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This is a condition which is observed commonly all around the world. Approximately one-sixth of couples is infertile. Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 1 year or more of regular unprotected sexual intercourse. For the diagnosis, it is compulsory to perform the necessary examinations for both of the couples and obtain their history completely and accurately. In some cases, the reason of infertility cannot be explained even though all kinds of researches are made. This is called ""unexplained infertility". 10% of the infertile couples are in this category. With the modern infertility treatments, the success rate in infertility phenomena is increased.
In primary infertility phenomena, no pregnancy has been achieved.
In secondary infertility phenomena, no pregnancy has been achieved following the birth of one or more children.
One-third of infertility cases are caused by male reproductive issues, one-third by female reproductive issues, and one-third by both male and female reproductive issues. In some cases, low sperm and/or egg quality or the obstruction in the pathway for sperm to reach the egg (in fallopian tubes) may occur. The embryo must be able to make its way into uterus and be healthily grown. Metabolic disorders, stress, advanced age, alcohol or drug use, malnutrition or excess weight can have negative impact on the fertility.
The male infertility can be caused by the abnormality of the sperm production and function, general state of health, life-style and environmental factors. The male fertility is a highly complex process. Secretion of reproduction hormones, gonad maturation and sperm production are parts of this process. For a male to make a female pregnant, the healthy sperm needs to reach and fertilize the egg. In this process, abnormal sperm morphology (size and shape of sperm) prevents the sperm from penetrating and fertilizing the egg. The first test to be made for the couples who apply with the complaints of infertility is spermiogram. The test is inexpensive and simple. However, it is of extreme importance. A normal spermiogram must have a volume of 2-4 ml with the sperm count of more than 20 million per 1 ml. Progressive movement (motility) must be around 50%. 60% of sperms must be normally shaped. In the assessment of sperm morphology, Kruger strict criteria are used. 14% of sperms examined through the special staining methods should be morphologically normal. Many factors may result in abnormal sperm parameters. These are as follows:
Factors resulting in abnormal sperm parameters
Varicocele: Varicocele is a condition which occurs in %20 of men and %40 of women. This does not mean that every man with varicoceles is infertile. This condition can be seen in many males who are fertile. The varicocele results from the excessive enlargement of veins in the spermatic cord. It keeps the local temperature too high, affecting the sperms. In the meta-analyses made, it was not concluded that the surgery would be completely efficient. Suggesting this method for every male, which may not cause the sperm count and movement to reach a level that increases the pregnancy rate, may cause loss of time. Only for the patients with borderline sperm count and in cases where it causes pain in patients, it is suggestible to perform surgical repair. It is a procedure of which recovery time is short and surgery is simple. For the patients with borderline sperm count, if no pregnancy is achieved within 6-9 months, the adjunct fertility methods should be applied.
Undescended testicles: In the male babies, both testicles are within the abdominal cavity before the birth. They move down to scrotum just before the birth. This is the reason why the undescended testicle is observed in the premature infants three times more. They are generally unilateral; however they can be rarely bilateral. The temperature of sperms must be lower than the body temperature. Otherwise, their vitality and movements can be impaired. If no treatment is applied for the patients with undescended testicles, the infertility occurs. The most ideal treatment age is between 6-12 months. The treatment must be completed until the age of 2 at the latest.
Absence of testosterone (male hypogonadotropism): It is a condition characterized by the inability of testicle to produce hormones or the inadequate stimulation of testicles by hypothalamus or pituitary gland. This is another factor resulting in the infertility.
Chromosome abnormalities: A normal male karyotype is 46 XY. In some chromosomal disorders, this sequence is impaired, resulting in the infertility. The most common chromosomal disorder that is known to result in male infertility is Klinefelter’s syndrome. In this syndrome, the chromosome sequence is 47 XXY. It occurs in 1/1000. Affected cases include generally infertility. Testicles are small. It can lead to physical and behavioral disorders. Gynecomastia is observed at the rate of 1/3. It can be diagnosed through the methods of chorionic villus sampling or amniocentesis in the prenatal period.
Infections: Infection agents lead to generally temporary sperm disorder. However, Chlamdia and Gonorrhea infections which are sexually transmitted lead to the infertility by blocking the passage of sperms. If an epidemic parotitis occurs in the adulthood after the adolescence period, it can have negative impact on the sperm production. Likewise, prostate infections, urethritis and epididymitis are also reasons that affect the sperms negatively.
