Hysteroscopy
Hysteroscopy is a procedure in which a thin telescope is passed through the cervix so the inside of the uterus can be seen directly, and it is the only test that shows the uterine cavity as it really is rather than as a shadow on a scan.
It is used both to find a problem and, in the same sitting, to treat one. This page explains when it is worth doing, when the evidence says it is not, what it feels like, and what can go wrong.
On this page
- What hysteroscopy is
- Diagnostic and operative procedures
- Why hysteroscopy is recommended
- What it can find and treat
- Before IVF: what the evidence shows
- How the procedure is done
- Preparing for it
- What it feels like
- Risks and complications
- Recovery and results
- Questions patients ask
What hysteroscopy is
The hysteroscope is a rigid or flexible telescope, usually between 2.9 mm and 5 mm across, connected to a camera and a light. Salt-water solution or carbon dioxide gas gently opens the cavity so the walls separate and can be inspected.
Nothing is cut to get in. The instrument passes along the natural route through the vagina and cervical canal, which is why there is no scar and, for a straightforward procedure, no stitches and no overnight stay.
The operator looks at the shape of the cavity, the lining, the two openings where the tubes enter, and anything growing inside. Findings are recorded as images so they can be discussed with you afterwards.
Diagnostic and operative procedures
A diagnostic hysteroscopy looks only. It takes five to ten minutes and is often done in a clinic room without general anaesthesia.
An operative hysteroscopy uses a slightly wider instrument with a working channel for scissors, graspers, an electrical loop or a mechanical shaver. Polyps are removed, small fibroids shaved away, adhesions divided, a septum cut, a coil or retained tissue retrieved.
In practice the two often merge: the plan is to look, with consent taken in advance to treat whatever is found. That saves you a second procedure.
Why hysteroscopy is recommended
The common reasons in fertility care are an abnormality suspected on ultrasound, abnormal or heavy bleeding, bleeding after the menopause, recurrent miscarriage, repeated implantation failure, and a cavity that looked irregular during a dye test of the tubes.
It is also used to investigate uterine causes of infertility, to remove a lost intrauterine device, to take a targeted biopsy of the lining, and to assess the cavity after surgery for fibroids.
What it does not do is assess the tubes or the ovaries. Those need ultrasound and a separate tubal test. Hysteroscopy answers one question: what is the inside of the uterus like.
What it can find and treat
Endometrial polyps. Soft overgrowths of the lining. They are common, frequently symptomless, and removing them is quick. Evidence that removal helps fertility is moderate rather than strong, but the procedure is low-risk.
Submucous fibroids. Fibroids bulging into the cavity distort it and are associated with reduced implantation and increased miscarriage. These are the fibroids most worth removing.
Intrauterine adhesions. Scar bands, often after a surgical uterine evacuation or infection. Severe scarring is Asherman syndrome. Division is technically demanding and adhesions can re-form, so repeat assessment is usual.
A uterine septum. A wall of tissue dividing the cavity from birth. It is linked to miscarriage, and division is straightforward, though the size of the benefit is still debated.
Chronic endometritis and retained tissue. Both can be identified and sampled, and both are treatable.
Before IVF: what the evidence shows
This section matters because it runs against what many patients are told. Two large randomised trials tested routine hysteroscopy before IVF in women with a normal scan, and neither found an improvement in live birth.
The honest reading is that the procedure is valuable when there is a reason to suspect a cavity problem, and of no proven benefit when the cavity already looks normal. Add-ons are offered selectively here, not as a standard package.
The same principle has been applied elsewhere at this clinic. The endometrial receptivity array was used in more than 750 patients and is no longer offered. If hysteroscopy is suggested to you, ask what specific question it is expected to answer.
How the procedure is done
Outpatient hysteroscopy is done awake, sometimes with local anaesthetic injected around the cervix. You lie on a couch, the telescope is passed, and you can watch the screen if you want to. Most women go home within the hour.
Under general or spinal anaesthesia, hysteroscopy is done in theatre. That is chosen for longer operative work, for a tight or scarred cervix, for larger fibroids, and for anyone who would find an awake procedure distressing. Preference counts here; it is a legitimate reason to choose anaesthesia.
The RCOG patient information on outpatient hysteroscopy sets out both routes in detail and is worth reading before you decide.
Preparing for it
Hysteroscopy is usually timed to the first half of the cycle, after bleeding stops and before ovulation, when the lining is thin and easy to see. It is not done if there is any chance you are pregnant.
For an awake procedure, eat normally and take ibuprofen or paracetamol about an hour before unless you cannot take them. For anaesthesia you will be asked to fast and to arrange someone to take you home.
Tell the team about blood-thinning medicines, previous cervical surgery, latex allergy, and any past experience of fainting during a smear or coil insertion. Each of those changes how the procedure is set up.
What it feels like
Most women describe period-type cramping that builds while the cavity is filled and settles quickly once the instrument is out. Some feel very little. A minority find it genuinely painful, and that is not a failure of tolerance.
You are entitled to stop at any point. Saying so is not a waste of anyone’s time; the procedure can be rescheduled under anaesthesia. Agreeing that signal in advance makes the experience easier for most people.
Risks and complications
Serious complications of hysteroscopy are uncommon. Published series put the overall complication rate for diagnostic hysteroscopy well below 1%, with operative procedures carrying a modestly higher rate.
Perforation of the uterine wall is the main one, reported in the order of 1 in 1,000 diagnostic procedures and more often during operative work, particularly when dividing dense adhesions. It usually heals without further surgery but occasionally needs a laparoscopy to check the bowel and bladder.
Other recognised risks are infection, bleeding, cervical tearing, a vasovagal faint during an awake procedure, absorption of too much irrigation fluid during long operations, and failure to enter the cavity at all.
Seek help the same day for fever, heavy bleeding, offensive discharge or worsening pain. Those are the signs that need assessment, not observation at home.
Recovery and results
Expect cramping for a day and light spotting for a few days. Use pads rather than tampons until bleeding stops, and avoid sex and swimming for a week after operative work.
The NHS guide to hysteroscopy covers aftercare in plain language and is a useful thing to show whoever is collecting you.
Findings are available immediately; biopsy results take a week or two. Your next appointment should cover what was seen, what was done, whether anything needs repeating, and what it means for your treatment plan.
Questions patients ask
Will hysteroscopy affect my ovarian reserve? No. It does not touch the ovaries.
How soon can we try to conceive? After a diagnostic procedure, the same cycle. After significant operative work, usually after one or two cycles, so the lining can recover.
Is hysteroscopy the same as a D&C? No. A dilatation and curettage scrapes the lining blind. Hysteroscopy looks first and then treats only what is actually there, which is why it has largely replaced blind curettage for investigating the cavity.
Does it need repeating? Only after division of adhesions, or if the original problem may have returned.
Can I have it done while I am bleeding? It is possible but the view is poor, so it is normally rescheduled rather than attempted through heavy bleeding.
Written and medically reviewed by Dr. Vani Sundarapandian, MD, DGO, FRCOG (UK) — founder and Medical Director, Jananam Fertility Centre, Chennai.
