Clinical UM Guideline

This document addresses the use of hysteroscopy for the diagnostic work-up of infertility.

Note: Please see the following related document for additional information:

• CG-MED-103 Assisted Reproductive Technology
• LAB.00045 Selected Tests for the Evaluation and Management of Infertility

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Medically Necessary:

Hysteroscopy is considered medically necessary in the evaluation of infertility for any of the following indications:

1. Suspected uterine abnormality as evidenced by abnormal hysterosalpingogram or hysterosonogram (for example, but not limited to endometrial polyp, submucosal myoma, intrauterine synechia, or uterine anomaly [unicornuate, bicornuate, septate uteri]); or
2. Proximal tubal occlusion on hysterosalpingogram; or
3. Cervical stenosis; or
4. Inadequate or non-diagnostic hysterosalpingogram or sonohysterogram.

Not Medically Necessary:

Hysteroscopy in the evaluation of infertility is considered not medically necessary when the above criteria have not been met*.

*Note: hysteroscopy for indications other than infertility are not within scope of this document.

This document describes clinical studies and expert recommendations for the use of hysteroscopy for the diagnostic work-up of infertility and explains whether these procedures are appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Hysteroscopy is a procedure that uses a thin, lighted tube (called a hysteroscope) to look inside the uterus. It is inserted through the vagina and helps doctors find or treat issues that may affect fertility. It may be used after other tests such as ultrasound or x-ray do not show clear results. Hysteroscopy can find growths or scars inside the uterus, which might interfere with getting pregnant. In some cases, treatment can be done during the same procedure. However, for people trying in-vitro fertilization (IVF), a medical procedure used to help people with infertility to have a baby, studies show that routine use of hysteroscopy does not increase the chances of having a baby if earlier imaging tests (like ultrasound) were normal. It may help identify or treat issues in some people, especially after failed IVF attempts, but it is not recommended for everyone.

What the Studies Show

Several studies tested whether using hysteroscopy before starting IVF improves the chance of live birth. In people with normal ultrasound results, adding hysteroscopy before the first IVF cycle did not help more people give birth. Some studies found that hysteroscopy slightly increased implantation or clinical pregnancy rates (the number of people who became pregnant), but these benefits did not lead to more live births. A large review of studies found no clear benefit in using hysteroscopy for all people before IVF, especially when earlier test results were normal. The studies also had design problems, such as unclear methods or small numbers of people, which makes it hard to know how reliable the results are.

However, some research suggests that hysteroscopy may help people who had two or more failed IVF attempts, even when earlier ultrasounds looked normal. In those cases, it may slightly improve pregnancy rates, but not live birth rates or miscarriage rates. Other studies found that hysteroscopy helped doctors find unexpected problems that were missed by ultrasound or x-ray, which then helped guide treatment decisions. These included conditions like blocked tubes, scar tissue, or uterine cysts. Still, the evidence is not strong enough to recommend routine hysteroscopy for everyone with infertility, and better studies are needed.

When is Hysteroscopy Clinically Appropriate?

Hysteroscopy may be appropriate in these situations:

• When other tests (such as ultrasound or hysterosalpingogram) suggest an abnormality in the uterus.
• When someone has had two or more failed IVF attempts and doctors suspect undetected uterine problems.
• When direct treatment is needed for confirmed uterine issues, such as polyps, fibroids, or scarring.

When is this not Clinically Appropriate?

Routine use of hysteroscopy before IVF is not appropriate when earlier tests (like ultrasound or hysterosalpingogram) show a normal uterus, and there are no signs of uterine problems.

Hysteroscopy is not clinically appropriate in scenarios other than those listed above. Better studies are needed to know if hysteroscopy improves health in people with unexplained infertility or before IVF when earlier tests show no problems.

(Return to Description)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.

