title: The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review.
abstract: BACKGROUND
  Although hysteroscopy is frequently used in the management of subfertile women, a systematic review of the evidence on this subject is lacking.
  
  
  METHODS
  We summarized and appraised the evidence for the benefit yielded by this procedure. Our systematic search was limited to randomized and controlled studies. The QUOROM and MOOSE guidelines were followed. Language restrictions were not applied.
  
  
  RESULTS
  We identified 30 relevant publications. Hysteroscopic removal of endometrial polyps with a mean diameter of 16 mm detected by ultrasound doubles the pregnancy rate when compared with diagnostic hysteroscopy and polyp biopsy in patients undergoing intrauterine insemination, starting 3 months after the surgical intervention [relative risk (RR) = 2.3; 95% confidence interval (CI): 1.6-3.2]. In patients with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant management (RR = 1.9; 95% CI: 1.0-3.7). Hysteroscopic metroplasty for septate uterus resulted in fewer pregnancies in patients with subfertility when compared with those with recurrent pregnancy loss (RR = 0.7; 95% CI: 0.5-0.9). Randomized controlled studies on hysteroscopic treatment of intrauterine adhesions are lacking. Hysteroscopy in the cycle preceding a subsequent IVF attempt nearly doubles the pregnancy rate in patients with at least two failed IVF attempts compared with starting IVF immediately (RR = 1.7; 95% CI: 1.5-2.0).
  
  
  CONCLUSIONS
  Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps, fibroids, septate uterus or intrauterine adhesions indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic surgery in the general subfertile population can be justified.
authors.affiliation: Department of Obstetrics and Gynaecology, Imeldahospital, Bonheiden, Belgium. jan.bosteels@imelda.be
authors.forename: Jan
authors.initials: J
authors.lastname: Bosteels
authors.forename: Steven
authors.initials: S
authors.lastname: Weyers
authors.forename: Patrick
authors.initials: P
authors.lastname: Puttemans
authors.forename: Costas
authors.initials: C
authors.lastname: Panayotidis
authors.forename: Bruno
authors.initials: B
authors.lastname: Van Herendael
authors.forename: Victor
authors.initials: V
authors.lastname: Gomel
authors.forename: Ben W J
authors.initials: BW
authors.lastname: Mol
authors.forename: Chantal
authors.initials: C
authors.lastname: Mathieu
authors.forename: Thomas
authors.initials: T
authors.lastname: D'Hooghe
mesh_terms: D005260:Female; D005307:Fertilization in Vitro; D006801:Humans; D015907:Hysteroscopy; D007247:Infertility, Female / Q000601:surgery*; D007889:Leiomyoma / Q000601:surgery; D011127:Polyps / Q000473:pathology / Q000601:surgery; D011247:Pregnancy; D018873:Pregnancy Rate; D016032:Randomized Controlled Trials as Topic; D000267:Tissue Adhesions / Q000601:surgery; D016896:Treatment Outcome; D014591:Uterine Diseases / Q000601:surgery