Removal of endometrial polyps prior to infertility treatment

Review question

Cochrane authors investigated whether the removal of endometrial polyps in women presenting with subfertility was safe and whether it improved the chance of pregnancy.

Background

Endometrial polyps, which are benign and often asymptomatic growths of the lining of the womb, have the potential to interfere with female fertility. This can be due to alteration of the micro-environment of the womb or due to physical interference with sperm transport impeding fertilization and subsequent implantation of the embryo. Diagnosis of these growths is mainly through using ultrasound during routine investigations prior to treatment for infertility. Removal of these polyps prior to embarking on any fertility treatment has been suggested as a way to improve the overall outcome of the treatment.

Study characteristics

The authors did not identify any analysable studies that were of sufficient quality to draw any conclusions. The searches are current to July 2014.

Key results and quality of evidence

Due to the lack of available randomised evidence, the authors of this review are unable to draw any conclusions on the routine removal of endometrial polyps prior to treatments for infertility. To answer this question, large and well designed studies are required.

Authors' conclusions: 

Removal of endometrial polyps in subfertile women is commonly being performed in many countries with an aim to improve the reproductive outcome. We did not identify any analysable randomised trials which would allow us to reach any sound scientific conclusions on the efficacy of endometrial polypectomy in subfertile women. Well designed, methodologically sound, randomised controlled trials are urgently needed.

Read the full abstract...
Background: 

Endometrial polyps, which are benign growths of the endometrium, may be a factor in female subfertility. Possible mechanisms include physical interference with gamete transport, alteration of the endometrial milieu and unresponsiveness to the cyclical global endometrial changes. As such polyps remain mostly asymptomatic, their diagnosis is often incidental during routine investigations prior to embarking on assisted reproductive treatment. Transvaginal sonography, hysterosalpingography and saline infusion sonography are the diagnostic tools most commonly employed. However, hysteroscopy remains the gold standard for diagnosis, as well as for treatment. Due to the possible effect of endometrial polyps on fertility, their removal prior to any subfertility treatment is widely practiced.

Objectives: 

To determine the effectiveness and safety of removal of endometrial polyps in subfertile women.

Search strategy: 

Electronic databases were searched, including the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL and trial registers. The reference lists of identified articles were checked. The last search was performed on 30 July 2014.

Selection criteria: 

Only randomised controlled trials, reporting pregnancy or live birth rates and complication rates as primary or secondary outcomes, in which polyps were removed surgically prior to treatment of subfertility were eligible for inclusion. The diagnosis of endometrial polyps was required to be made by transvaginal ultrasound, hysterosalpingography, saline infusion, sono-hysterography or hysteroscopy. Any surgical technique of polyp removal was acceptable, with no intervention in the control groups.

Data collection and analysis: 

Two review authors independently screened the titles, abstracts and full articles to assess their suitability for inclusion in this review. Quality assessment was attempted independently by two authors with discrepancies being settled by consensus or consultation with a third review author.

No data extraction was performed due to the absence of useable data in the one eligible study. If there had been data to include, two review authors would have independently extracted the data from the studies using a data extraction form designed and pilot tested by the authors. Any disagreements would have been resolved by discussion or by a third review author.

Main results: 

Only one randomised controlled trial of endometrial polypectomy was identified for inclusion. However, a single set of data could not be extracted from this study due to internal inconsistencies of the results reported. Attempts to contact the authors to resolve the issue were unsuccessful, by phone, post and e-mail.

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