Uterine Polyp Diagnosis
What do the studies say?
There was a study looking at people who had infertility and doing a polypectomy did improve rates of getting pregnant afterwards. But really interestingly, there was no difference in that improvement if the polyp was small, less than a centimeter, or if it was big and you had a lot of them, which is interesting because people previously said maybe you can just ignore an extremely small polyp. But showing that everybody had improvement in that group, regardless of the size or the number of the polyps, would tell us that it might be a more local reaction versus a true obstruction. If it was truly related to obstructing sperm transport or an actual issue with the precise location where an embryo is trying to implant, you would think more polyps or bigger polyps would be worse. As you know, I'm a big believer in some type of inflammation or something that is actually happening from just the presence of the polyp there. Because polyps are relatively common, especially in infertility patients and do appear to have an impact on pregnancy rates through proposed mechanism of inflammation with implantation. I am a believer everybody needs to be evaluated to see if they have a polyp, especially if you're doing IVF sometime before you do the embryo transfer. Believe it or not, this is not standard of care. There are definitely practices that I have gotten records from that just do not look. They do not take the time. And why not? I don't know, but it blows my mind.
How is a polyp diagnosed?
The way that you can diagnose a uterine polyp (you cannot always see it on vaginal ultrasound) is by some type of imaging inside the uterus, and the best two options are going to be a saline sonogram or hysteroscopy. So you can see a filling defect on an HSG, but it doesn't really tell you what it is. So HSG is the x-ray dye test. This is where speculum goes in the vagina, catheter to cervix, and dye gets injected into the uterus and the fallopian tubes while taking an x-ray. It is a very good test to see if the fallopian tubes are open. For the inside of the uterus, though, the dye is just filling the uterus, and so it can tell you does it look normal, or does it look like there's a filling defect or an area where the dye is not going. It's not the world's best test for the inside of the uterus because you're getting a flat picture of something that's three-dimensional, but it typically will pick up most abnormalities. Saline sonogram and hysteroscopy are the better tests. Your clinic may do 1 or the other, and honestly, they're both very good in trained hands.
Saline Sonogram
Saline sonogram and SIS, saline infused sonogram, and hysterosonogram are all the same thing. This is where, very similar to an HSG, a speculum is placed in the vagina, a catheter goes to the cervix, and saline or water is put into the uterus while you watch with vaginal ultrasound. Volume is much less than an HSG. So if you had a very painful HSG, please don't worry. This is not like that. The catheter is smaller. It's ultimately just an easier test. But because you're distending the uterine cavity, you can see those innermost projections. Remember, the uterus is a potential space, meaning it's really collapsed upon itself and those two layers of endometrium touch in its resting state. That's what when we look at your uterus and we're measuring the lining, we're really measuring both sides together, and that's that trilaminar aspect. You have the top, where they connect, and the bottom. So when you have a polyp in there, it can sometimes be hard to see, especially depending on what time of the cycle you're looking with vaginal ultrasound. Meaning, in the luteal phase, once progesterone compacts the lining and you lose that trilaminal appearance and suddenly now everything's homogeneous or just kind of solid or grainy looking, it can be really hard to see a polyp. When it's trilaminar and very organized, you often can see a polyp. So I will sometimes tell patients during monitoring during IVF, when your lining is growing, it's trilaminar, getting the thickest that it can. I might see a polyp and say, “hey, you have a uterine polyp? This is gonna need to be removed before we do an embryo transfer.” Then you might skip the saline sonogram or the hysteroscopy step because we did clearly see it and we know it's abnormal.
When to do the test?
Vaginal sonogram alone cannot catch them all. So saline sonogram, when you push the water in, you are separating these two walls, and then you're able to see the inside of the uterine cavity better, and you can see these small projections. Now, it's best to do the test when the lining is thin. That means early follicular phase after you're done bleeding, but before you start getting a lining thick enough. Typically, that's days 6 to 10 for most people or when you're on birth control pills. If you do the test in the luteal phase, if you do the test while you're bleeding, you might have a higher incidence of missing a polyp or, diagnosing a blood clot as a polyp. So again, it's a very good test. It's not a perfect test.
Hysteroscopy
Hysteroscopy is the perfect test. However, hysteroscopy is more painful. It is a thicker gauge. It's a camera that's going through the vagina, through the cervix, and looking inside the uterus. Some clinics do hysteroscopy in the office. Some only do it in the operating room, so I do both. In office hysteroscopy can totally differ. Sometimes it's only diagnostic, meaning they can put the camera in and look, but all they can say is, “oh, you have a polyp.” And sometimes it can be diagnostic and therapeutic, meaning you put a camera in, you see a polyp, and you can grab it with a tiny little grasper or a tiny little scissor and take it out. It depends on the setup. So to make it less painful, the camera will be thinner if they do it in your clinic without anesthesia, but it might be so thin that they can't pass the tools through, and then you have to do it again if you actually have a polyp. I personally have never done a polypectomy or a hysteroscopy without anesthesia. That doesn't mean it's wrong. It's just not how my clinics have ever been set up. So if your clinic says that they have in office hysteroscopy and this is the gold standard, they're not lying. A camera, you can see exactly what is happening. Fantastic. You do wanna ask if it is done under anesthesia? Can you treat if you see it at the same time? Just know what to expect. That is my only thought. The best way to remove a polyp if you are an infertility patient or trying to get pregnant is definitely hysteroscopy, as we said. Camera in the uterus directed, see the polyp, grab it. Occasionally, you can do blind curettage, which is where you put a curette in and you just scrape. That sometimes is needed if somebody has a plethora of polyps, if you think it's cancerous, if you need to get all the cells, but blind curettage can miss about 10% of polyps. So, certainly, if you're in this category, you're having a difficult time getting pregnant or you're paying for fertility treatments. 10% is too much to risk, so you wanna have a hysteroscopy, not just a blind polypectomy. If for some reason you do have a curettage, you wanna have a saline afterward or some imaging to make sure everything is actually removed and everything looks good prior to getting to the next step.
