Dear Veena,

I think interesting polyp removal, but understand that it takes a husband investigation before making further tests, since we can be before the male factor.

Dear Claudio,

Husband's semen analysis has already been done. Semen analysis shows reduced motility and husband has been referred to andrologist. My query was whether one should do only polyp removal at the first instance or can combine it with laparoscopic evaluation too.

Dear Veena,

In this case since the husband was evaluated I think it is appropriate to accomplish the polyp removal concomitant to the laparoscopy in order to evaluate possible pelvic adhesions but also perform the injection of methylene blue by tubas for verification of its patency rates

Dear Veena,

Clearly this patient needs hysteroscopic removal of her polyp, and it would be appropriate to undertake a laparoscopy at the same time.

Data from Thomas D'Hoogue presented at the World Endometriosis Society in 2008 showed that 47% of patients such as this will be found to have endometriosis. Surgical resection of this will improve embryo implantation,  both naturally and with assisted reproduction.

Establishing tubal status will also assist in planning further management 

In this setting as outlined  concomitant assessment of the male with a semen, TPHA/ FSH will be a birds eye into the male factors. The lady can have her laparoscopy, dye , D&C/ et polpectomy to  evaluate her endometrium and polyp and establish that dates and hormonal profile are in synchrony. The dye will ascertain tubal patency and the laparoscopy can be useful to rule out small deposits  of endometriosis which could be have diathermy.

The psoriasis generally may not be contributory but autoimmunity basis needs some query as to its management and any teratogenicity when pregnant. However the increased hormones in pregnancy may improve the skin condition. Are there any psoriatiform joint involvement? 

I would suggest an outpatient hysteroscopic polypectomy if this facility is available in your hospital, otherwise, an inpatient procedure is warranted +/- laparoscopy if the patient gives symptoms suggestive of endometriosis.

My intention of asking the query was when would one do chromopertubation in this case, before or after polypectomy? If done before polypectomy, polyp itself may hinder the free flow of dye. If it is done after polypetomy, the procedure itself is likely to result in endometriosis. 

There is no evidence to suggest that polypectomy before tubal dye testing predisposes to endometriosis. 

I woud do a small pusch biopsy to exclude out a beginning  Lichen sclerosus  of the vulva

Dear Frederike,

I have not understood the rationale behind doing a biopsy in case of infertility with uterine polyp.

I would suggest a 3 D  detailed ultrasound and hysterosalpingosonography before surgery  .I agree to remove the polyp by histeroscopy to improve embrio implantation and only in a second stage to evaluate to perform a laparoscopy to eradicate the endometriosis and pelvic adhesions  if suspected. I do not remove the fibroids because are subserous .Anyway  the infertility might be related to psoriasis and immunological factors .

I would like to know whether psoriasis itself can be cause for infertility. Are there are any references in this regard?

I would carry out a hyeteroscopic polypectomy in the first instance. Laparoscopic evaluation will be done only if no success even after polypectomy. The question I often ask myself is "what is the size of a polyp that can have an effect thus needs removal?"

Dear Veena,

I would like to recommend you to read this: 

AAGL Practice Report: Practice Guidelines for the Diagnosis and

Management of Endometrial Polyps

http://www.aagl.org/wp-content/uploads/2013/03/aagl-Practice-Guidelines-for-the-Diagnosis-and-Management-of-Endometrial-Polyps.pdf

Maybe it will be helpful.  

Greetings. 

You can do a diagnostic hysteroscopic, and after an operative hysteroscopic  to remove the  endometrial polyp and you must to consider  the dimensions and if it's an intramural or submucous polyp.

Polypectomy with  Hysteroscopy approach

Only if is a sottosierous polyp.

Dear Astrit,

I have not understood your answer. It is an endometrial polyp. Where does the question of Laparoscopy come in that?

sorry I 'm not remember that was an endometrial polyp

Excuse me, I thought we Hysteroscopy

In a case of infertility where an endometrial polyp has been detected on pelvic ultrasound, the initial management typically involves a multidisciplinary approach involving both gynecologists and infertility specialists. Here's a general outline of the initial management:

Confirmation of Diagnosis: Confirm endometrial polyp through imaging or diagnostic procedures like hysteroscopy or SIS.

Evaluation of Infertility: Assess other factors contributing to infertility in both partners.

Assessment of Hormonal Status: Check hormone levels to understand hormonal imbalances.

Treatment Options:

Medical Management: Hormonal therapy to regulate cycles and shrink the polyp.

Surgical Removal: Polypectomy via hysteroscopy for large or symptomatic polyps.

Fertility Treatments: Consider IUI or IVF, with or without polyp removal.

Follow-Up: Regular appointments to monitor response, assess recurrence, and evaluate treatment effectiveness.

Address Other Contributing Factors: Identify and address any additional factors affecting infertility.

Lifestyle Modifications: Encourage healthy habits like weight management, stress reduction, and smoking cessation.