibroid, or scar tissue. The effect of septum treatment on live birth remains uncertain, and an unindicated hysteroscopy has not been shown to improve live birth when the cavity is already normal.
Is hysteroscopy painful?
Diagnostic office hysteroscopy performed with modern miniature scopes typically causes brief, mild to moderate menstrual-like cramping, though individual sensitivity varies. When operative procedures (such as fibroid resection) are planned, intravenous sedation or anaesthesia is used to manage discomfort effectively throughout the procedure.
Can hysteroscopy treat all types of uterine fibroids?
No. Hysteroscopic myomectomy is specifically designed for submucosal fibroids that project into the uterine cavity (FIGO types 0, 1, and selected type 2). Fibroids located deep within the myometrium or on the outer uterine wall require laparoscopic or open surgical approaches.
How soon after hysteroscopy can an embryo transfer or pregnancy attempt occur?
Following a minor diagnostic hysteroscopy or small polyp removal, patients can often proceed with an embryo transfer in the next menstrual cycle. After extensive adhesiolysis for Asherman syndrome, a recovery interval with temporary hormonal support or mechanical barriers may be used. Following septum resection, timing and any hormonal support are individualised according to how the cavity heals.
Sources
- ACOG Committee Opinion No. 800. The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology (2020). Obstet Gynecol, 135(3):e138-e148.
- ASRM Practice Committee. Fertility Evaluation of Infertile Women: A Committee Opinion (2026). Fertil Steril. 2026. doi:10.1016/j.fertnstert.2026.08.686.
- ASRM Practice Committee. Evidence-Based Diagnosis and Treatment for Uterine Septum: A Guideline (2024). Fertil Steril, 122(2):251-265. PMID: 38556964. DOI: 10.1016/j.fertnstert.2024.02.033.
- El-Toukhy T, Campo R, Khalaf Y, et al. Hysteroscopy in Recurrent In-Vitro Fertilisation Failure (TROPHY): A Multicentre, Randomised Controlled Trial (2016). Lancet, 387(10038):2614-2621. PMID: 27132053. DOI: 10.1016/S0140-6736(16)00258-0.
- ESHRE Working Group on Recurrent Implantation Failure. Good Practice Recommendations on Recurrent Implantation Failure (2023). Hum Reprod Open, 2023(3):hoad023.
- Practice Committee of the 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.
- Variation of Diagnostic Criteria in Women with Chronic Endometritis and Its Effect on Reproductive Outcomes: A Systematic Review and Meta-analysis (2020). PMID: 32442825.
- Kamath MS, Bosteels J, D’Hooghe TM, Seshadri S, Weyers S, Mol BWJ, Broekmans FJ, Sunkara SK. Screening hysteroscopy in subfertile women and women undergoing assisted reproduction (2019). Cochrane Database Syst Rev, 2019(4):CD012856.
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The content has been created by Dr. Senai Aksoy and medically approved.