Hormonal disorders: The most common one among these is Kallmann syndrome. It is a condition arising from hypothalamus in the brain. Sex hormone production is decreased and the lack of sense of smell occurs.
Other important factors resulting in the male infertility: Those are problems confronted in the sexual intercourse. Difficulty of erection, early ejaculation, dyspareunia (painful sexual intercourse), and psychological problem may make the sexual intercourse impossible. If there is a blockage in epididymis and vas deferens, the sperms are produced in the testicle and may not be ejaculated.
Retrograde ejaculation: It may occur in cases of diabetes, spinal cord injuries, after bladder prostate surgery and due to usage of some drugs. In ejaculation, the semen flows into the urinary bladder instead of being ejaculated through urethra.
In some of the spinal cord injuries and disorders, the semen does not exist. In this case, as there is no liquid to carry the semen, the infertility occurs.
In hypospadias which is a congenital disorder, the opening of urethra channel is under the penis, which prevents the semen reach the cervix during the sexual intercourse.
In cystic fibrosis which is congenital disorder, vas deferens is impaired and the sperms may not be ejaculated. General life-style, excessive alcohol usage and smoking affect the sperm production and quality negatively. Extreme stress inhibits the secretion of hormones which are required for the sperm production.
Serious injuries, some chronic diseases, renal diseases, cirrhosis, sickle-cell anaemia and coeliac disease may also lead to the infertility. The age limit for the males is not a primary factor as it is for the females. However, the fertility in males over the age of 35 can also be affected.
The deficiency of Vitamin C, selenium, zinc and folate and excess weight may also have negative impacts on the fertility. Hot temperature, toxins, chemicals, pesticides and lead have negative effect on the sperms.
Extreme hot sauna or dressing warmly may block the sperm production and movement.
Exposure to radiation inhibits the sperm production irrecoverably. The usage of chemotherapeutic medicine may impair the sperm production.
The main cause of female infertility is the difficulties of ovulation. Causes:
One of the causes is disorders of hypothalamus which is the most functional portion of the brain. The organic defects in this area (tumor, formation abnormalities etc.) may cause trouble. In addition to this, extreme stress, anxiety, excessive weight loss or weight gain also affect this area. Increased milk hormone in blood (prolactin) affects the hypothalamus and decreases GnRH level, inhibiting the ovulation.
Polycystic ovary syndrome (PCOS): It is one of the most common reasons of anovulation. It affects 10% of childbearing-age women. 35 - 60% of women with the disease including various hormonal abnormalities are obese. 50% of them are unable to menstruate, 30% have abnormal uterine bleeding and 70% have the complaints of hirsutism. In 30% of cases, insulin resistance is observed and 8% is non-insulin-dependent diabetes. In 30 of cases, hyperprolactinemia is observed. In ultrasonography, polycystic ovary appearance has been reported only in 30% of cases. In this appearance, small, regular antral follicles around ovary and increased stroma are observed. In 30% of cases, it is observed in the blood samples obtained in the third day of cycle menstrual that FSH, LH level increased toward LH. Whether with the desire to have a child or not, the precautions must be taken for the cases not to be affected by high estrogen levels. In the patients with long-term polycystic ovary syndrome, unopposed (increased) estrogen increases the risk of endometrium and ovarian cancer. Besides, the risk of hypertension, coronary heart disease and diabetes would be increased.
This syndrome is not only caused by the ovarian disorders, but also by the pathology of other endocrine diseases (adrenal tumor, cushing syndrome, 21-hydroxylase deficiency etc.)
Examinations which may be requested from the patients: Blood testosterone, FSH; LH level, 17-OH progsterone level, when required 24-hour urinary cortisol level, prolactin, thyroid hormone level, oral glucose tolerance test, fasting glucose-insulin ratios.
Causes of polycystic ovary syndrome: In the occurrence of the disease, both genetic and environmental factors play a role. The same syndrome can be also observed in the patient's mothers and sisters.
In the patients with PCOS, androgens known as male hormones increases; this increase probably leads to impaired blood glucose and insulin production. In women with PCOS, LH levels are increased, which is the most significant hormonal disorder that causes the abnormality. Other hypotheses made about the occurrence of disorder are the exposure of fetus to androgens in utero, and moderate chronic infection in the body of patient with PCOS.
