Uterine factors and infertility.

A literature review was performed to explore the available information regarding the association of uterine factors--intrauterine adhesions, uterine septa, uterine myomas and endometrial polyps--with infertility and reproductive loss. The literature was reviewed also to ascertain evidence that treatment of these abnormalities improves fertility. A MEDLINE search was performed to identify the relevant publications in the English-language literature. There is minimal published evidence to demonstrate that intrauterine adhesions lead to infertility or pregnancy loss, but the literature does contain several observational series that demonstrate successful fertility, with term pregnancy rates ranging from 32% to 87% following hysteroscopic division of intrauterine adhesions. The evidence supporting a direct link between a septate uterus and reproductive loss/infertility is derived from the results of metroplasty. Several case series demonstrated a reduction in the spontaneous abortion rate, from 91% to 17%, on average, after hysteroscopic metroplasty. Furthermore, following metroplasty, the mean pregnancy rate in previously infertile patients is 47%. Little has been written regarding the association of endometrial polyps and infertility. One study did demonstrate a pregnancy rate of 78% after hysteroscopic polypectomy as compared to 42% in infertile patients with normal endometrial cavities. The literature that associates myomas with infertility/reproductive loss is more extensive but quite controversial. Evidence from the in vitro fertilization literature suggests that only those myomas that distort the endometrial cavity impair fertility. Pregnancy rates approximating 50% are achieved with myomectomy by laparotomy, laparoscopy or hysteroscopy.