A hysteroscopy is a procedure in which a thin, telescope-like camera (hysteroscope) is passed through the cervix into the uterine cavity, allowing direct visualisation of the inside of the uterus. It is both a diagnostic and therapeutic tool — many findings can be treated in the same procedure.

What Hysteroscopy Can Find and Treat

Endometrial polyps: Small benign tissue growths from the endometrial lining. Polyps are common (present in approximately 10–25% of women undergoing IVF investigation) and are associated with reduced implantation rates. Hysteroscopic polypectomy (removal of the polyp in the same procedure) is associated with improved IVF success rates in studies, making this one of the clearer justifications for hysteroscopy before IVF.

Submucosal fibroids: Fibroids that project into the uterine cavity. These are among the most significant structural causes of implantation failure. See uterine fibroids and IVF. Hysteroscopic myomectomy removes submucosal fibroids through the same approach.

Intrauterine adhesions (Asherman's syndrome): Bands of scar tissue within the uterine cavity, usually resulting from previous uterine surgery, D&C procedures, or post-delivery infection. Adhesions can distort the cavity, reduce endometrial blood flow, and severely impair implantation. Hysteroscopic adhesiolysis (cutting the adhesions) is the treatment.

Uterine septum: A band of fibrous or muscular tissue dividing the uterine cavity, present from birth. Associated with recurrent miscarriage and implantation failure. Hysteroscopic resection of the septum is the treatment.

Endometritis: Chronic inflammation of the endometrial lining. May be suggested by a "strawberry appearance" of the endometrium on hysteroscopy, or confirmed by biopsy during the procedure. Treatment is with antibiotics.

Normal uterus: A significant proportion of hysteroscopies before IVF find no abnormality — which is itself useful information, ruling out treatable uterine causes of implantation failure.

Types of Hysteroscopy

Office/outpatient hysteroscopy: Performed without general anaesthetic, using a very thin hysteroscope (typically 2–3mm). A speculum is placed, the hysteroscope is passed through the cervix, and the cavity is distended with saline for visualisation. Most patients experience cramping similar to a period during and for a short while after the procedure. Takes approximately 10–15 minutes. No recovery time needed.

Operative hysteroscopy under general anaesthetic: Used when significant treatment is planned (polyp removal, myomectomy, adhesiolysis, septum resection) or where outpatient hysteroscopy is not tolerated. Performed as a day case. Recovery involves rest for 1–2 days and avoiding strenuous activity for a week or two.

Routinely for all patients before IVF? This is debated. The largest RCT of routine hysteroscopy before a first IVF cycle (the inSIGHT trial, 2019) found that performing hysteroscopy in all patients before IVF — rather than only in those with suspected uterine abnormality — did not improve live birth rates. This has led to a shift away from routine pre-IVF hysteroscopy in the absence of clinical indication.

Selectively, in the following situations (widely supported):

  • Ultrasound or saline sonogram suggests a polyp, submucosal fibroid, septum, or adhesions
  • Recurrent IVF failure (2+ failed transfers) where a uterine cause has not been excluded
  • History of uterine surgery, D&C, or pelvic infection that could have caused adhesions
  • Recurrent miscarriage investigation
  • Unexplained implantation failure after good embryo transfers

What to Expect From the Procedure

Preparation: For an outpatient hysteroscopy, no special preparation is usually required. Some clinics recommend taking ibuprofen or mefenamic acid 1–2 hours before to reduce cramping.

During the procedure: Mild to moderate cramping during cervical dilation and cavity distension is expected. Most patients describe it as uncomfortable rather than severely painful. Some patients find it more painful than a smear test; a minority find it very difficult.

Immediately after: Cramping typically subsides within 30–60 minutes. Light spotting or watery discharge for 1–2 days is normal.

Return to normal activity: The same day for outpatient hysteroscopy. After operative hysteroscopy under general anaesthetic, rest for 24–48 hours.

When to start an IVF cycle after hysteroscopy: For diagnostic hysteroscopy only, the next cycle. After operative hysteroscopy with polyp removal, myomectomy, or adhesiolysis, most clinics recommend 1–2 months' recovery to allow healing before IVF stimulation.

NHS Availability

Diagnostic and operative hysteroscopy is available on the NHS through gynaecology or fertility services. Where a clear clinical indication exists (polyp on ultrasound, adhesions suspected after uterine surgery), NHS hysteroscopy should be accessible. Private outpatient hysteroscopy is available at many fertility clinics, typically costing £600–£1,200.

Frequently Asked Questions

Q: My clinic wants me to have a hysteroscopy before starting IVF. Is this necessary?

A: It depends on why it is being recommended. If there is a clinical indication — a suspected polyp or fibroid on ultrasound, a history of uterine surgery, or prior IVF failure — hysteroscopy is well-supported. If it is being offered as a routine add-on for all patients before a first IVF cycle without clinical indication, the evidence from the inSIGHT trial does not support this as improving live birth rates.

Q: What is the difference between a hysteroscopy and a saline sonogram?

A: A saline sonogram (SIS) uses ultrasound with saline introduced into the cavity to outline its shape. It is good at identifying polyps and fibroid distortion, but cannot directly treat what it finds. Hysteroscopy allows direct visualisation and simultaneous treatment. For diagnostic purposes, SIS is a reasonable first step; hysteroscopy is appropriate when treatment may be needed or when SIS findings are inconclusive.

Q: How painful is a hysteroscopy?

A: This varies considerably between patients. Outpatient hysteroscopy is typically described as moderately uncomfortable — similar to period cramps — by most patients. Patients with cervical stenosis (narrowing), significant anxiety, or who are postmenopausal (narrower cervix) may find it more difficult. If you are concerned about pain, discuss options with your clinic — some offer procedural sedation for outpatient hysteroscopy.

Q: I had a D&C after a previous miscarriage. Do I need a hysteroscopy before IVF?

A: Having had a D&C is a risk factor for intrauterine adhesions (Asherman's syndrome). Whether hysteroscopy is recommended before IVF depends on whether there are symptoms suggesting adhesions (scanty periods, pelvic pain) and whether the uterine cavity appears normal on ultrasound. Many clinics would recommend hysteroscopy in this situation, particularly if multiple D&C procedures were performed.

Q: If the hysteroscopy is normal, does that mean IVF will work?

A: A normal hysteroscopy rules out treatable uterine structural pathology as a cause of implantation failure. It does not guarantee IVF success — embryo factors, endometrial receptivity at a more subtle level, and other factors remain relevant.

This article is for information only and does not constitute medical advice. Discuss whether hysteroscopy is appropriate for your specific situation with your fertility specialist.