PCOS treatment: If the patient is overweight, the primary treatment is weight-loss and to reach the ideal body fat level. In this stage, the patient's desire to have a baby is of importance. For the patients who want the birth control to be applied, the birth control pills must be prescribed in order to regulate the menstrual cycle and minimize the androgenic adverse effects of disease. This is for protection against endometrium cancer which may develop in the future. The progsterone treatment to be applied for 14 days per month is not for the birth control but protects against endometrium cancer and regulates the menstrual cycles. Spironolactone (aldactone) can be applied for the acne and hair growth problems on condition that the blood potassium control is performed frequently.
For the patients who want to have a baby, the primary medication is Clomiphene Citrate. The medication must be applied at a maximum of 6 doses. On 3-5th day of the menstrual cycle, it is administrated as single dose daily for 5 days. If the response is not satisfactory, the dosage can be increased to a maximum of 3 doses daily. For the patients with no response to clomiphene, the treatment can be replaced by the injections called as gonadotropin in company with the vaccination. Metformin (Glukophage) which is an oral antidiabetic medication may be administrated following the renal function tests made. This helps to treat the disease by decreasing LH level in blood.
In some cases with PCOS, a surgical procedure called as ovarian drilling can be performed by laparoscopy. In this method, a specific number of holes are made in ovaries; this is intended to eliminate the tissue in the area where the secretion of androgen is high.
Endometriosis is another cause of the infertility. Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, peritoneum or bowel etc. This tissue can also be present at urinary bladders, fallopian tubes, cervix and vagina. This is a childbearing-age disease. It is rarely observed after menopause. It leads to painful menstrual cycles and painful intercourse. It is assumed that it is observed more in tall and thin women. Postponing the pregnancy to an advanced age may lead to this disease.
Endometriosis causes the infertility by leading to the development of intra-abdominal adherences and releasing some hormonal and chemical agents. The most significant method for the diagnosis of the disease is laparoscopy which ensures directly the view of lesions. In addition to the diagnosis, this method ensures the cauterisation of lesions and, in case of ovary involvement, the treatment by cystectomy. In nulliparous women, particularly with endometrioma on the ovaries, endometrioid ovarian cancer may develop.
The treatment must be administrated with drugs and/or surgically. The treatment must be aimed to eliminate the pain, and to ensure fertility for the patients who want to have a baby. Drugs called as anti-inflammatory are given for the elimination of pain. These block the most significant mediator prostaglandins which transmit pain. As the disease is observed in the childbearing age, birth control pills, progsterones and gonadotropin-releasing hormone analogues which block the secretion of hormones by ovaries can be given. Apart from these, danazol and aromatase inhibitors can be given. In cases where the response is not satisfactory with the medical treatment, the surgical therapy is applied. If the organs are to be protected, only local lesions are removed surgically. The recurrence rate is about 40%. Laparoscopic surgery is preferred; however in cases of excessive adherence and abnormal anatomy, open surgery must be administrated. If the organ is to be protected, uterus and ovaries are removed.
Injection (IUI, intrauterine insemination): It is one of the options for the treatment of infertility. HCG (human chorionic gonadotropin) injection is given after ovulation. After 36-48 hours, the sperm sample obtained from the men by masturbation is subjected to special tests. It is a process which can be performed under the clinical conditions without the need of IUI anesthesia. The sperm sample is injected into the uterus with a thin catherer. For such an operation, the fallopian tubes of women must be open. Sperm count must be adequate. Sperm count and morphology are so significant. IUI should not be performed if the sperm count is below 10 million/ml. Besides, if the sperm morphology is 5% or less according to Kruger criteria, the treatment is not administrated. Injection treatment is particularly preferred in the unexplained infertility cases and the success rate is not increased by trying it more than four times. After the injection process, there's no need to limit any of normal activities. Even if the injection is given after HCG, the sexual intercourse is recommended in the following days. It is assumed that before the injection the sperms remain in the vagina will make a contribution. In the injection treatments combined with clomiphene citrate, the success rate is around 8-10%. In the injections following the ovulation inductions combined with gonadotropins, the success rate is around 15-19%.
