Endometrial polyps affect fertility by mechanical interference with sperm transport, embryo implantation, and increased production of inhibitory factors such as glycodelin which can inhibit natural killer cell function [1]. Furthermore, reduced blood flow to the endometrial lining disturbs implantation and increases the miscarriage rate. Abnormal bleeding is a frequent symptom due to vascular fragility and surface erosion. Chronic endometrial inflammation, endometrial erosion and vascular dilatation are usually prominent characteristics during hysteroscopy. Larger polyps may develop ischemic necrosis at their apex and undergo torsion and thrombosis [2]. The frequency of endometrial polyps being diagnosed at hysteroscopy is 16.5–26.5 % in women with unexplained infertility [3], 46.7 % in infertile women with endometriosis [4] and 0.6–5 % in women with recurrent pregnancy loss [5].

Sonohysterography and hysterosalpingogram (HSG) have similar diagnostic accuracies (52 % versus 60 %) [6–8]. HSG has a sensitivity between 50 and 98 % for intrauterine lesions, but cannot distinguish between submucosal myomas and endometrial polyps [9]. 3D ultrasound and contrast sonography have excellent sensitivity in identifying the exact location of endometrial polyps, measure its volume in relation to the entire endometrial cavity, and quickly provide all the information needed before hysteroscopic surgery [10]. Hysteroscopy provides the gold standard technique for the diagnosis of a polyp and permits treatment under direct vision at the same time [11]. A randomized controlled trial (RCT) examined the implication of endometrial polyps on pregnancy rates in patients undergoing intrauterine insemination (IUI) [12]. Infertility patients underwent hysteroscopy and were randomized to a hysteroscopic polypectomy or a hysteroscopic biopsy of the polyp. The spontaneous pregnancy rate prior to IUI was 29 % in patients who underwent polypectomy whereas only 3 % of the women with a polyp removal achieved a pregnancy. The clinical pregnancy rate after 4 IUI cycles was 63 % in the polypectomy group and only 28 % in the other group.

Of note is that 65 % of all pregnancies in the polypectomy group occurred before the first cycle of IUI. No significant difference was found between the groups and sizes of the polyps [12].

Some nonrandomized controlled trials (NRCT) have not demonstrated the effectiveness of hysteroscopic polypectomy in enhancing fertility [13]. However, these studies are fewer than those that do show a benefit. In addition, higher pregnancy rates are observed after removal of tubocornual polyps when compared to other intrauterine locations. Tubocornual polyps may have a different effect on reproductive function [14]. They may interfere with oocyte/embryo transport, especially when they are bilateral and large. Polyps in the isthmic-cervical part of the uterus may interfere with sperm transport [15].

It is important to modify the operative technique according to location and size of the polyps. Endometrial polyps ≤0.5 cm can be removed intact with a 5F crocodile forceps or a 5F tenaculum after resection at the base with 5F microscissors. Endometrial polyps >0.5 cm can be sliced from the free edge to the base in fragments by bipolar and /or Twizzle electrode. With fundal polyps, it is important to cut the base without going too deep into the myometrium [15].