Endometrial Polyps The incidence of asymptomatic endometrial polyps among women with infertility has been reported to range from 6% to 8%, but may be as high as 32% (247–249). Risk factors for polyp development include obesity, unopposed estrogen exposure, and polycystic ovary syndrome. The mechanisms by which endometrial polyps may impair fertility are incompletely described but may relate to disordered endometrial receptivity (250). One report localized 32% of endometrial polyps in infertile women to the posterior uterine wall, indicated that 40.3% of patients had multiple polyps, and stated a 6.9% hyperplasia rate (251). Polypectomy is generally performed via curettage, blind avulsion, or hysteroscopic removal (249). Although the efficacy of polypectomy prior to infertility treatment has not been clearly established, a prospective randomized trial showed a 2.1-fold higher rate of pregnancy among women who underwent the procedure prior to IUI (249,252). Higher pregnancy rates have been noted for polyps removed from the uterotubal junction when compared to those removed from other locations (251). Smaller nonrandomized studies provide conﬂicting data on the negative fertility effects of polyps less than 1.5 to 2 cm (251,253,254).
Intrauterine Synechiae or Asherman’s Syndrome Severe trauma to the basalis layer of the endometrium with subsequent tissue bridge formation leads to intrauterine synechiae or Asherman’s syndrome. Symptoms of severe disease include amenorrhea, menstrual irregularities, spontaneous abortion, and recurrent pregnancy loss. The causes of intrauterine adhesions are often iatrogenic, with patients typically reporting intraoperative or postoperative complications of uterine evacuations for incomplete pregnancy loss, pregnancy termination, or postpartum hemorrhage. Myomectomy, hysterotomy, diagnostic curettage, cesarean section, tuberculosis, caustic abortifacients, and uterine packing are less-common causes in Western countries (255). In developing countries, Asherman’s syndrome resulting from genital tuberculosis is quite common (256). Hysteroscopic resection of synechiae is the preferred treatment to restore fertility in women with Asherman’s syndrome, and success rates are generally very high. Patients with genital tuberculosis have a very poor prognosis. Postoperative prevention of adhesion reformation disease may involve estrogen therapy alone for 1 month or in combination with intraoperative placement of an intrauterine device (such as a small Malecot catheter or pediatric Foley catheter) for 1 to 2 weeks. There is no standard regimen for estrogen therapy, but oral conjugated estrogens 2.5 mg daily overlapping with progestin or estradiol valerate 2 mg injections daily have been suggested (255,257).