In-vitro fertilizasyon (IVF): In cases where no success is achieved with intrauterine insemination, it is a last-resort therapy. IVF is applied for the women whose tubes are blocked, the ovaries with no response to the infertility medicines and low sperm count and morphology. IVF is also applied in cases where the sperm movement is weak, in existence of the immunological factors, in cases of unexplained infertility and for the women with endometriosis resulting in the infertility.
With the start of IVF, many infertile couples could achieve the happiness. In this method, eggs obtained from the women and sperms from the men are fertilized in the laboratory setting. Fertilized ovum (zygote) is transferred to uterus. In 1978, this method was successfully done for the first time. Loise Brown is the world's first test-tube baby. Before this success, biochemical pregnancy in 1973, in Australia and ectopic pregnancy in 1976 had been reported.
In conventional IVF, sperm and egg are fertilized in the laboratory setting. In intracytoplasmic sperm injection (icsi), a single sperm is injected into an egg. For in-vitro fertilization, ovulation induction is performed In other words, the eggs of women are matured. The methods named short, very short or long protocols are used. In short protocol, while the medicines which stimulate the ovaries are given on the third day of menstrual cycle, GnRH analogues are given on the second day of menstrual cycle and the analogue dosage is decreased. In long protocol, GnRH analogues are started to be given on the 21th day of menstrual cycle. Gonadotropin is applied for ovulation induction on the third day following the menstrual bleeding. In cases where adequate response is not achieved, microdose GnRH analogues can be used or the treatment is discontinued after a short-term usage. The use of GnRH antagonists is highly common and is recommended especially for the cases with low egg reserve. In all treatments, it is aimed to inhibit early ovulation during the process of egg maturation. 36 hours after the administration of human chorionic gonadotropin, the eggs of 17 to 18 cm are collected under anesthesia through the transvaginal ultrasonography by using a long needle. The process is known as ovum pick up (OPU). Ideal ovum count is around 10. The process takes approximately 15 minutes. The complication rarely occurs. Bleeding, infection and bowel and internal organ injury are rarely observed. The eggs obtained in the laboratory setting are fertilized with the sperm which is washed and subjected to the special treatment. Embryos which are maturated in the laboratory setting are 2-cell on the first day, 4-cell on the second day and 8-cell on the third day. On the fifth day, they are called as blastocyst. Transfer date is determined according the condition of patient. For the embryo transfer procedure, there is no need for anesthesia. It is performed with transabdominal ultrasonography. The urinary bladder is preferred to be full in order for the ultrasound image to be sufficient and the uterus axe to be become even. It is performed by using a sterile, special catheter. This is a delicate procedure which requires the operator to be experienced. Rarely, upon the request of patient, a short-term and mild anesthesia can be applied. 12 days after the transfer procedure, it is determined through a blood pregnancy test whether the pregnancy has been achieved or not.
TESE (testicular sperm extraction) or TESA (testicular sperm aspiration) procedures can be performed in cases where the sperms parameters are abnormal. The cases where no sperm is detected in the spermiogram are called azoospermia.
Azoospermia is associated with various reasons. In one of these reasons, there may be disruption or complete blockage in the signals to the brain and its structures due to the various reasons. History of meningitis infections, Kallman syndrome, brain tumors, serious trauma in the head or anabolic medicines used for the muscle building impair these signals. Thus, hormone production does not occur. Another reason of azoospermia is directly related to the problems in testicles. Congenital absence of a testicle, undescended testicles and untreated cases, Klinefelter syndrome, epididymo-orchitis associated with severe epidemic parotitis in the adolescence period, testicular torsion, radiotherapy for the cancer treatment, and the history of chemotherapy impair directly the sperm production. In some cases, even though no problem exists in the sperm production, the semen may not be ejaculated. Absence of congenital vas deferens, cystic fibrosis, severe infections (for example, tuberculosis, gonorrhea etc.) may block testicular channels. In the patients with the history of pelvic surgery, hernia or hydrocelle operation and vasectomy, the sperms in the semen may be run out. Before the final diagnosis of azoospermia is made, the pellet must be centrifuged and examined at 1500 rpm. In some cases, it is possible to see the sperm in the pellet. It is seen in 10 to 15% of the infertile males. It has been observed in %1 of the male population. The sperm production can be achieved in the testicle. On the contrary to the women, it does not end at a specific age. As described above in detail, the sperm production is not possible due to specific reasons (non-obstructive azoospermia). In these cases, the testicle may be undersized and the blood FSH level is high. In this case, TESE is performed in order to obtain sperm from the men. This is a minor surgery. It must be performed by a specialist urologist under local or short-term general anesthesia. The samples are collected from various parts of testicle and subjected to the examination by the embryologist. It is to detect the semen in the samples. When a positive response is received, the procedure is terminated. If no semen is detected in the end of this procedure, it is terminated after taking a certain amount of samples. In general, a maximum of 4 samples are collected from one testicle with aim not to cause atrophy in the testicle. The second trial is not to be made before 6 months. If the testicular volume is less than 10 ml and in the sertoli cell-only cases, the risk of atrophy following TESE is higher. TESE procedure is performed according to the joint judgment by the patient and the physician. If the semen is detected, it is frozen and utilized after defrosting. Or it is performed on the day of Ovum Pick-Up and the semen is utilized freshly. In general, simultaneous procedure is preferred.
