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Polyps

Posted Apr 28 2009 1:41pm
It looks like vacation is over and I have a little catching up to do. I will try to get to as many questions as I can. The first question was about polyps, so here we go.

First a little story. I had a patient whose uterus looked fine on her initial ultrasound and HSG. She started an IVF cycle and lo and behold, a day before her hCG, a couple of polyps were discovered in her uterus. They were just under 1 cm each.

We had a few of options. First we could have canceled the cycle, removed the polyps, and restarted a cycle in another month. The second option was to continue the cycle, freeze the embryos, remove the polyps, and then do the frozen cycle. The third was to do nothing, continue with the retrieval and transfer and see what happens. We did the last, and she became pregnant and delivered twins.

What are polyps? Going back a little, uterus is composed of 2 basic parts, the first being thick outer muscular layer; the myometrium. The second part is the innermost layer made of glands; the endometrium. Most of the endometrium sheds every month with menses. Polyps are little balls, usually round or oval, that are overgrowths of the endometruim. So they grow on the inside of the uterus. They are not shed every cycle, they stick around each month and can get bigger with time. Sometimes I explain they are like skin tags, except inside the uterus. We don’t know what causes them.

Theoretically, they interfere with implantation. How? One possibility is that because the glands are growing in an abnormal way, an embryo may not be able to attach if it tries to stick on top of the polyp. This is probably because the embryo will not be able to receive proper nutrients and blood flow. Also theoretical, a polyp located in one area of the uterus can make even the normal areas inhospitable because the polyp may create a generalized inflammation in all areas of the uterine lining. This inflammation could interfere with any of the many very complicated implantation steps.

Should polyps be removed? It depends what you call a polyp. Some doctors see a little area of irregularity in the uterus, which can be normal, and call it a polyp and want it removed. Most doctors are more reasonable and agree that we don’t know much about small polyps, and we don’t know if they interfere with conception. There are many women with polyps who get pregnant all of the time, but when we have a patient who is not getting pregnant and has a polyp, we at times want it removed.

The smaller a polyps, the less we worry about them. We really don’t have a size chart to tell us what’s too big. In general, polyps less than 5 mm are really small and rarely removed. Polyps 5-10 mm are a little more of a concern, but your doctor may see one of these and not worry. Larger than 1 cm is more significant and more doctors would recommend removal. 2 cm is pretty big; too big.

Most women do not know they have polyps. Occasionally they cause pre menstrual, or post menstrual spotting, sometimes mid cycle bleeding or spotting. Larger polyps can make the period very heavy and long.

So what do we know? We know if there are one or more large polyps, and everything else is normal, women have a good chance of getting pregnant after the polyps are removed. The effect of smaller polpys on infertility is less known. Some women get pregnant after having small polyps removed; some women get pregnant with the polyps in.

Doctors and patients have their breaking point for polyp removal, but the thresholds can be different from case to case and from practice to practice.

Polyps can grow back. Sometimes they are completely removed the first time, and they grow back anyway, or there is a new one that develops. Sometimes the first polyp is not completely removed. Many polyps grow from a stalk, so that if the polyp is removed, but the stalk is not, it is more likely to come back.

This is one reason that a hysteroscopy is mandatory for proper polyp removal. A standard D and C, where the doctor does not actually look in, is not the right surgery, and in many cases leads to failure and a repeat procedure. During this procedure, the doctor scrapes “blindly”, not seeing where the curette (scraper) is going. Here it’s common for the polyps to be pushed aside, but not removed. Looking in with a scope to be sure all of the polyps have been removed, including their stalks, is the way to go. During hysteroscopy the doctor can slide a tiny grabber through a narrow channel in the scope, and target and directly watch the polyp removal.

Can polyps be cancerous? Very very rarely. You can discuss this one with your doctor.

Thanks for reading and please see disclaimer 5/17/06. Dr. Licciardi
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