Summary

A hysteroscopy is a surgical procedure used to diagnose or treat problems of the uterus. It involves the use of a thin, lighted telescope-like device that is inserted in the vagina and then into the uterus. The hysteroscope transmits the image of the uterus onto a screen and can assist with diagnosis of uterine problems. The American Society of Reproductive Medicine (ASRM, 2023) defines infertility based on various clinical factors and recommends evaluation after 6-12 months of unsuccessful conception. While hysteroscopy is useful for diagnosing intrauterine abnormalities, current results from randomized controlled trials and meta-analyses indicate that it does not significantly improve live birth rates in individuals undergoing in-vitro fertilization (IVF), especially when prior ultrasound results are normal. Although some data suggest improved implantation and clinical pregnancy rates, routine hysteroscopy is not broadly recommended due to inconsistent findings and methodological limitations in existing studies.

Discussion

The American Society of Reproductive Medicine (ASRM, 2023) defines infertility as the inability to achieve a successful pregnancy based on the medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors, also noting:

The need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner.

In patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.

Tests to rule out uterine anatomic abnormalities include ultrasound, sonohysterogram, and hysterosalpingogram. Ultrasound can be done to diagnose uterine pathology such as myomas. Sonohysterogram which involves injecting saline into the uterine cavity and then using transvaginal ultrasound to view the uterine cavity can detect pathology such as endometrial polyps, submucous myomas, and synechiae. The hysterosalpingogram involves the use of x-rays and injection of a contrast agent into the cervical canal, uterine cavity, fallopian tubes, and peritoneal cavity to look for blockages. Hysterosalpingogram can also show developmental anomalies of the uterus or acquired anomalies such as endometrial polyps or submucous myomas. A definitive method for the diagnosis and treatment of intrauterine pathology is hysteroscopy. This exam is invasive and is usually reserved for use after less invasive methods have been unsuccessful.

In a retrospective chart review, Acholonu (2011) reported on the comparison of hysterosalpingogram to sonohysterogram for detection of polyps, fibroids, adhesions and septae in infertile participants. The reports were then compared to hysteroscopy. All 149 participants underwent hysterosalpingogram and hysteroscopy. A total of 110 participants had abnormalities found on hysteroscopy, whereas hysterosalpingogram detected abnormalities in 64 participants. Ninety-three participants had sonohysterogram and hysteroscopy. Of those 93, 77 showed abnormalities on hysteroscopy, while sonohysterogram showed abnormalities on 63. Those who showed normal hysterosalpingogram or sonohysterogram did not generally go on to have hysteroscopy. Hysterosalpingogram can be an important screening tool for infertile individuals in evaluating the architecture and patency of the fallopian tubes while sonohysterogram can be more reliable for the evaluation of intrauterine abnormalities.

In a 2016 randomized-controlled trial by Smit and colleagues, the authors reported on whether routine hysteroscopy before the first treatment cycle of IVF affects the livebirth rate. Participants were included if they had a previous normal transvaginal ultrasound and were scheduled to receive IVF for infertility. The participants were randomized 1:1 to either hysteroscopy and then IVF or immediate IVF. A total of 325 participants received hysteroscopy and then IVF, while 364 participants received IVF only. With an 18-month follow-up, the primary outcome was ongoing pregnancy resulting in livebirth, defined as delivery of a live fetus after 24 weeks gestation. After 18 months, 209 participants who had hysteroscopy followed by IVF met the primary outcome measure while 200 participants who had immediate IVF met the primary outcome measure. The authors concluded that a routine hysteroscopy does not improve livebirth rate in those who have a normal transvaginal ultrasound before receiving IVF, therefore those who have a normal transvaginal ultrasound should not be offered routine hysteroscopy.

A similar trial in 2016 by El-Toukhy and colleagues also reported on whether or not hysteroscopy done prior to starting a cycle of IVF could improve the outcome in those who had already had two to four unsuccessful cycles of IVF. The included participants had all previously had normal transvaginal ultrasounds. The primary outcome measure was the livebirth rate, defined as those who had at least one live baby beyond 24 weeks gestation after one cycle of IVF. In this randomized controlled trial, 301 participants received hysteroscopy prior to IVF and 290 participants received IVF only. A total of 133 participants in the hysteroscopy group became pregnant after IVF with 102 participants meeting the primary outcome measure. In the IVF only group, 136 participants became pregnant and 102 met the primary outcome measure. The authors concluded that hysteroscopy (after a normal transvaginal ultrasound) and unsuccessful IVF cycles did not improve livebirth rate.