TESA is performed under local anesthesia. It is an easier procedure than TESE. This procedure is performed in cases where the sperm is able to be produced but not ejaculated (obstructive azoospermia). In obstructive azoospermia, the size of testicle is generally normal. FSH level is also normal. In TESA, an aspiration needle is inserted through the testicle to detect the semen in the aspirated material. In obstructive azoospermia, if the aspiration is performed from rete testis, it is called as RETA; if performed from epididymis, it is called as percutan epididimal sperm extraction (PESA); if performed by microsurgery from epididymis, it is called as MESA; and if the sperm precursor cells called spermatocele are aspirated, it is called as spermatocele aspiration (SPAS). Both TESE and TESA procedures are one-day surgical operations. In micro-tese procedure, the biopsy areas obtained from the testicle are detected under the microscope. The chance for the detection of semen is higher in this method. The possibility of hematoma and tissue loss is lower. In IMSI, the semen is examined under a microscope with a magnification of 2 to 6 thousand times. In this method, the structure of sperm cell is viewed so as to obtain more information and the genetic content is examined. Some of the factors resulting in azoospermia in the males are as follows:
Klinefelter syndrome: While the normal male karyotype is 46 XY, it is 46 XXY. This syndrome is observed in 0.1% of the patients. It is characterized by impaired disjunction during the maternal meiosis and thus a chromosomal error occurs. The men with this syndrome have long arms and legs Symptoms may include smaller testicles, breast growth and less body hair. However, their sexual functions are normal. These cases are infertile. It may be very difficult to detect the semen in TESE procedures. In general, histological results are obtained as maturation arrest or sertoli cell-only.
Cystic fibrosis: These cases are characterized by the impaired ejaculation even though the sperm production in the testicles is available. It is defined by the bilateral vas deferens (carrying-away duct) absence. For this reason, these cases are infertile. Normally, it is observed at 1/25 and more common in Nordic Countries. In 60% of males, the deletions are found in the CFTR gene which result in this disease In some males, it accompanied with renal abnormalities and pulmonary disorders. While a man with the congenital bilateral absence of the vas deferens (CBAVD) is included in a IVF program, her spouse must also be subjected to the genetic screening. If the mother has cystic fibrosis conductivity, the baby to be born will have this disease with the possibility of 25%. This can be prevented by pre-implantation genetic diagnosis.
Preimplantation genetic diagnosis (PGD) is defined by the detection and elimination in the early period. The world's first procedure was performed in 1985, in England with the invention of a method called polymerase chain reaction in 1980's. In the first stage of PCD, in-vitro fertilization is performed, the biopsy is performed and the embryo material is examined genetically. By this method, the information that their baby will not have any genetic disorder is given to the parents before the onset of pregnancy. However, amniocentesis must be performed in these pregnancies. Most of the cases in which PGD will be performed include the patients with chromosomal abnormality; the most common is translocation carriers among those. Other group consist of the patients carrying the risk to transmit X chromosomal abnormalities. In these cases, it is principal to detect and not to transfer all of male babies with the risk for X chromosomal abnormalities. PGD is performed for the patients with recurrent pregnancy loss, recurrent in-vitro fertilization failure and genetic disorders. Sometimes, there may be disorders which are unable to be detected by PGD. In this case, the couples must be informed immediately. There are three pre-implantation stages to obtain the samples for the genetic diagnosis. The first one is body biopsy. The second is cleavage stage embryo biopsy which is the most commonly used method. And the third one is blastocyst biopsy. Performing the biopsy during the stage of 6 to 10-cell embryo does not have a negative impact on the maturation.
