Successful pregnancy after recurrent hysteroscopic polypectomy

Abstract

This case demonstrates that hysteroscopic polypectomy can enhance fertility. A 35-year-old woman was being evaluated for assisted conception. She was referred from an in vitro fertilisation clinic for polypectomy, which she had undergone on two occasions. She conceived spontaneously, had an uneventful antenatal period, and delivered a healthy baby at 39 weeks' gestation.

Introduction

Endometrial polyps are common during the reproductive years, occurring in up to 24% of women [1]. Solitary polyps account for the majority. They may be associated with subfertility.

Case study

A 35-year-old Caucasian woman was referred from an in vitro fertilisation (IVF) clinic for endometrial polypectomy. This procedure was to be her third polypectomy, with the polyps varying in size from 8 to 14 mm (see Figs. 1, 2, 3, 4, 5).

Fig. 1

Hysteroscopic picture showing a 14×5×6-mm polyp

Fig. 2

Before: polyp blocking right ostium

Fig. 3

After: same polyp as in Fig. 2 following resection; histology benign

Fig. 4

Solitary polyp 8 mm long; histology benign with secretory endometrium

Fig. 5

Solitary polyp 8 mm long

The patient planned to have assisted conception after the procedure; however, she conceived naturally after the third polypectomy in November 2004.

Her antenatal care was uneventful. It began at 12 weeks, and her body mass index at that time was 32, and blood pressure was 102/56 mmHg. She was a nonsmoker and in good general health. A dating scan put her delivery date at 13 August 2005.

Due to anxiety, labour was induced at 39 weeks. The induction failed, and an emergency lower-segment caesarean section was subsequently performed. A live boy weighing 3,600 g was delivered on 8 August 2005.

Mother and baby were discharged home after an uncomplicated 4-day postpartum course. At postnatal follow-up, the patient was noticed to have a polyp measuring 4 mm on transvaginal scan (her fourth successive one).

Discussion

Endometrial polyps are localised overgrowths that project into the uterine cavity. Their cause is unknown, but they can be associated with excess oestrogen production or with certain ovarian tumours such as thecomas.

The overall incidence rises steadily with age and peaks in the 5th decade of life. Endometrial polyps have been described as the most common endometrial pathology in postmenopausal women. Subfertility in premenopausal women might result from blockage of sperm passage or embryo implantation. Small polyps (<2 cm) do not decrease pregnancy rates, but there is a trend towards increased pregnancy loss [2].

Methods of diagnosis include hysteroscopy, sonohysterography, and hysterography (in cases of large polyps).

Treatment is by hysteroscopic-guided removal, which involves removing the endometrial lining of the uterus. Little data exist on the effects of polypectomy on reproduction [3].

Based on the results from a randomised study on IVF patients with endometrial polyps diagnosed by sonography [4], hysteroscopic resection was associated with significantly reduced miscarriage rates compared with patients who had not undergone polyp resection and with those having normal uterine cavities.

The recurrence risk of endometrial polyps (and presumably abortions) is expected in the presence of abnormal proliferative activity or hyperplasia, both in the polyp and the surrounding endometrium.

In summary, this patient presented with three occurrences of endometrial polyps that were all removed hysteroscopically. They varied in length from 8 mm to 14 mm. She conceived naturally after the third polypectomy and delivered a healthy baby via caesarean section. At postnatal follow-up, she had developed a further small polyp, which is at the moment under review.

We can postulate that endometrial polyps, however small, may likely impair a woman’s fertility. Also, the site of such polyps could play an important factor in this. We suggest that a transvaginal scan is essential in all cases of recurrent miscarriage and subfertility. Hysteroscopy can then be undertaken to resect any endometrial polyps; this will improve the chances of success.