Endometrial Polyps and Subfertility in Women Under 40: Pathophysiology, Fertility Outcomes, and Clinical Management

  1. Goksu Goc
  2. Ozer Birge

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Abstract

Background and Objectives: Endometrial polyps are common in women presenting with subfertility, yet uncertainty persists regarding which lesions warrant removal and how best to integrate hysteroscopic management with contemporary fertility treatment pathways. This narrative review synthesizes current evidence on pathophysiological mechanisms, diagnostic approaches, fertility outcomes, and practical clinical management for women under 40 years of age. Materials and Methods: PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched for English-language human studies published between January 2005 and December 2025. From 2352 records identified, 83 studies were included after screening of 1517 unique records (7 randomized controlled trials, 12 systematic reviews/meta-analyses, 14 prospective cohort studies, 31 retrospective cohort studies, 5 case–control and other study designs, 11 narrative reviews and supporting evidence studies, 1 clinical guideline, and 2 targeted 2025 additions). This structured narrative review employed a systematic search strategy to ensure comprehensive coverage, with evidence synthesized thematically in accordance with the SANRA guidelines. No formal risk-of-bias assessment or pre-registered protocol was used. Results: Across treatment modalities, hysteroscopic polypectomy was consistently associated with improved fertility outcomes. The landmark Pérez-Medina randomized trial reported a relative risk of 2.1 (95% CI 1.5–2.9) for pregnancy after polypectomy before intrauterine insemination. For IVF/ICSI, reported clinical pregnancy rates after polypectomy range from 53–72% and live birth rates from 43–66%. Proposed mechanisms include mechanical interference, chronic inflammation with cytokine dysregulation, altered endometrial receptivity (including dysregulation of HOXA10/HOXA11), and impaired decidualization. Conclusions: Current evidence supports hysteroscopic polypectomy as an effective intervention to improve fertility outcomes in subfertile women with endometrial polyps, particularly prior to intrauterine insemination. For IVF/ICSI, polypectomy of documented polyps appears beneficial, though evidence quality is moderate and heterogeneity exists across studies. It is critical to distinguish routine screening hysteroscopy before IVF from targeted polypectomy when a polyp has been documented. Contemporary guidance (including the 2024 SOGC guideline) favors polypectomy for symptomatic polyps and those that meet specific clinical criteria; for small asymptomatic polyps (<10 mm), individualized decision-making is appropriate, given limited direct evidence and the potential for spontaneous regression. Future research should clarify molecular predictors of polyp-associated infertility, optimal timing relative to fertility treatment, and long-term reproductive outcomes.

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  1. PREreview

    This Zenodo record is a permanently preserved version of a Structured PREreview. You can view the complete PREreview at https://prereview.org/reviews/20844638.

    Does the introduction explain the objective of the research presented in the preprint? Yes Yes, it explains the objective
    Are the methods well-suited for this research? Somewhat appropriate 1. There is not much clarity on the methodology used. We recommend a rewording as a narrative review with a systematic search method. 2. The type of systematic review study screened should be clearly spelt out.
    Are the conclusions supported by the data? Highly supported The conclusion of the study was highly based on the data realized from the study
    Are the data presentations, including visualizations, well-suited to represent the data? Highly appropriate and clear
    How clearly do the authors discuss, explain, and interpret their findings and potential next steps for the research? Very clearly
    Is the preprint likely to advance academic knowledge? Highly likely The study throws more light on the relationship between chronic endometrial polyps and infertility, as well as provides practical clinical recommendations.
    Would it benefit from language editing? No They might need minor language editing to improve lay knowledge.
    Would you recommend this preprint to others? Yes, but it needs to be improved The methodology
    Is it ready for attention from an editor, publisher or broader audience? Yes, as it is

    Competing interests

    The authors declare that they have no competing interests.

    Use of Artificial Intelligence (AI)

    The authors declare that they did not use generative AI to come up with new ideas for their review.

  2. Version published to 10.3390/medicina62040692
  3. Version published to 10.20944/preprints202603.2327.v1