In Embryo freezing-defrosting procedure, the storage of the remaining embryos after the transfer in the in-vitro fertilization treatment is performed to transfer them afterwards. These embryos can be transferred after being defrosted in the following months. The embryo freezing-defrosting procedure was firstly performed in 1970, in England. Through this method, the first pregnancy was achieved in 1983, in Australia. If a hyperstimulation syndrome occurs in the patient who has been stimulated by the usage of medicines for in-vitro fertilization, the embryo transfer is not administrated. In these cases, the embryos are frozen and transferred to the woman at a later time. Besides, the transfer is delayed for the patients with inadequate endometrial thickness. In all these cases, the embryo freezing-defrosting procedure is administrated. No difference was observed in terms of infant development abnormalities in the pregnancies achieved by the freezing-defrosting method. The success of freezing-defrosting procedures is closely associated with the viable embryo ratio. This ratio must not drop below 65%. The freezing procedure is recommended to be performed in the blastocyst stage. By this way, it is possible to obtain the best embryos. Not only embryo, but also gametes like semen and egg can also be frozen. The freezing and defrosting procedures are recently performed with the vitrification method. The importance of these procedures has been increased for the centers where the number of transferred embryo is limited.
Ovarian hyperstimulation syndrome (OHSS) is one of the rare complications occurring in the in-vitro fertilization treatment. Mild, moderate and severe cases are observed, respectively in the ratio of 33%, %4 and 0.1%. It is frequently seen in polycystic ovarian syndromes, younger patients, aggressive drug use, in the existence of high follicle rates during the HCG infection and increased blood estradiol level.
In mild forms of OHSS, the ovaries are enlarged (5-10 cm) and abdominal distension, pain, nausea and sometimes vomiting are observed. In moderate forms of OHSS, in addition to these, abdominal liquid accumulation (acid) is observed. In sever forms of OHSS, there may be pectoral liquid accumulation, advanced respiratory distress, decreased urine production and thrombosis. Symptoms can occur immediately after HCG injection or at later date. If the pregnancy has been achieved, the symptoms persist. OHSS occurs due to the fact that estrogens used to stimulate the eggs increase the vascular hyperpermeability. There are many intermediate reasons for this. In some of the unforeseen cases, this syndrome can occur. This is associated with the sensitivity of patients. If the risk of OHSS occurrence is available, the embryo transfer is not able to be performed. Or the dosage of HCG injection is decreased. The pick-up can be achieved with administration of 3.500 units of HCG. It is generally impossible to pick up ovum in the dosage below this. If OHSS risk exists, it would be protective to discharge some of follicles and then to perform HCG injection. During the process of ovum pick-up, it was observed in some studies that it is efficient to infuse human albumin 20% or HES solution to the patient. In mild cases, outpatient follow-up can be performed. After all possibilities are told, the patient is recommended to notify the physician of any worsening symptoms. In moderate forms of OHSS, bed rest is prescribed, the patient is recommended to stay hydrated and the outpatient follow-up is performed. In severe forms, the patient is hospitalized. Intravenous fluid is given; if peritoneal fluid accumulation is high and the patient is uncomfortable with this, a method called paracentesis is performed. In order to prevent blood coagulation, anticoagulant must be given. Sometimes the case is critical. Such patients must be followed and treated in the intensive care units.
Myomas ve polyps may be of importance in the cases of in-vitro fertilization. Myomas lead to the infertility in 10% of cases. Those which are located entirely inside the uterine wall (sub-mucosal) lead to discomfort mostly in this matter. If myoma is located outside the uterine wall and smaller than 4 cm, it does not interfere in the in-vitro fertilization. If myom is larger than 4 cm, the operation may be necessary; however this is not a conclusive result. The in-vitro fertilization can be performed 4-6 months after the removal of myom. If polyps are smaller than 2 cm, no operation is performed. However, if polyps are located in the area where the embryo is to be matured, it needs to be removed. In the modern medicine, this process is administrated by hysteroscopy.