Endometrial polyps (Fig. 19.2) are commonly identified during the investigation for infertility. The mechanism by which polyps may adversely affect fertility is also poorly understood. Endometrial polyps are identified by hysteroscopy in 16.5–26.5 % of women with otherwise unexplained infertility [29, 30]. A randomized controlled trial has shown benefit for hysteroscopic polypectomy prior of starting fertility treatment [31]. The results of this trial on the effectiveness of hysteroscopic polypectomy prior to intrauterine insemination (IUI) are consistent with the findings of a recently published observational study [32]. The hysteroscopic removal of endometrial polyps in women bound to undergo IUI for unexplained, male, or female factor infertility for at least 24 months increases the odds of clinical pregnancy compared to diagnostic hysteroscopy and biopsy only. The level of evidence of this single study was graded as high [33].

Hysteroscopic resection is the most effective management for endometrial polyps and allows histologic assessment, whereas blind biopsy or curettage has low diagnostic accuracy and should not be performed. Hysteroscopy-directed polypectomy using scissors, a loop electrode or a morcellator is preferred to minimize damage to the surrounding endometrium and to ensure the polyp has been removed in its entirety. Operative resectoscopy with a loop electrode appears to be the technique of choice for endometrial polyps >2 cm or with a fundal implant. The study of Dealberti demonstrated that it is possible to remove endometrial polyps by hysteroscopy, using the mini-resectoscope, in an office setting. The outpatient polypectomy is a less-costing procedure and represents an acceptable and effective alternative to inpatient resectoscopic polypectomy, leading to a complete polyp excision in nearly all patients [34]. Recently the use of a hysteroscopic morcellator or shaver has been reported to be advantageous in the treatment of polyps and type 0 an 1 myomas <3 cm [35, 36].

IVF outcomes seem to be unrelated to the time interval between the hysteroscopic polyp resection and the initiation of the IVF; where the success rate does not seem to be boosted by initiating treatment in the first few months postoperatively [37].

Müllerian defects are observed in 3–5 % of the general population, but their frequency increases between 5 and 25 % in women with recurrent miscarriages, late abortions and preterm deliveries [38]. Uterine septum is the most common congenital anomaly of the female reproductive tract, with an incidence of 2–3 % in the general population [39]. Although, the exact effect of an intrauterine septum on fertility is still controversial [40–43], its presence has been associated with poor reproductive outcomes including high risk of abortion, preterm delivery, as well as abnormal presentations and increased Caesarean section rates [40–42]. Arcuate uterus is associated with a slightly better but still impaired pregnancy outcome with term delivery rates of 65 % [43].

Different studies have shown that removal of a septum by hysteroscopic metroplasty can improve fertility outcomes in subfertile women. The hysteroscopic septum resection can be applied as a therapeutic procedure in cases of symptomatic patients but also as a prophylactic procedure in asymptomatic patients in order to improve their chances for a successful delivery [43–46].

In 1974, Edstrom performed the first hysteroscopic section of uterine septum, and in 1981 Chervenak and Neuwirth reported the first successful reproductive outcome after hysteroscopic metroplasty [47]. Nowadays, the septate uterus can be effectively treated by operative hysteroscopy (Fig. 19.3). The incision of the septum can be carried out by scissors, resectoscope or laser, with no obvious advantage from any of these techniques [46, 48, 49].

A T-shaped uterus is a rare uterine malformation, except in woman exposed in utero to diethylstilbestrol (DES). Several studies have showed very poor reproductive performance when this uterine malformation is not treated [50, 51]. The study of Fernandez shows that hysteroscopic metroplasty improves the live birth rate for women with a T-shaped uterus and a history of primary infertility, recurrent abortion or preterm delivery, although it is not a treatment of infertility [52].

It has been more than a century since Heinrich Fritsch first described a case of posttraumatic intrauterine adhesion. Schenker and Margalioth [53] analyzed the symptoms of 2,151 cases of Asherman syndrome. They found that infertility was present in 43 % of women studied. This syndrome occurs mainly as a result of trauma to the gravid uterine cavity, which leads to the formation of intrauterine and/or intracervical adhesions. Despite the advances in hysteroscopic surgery, the treatment of moderate to severe Asherman syndrome still presents a challenge. Furthermore, pregnancy after treatment remains high risk with complications including spontaneous abortion, preterm delivery, intrauterine growth restriction, placenta accrete or praevia, or even uterine rupture.

In most cases, adhesiolysis may be performed with the help of the hysteroscopic scissors or other cutting modalities such as laser (Fig. 19.4). Hysteroscopic adhesiolysis using scissors [54] has the advantage that it permits dissection and avoids complications related to energy sources, and it possibly minimises the destruction of endometrium. Preoperative administration of oestrogens stimulates the endometrial development and is helpful in a better identification of the endometrium by concurrent performed ultrasound examination during lysis of adhesions. Even with the use of ultrasound, it can be extremely difficult to perform the dissection in the correct planes.

Some investigators have performed hysteroscopic surgery under concomitant laparoscopic or ultrasound control to prevent perforation of the uterus [4, 55, 56].

Reformation of intrauterine adhesions after hysteroscopic surgery for Asherman is a real challenge and is reported between 3.1 and 23.5 %. In general, patients with severe intrauterine adhesions often require several repeated procedures because of the difficult nature of the procedure and the high rate of reformation of adhesions. One of the most important features of treatment is prevention of recurrence. Various methods have been used to achieve this aim. Wood and Pena [57] proposed the use of oestrogens to stimulate the regeneration of endometrium and promote re-epithelialization of the scarred surfaces. The insertion of an intra- uterine device (IUD) has been advocated in preventing adhesion reformation after hysteroscopic lysis of intrauterine adhesions [58]. Some studies have reported on the use of a Foley catheter introduced into the uterine cavity [59]. The introduction of an IUD or Foley catheter may carry a risk of perforation of the uterus and increases the risk for ascending infections. Newly developed adhesion barriers such as hyaluronic acid show promise for preventing new adhesions [22, 60, 61]. A recent meta analysis showed a beneficial effect of the use of hyaluronic gel in the prevention of intra-uterine adhesion formation [23] while in the study of Lin et al. [62] this effect could not be confirmed. Further RCT studies are necessary to evaluate the effect on postoperative adhesion formation.

The duration of endometrial wound healing is variable after various hysteroscopic surgeries. Polypectomy wounds healed the most quickly, with 86 % healing within 1 month. Myomectomy wounds take the longest time to completely heal, with 82 % healing 2–3 months after the operation. Wounds of septal incision and adhesiolysis heal in between these two time periods, with 100 and 96 % of the women completing their wound healing within 2 months [63]. Postoperative new intrauterine adhesion formation is an important factor influencing endometrial wound healing. Office hysteroscopy is a minimally invasive procedure that can be done at the outpatient clinic. Application of office hysteroscopy for the evaluation of wound healing after hysteroscopic surgeries is convenient for direct inspection, and it can be consecutively done until complete healing of endometrial wounds. Office hysteroscopy is an easy and effective procedure to separate these newly formed adhesions, as long as it is done within 2 weeks after surgery [64].