A Cochrane Library systematic review assessed the effectiveness and safety of screening hysteroscopy in subfertile individuals undergoing evaluation for infertility, and subfertile individuals undergoing intrauterine insemination (IUI) or IVF (Kalmath, 2019). The review included ten trials that included 1836 individuals who had a screening hysteroscopy and 1914 individuals who had no hysteroscopy prior to IVF. They reported that the main limitations in the quality of evidence were inadequate reporting of study methods and higher statistical heterogeneity. They also observed that 8 of the 10 trials had unclear risk of bias for allocation concealment. Their conclusions stated:

At present, there is no high‐quality evidence to support the routine use of hysteroscopy as a screening tool in the general population of subfertile women with a normal ultrasound or hysterosalpingogram in the basic fertility work‐up for improving reproductive success rates.

In women undergoing IVF, low‐quality evidence, including all of the studies reporting these outcomes, suggests that performing a screening hysteroscopy before IVF may increase live birth and clinical pregnancy rates. However, pooled results from the only two trials with a low risk of bias did not show a benefit of screening hysteroscopy before IVF.

Since the studies showing an effect are those with unclear allocation concealment, we are uncertain whether a routine screening hysteroscopy increases live birth and clinical pregnancy, be it for all women, or those with two or more failed IVF attempts. There is insufficient data to draw conclusions about the safety of screening hysteroscopy.

A 2024 retrospective study by Teka reported the results of 328 persons who underwent diagnostic and therapeutic hysteroscopy. No intra-cavity abnormalities were found in 20 participants. The most common abnormalities found on hysteroscopy included intracavity adhesions (48.2%), endometrial polyps (18%), and submucosal fibroids (9%). Surgical procedures performed via hysteroscopy included adhesiolysis for 158 cases, polypectomy for 68 cases, fibroid removal in 30 cases, septal resection in 6 cases, removal of intrauterine devices in 5 cases, and extraction of intrauterine fetal bone fragments in 3 cases. Primary infertility was the most common reason for hysteroscopic evaluation with removal of adhesions as the leading intervention during hysteroscopy.

Another retrospective observational study by Mahendra in 2025 reported the findings of 39 individuals with primary or secondary infertility who underwent hysterosalpingogram and diagnostic hysteroscopy. All participants underwent the hysterosalpingogram first. In detecting tubal patency, the hysterosalpingogram demonstrated a sensitivity of 95.83% with a specificity of 92.31%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 88.89%. For uterine abnormalities, the hysterosalpingogram showed a sensitivity of 70.00%, specificity of 85.71%, PPV of 80.00% and NPV of 77.42%. During the hysteroscopy the following findings were missed by hysterosalpingogram; hydrosalpinx was found in 4 individuals, fimbrial cysts were found in 2 individuals, and uterine adhesions were found in 3 cases. These findings led to an impact on treatment planning. Uterine abnormalities influenced management of hysteroscopic surgery or IVF in 4 individuals. Detection of hydrosalpinx led to the need for salpingectomy or IVF and the note of fimbrial cysts required laparoscopic tubal surgery in 1 person. While the sample size is small and may limit generalizability of the results, use of hysteroscopy enhances diagnostic accuracy and may improve treatment planning.

A 2019 meta-analysis by Mao reported on eight studies (three randomized controlled trials, three nonrandomized prospective studies, and two retrospective cohort studies) to determine if hysteroscopy before starting IVF in individuals with recurrent implantation failure can improve the implantation rate, clinical pregnancy rate, live birth rate, and reduce miscarriage rate. Included in the studies were individuals with normal ultrasound of the uterine cavity and individuals with at least two failed IVF attempts; a diagnostic hysteroscopy was performed before starting an IVF cycle. Participants in the control groups in the studies did not receive hysteroscopy. Study totals included 3932 individuals with recurrent implantation failure. There were 1841 participants in the hysteroscopy group and 2091 participants in the control group. Four studies provided information about implantation rate. There was no heterogeneity among the four studies. An overall analysis showed that the implantation rate was higher in the hysteroscopy group compared to the control group (pooled odds ratio [OR], 1.22, 95% confidence interval [CI]: 1.02-1.45, p=0.025). Seven studies provided data regarding pregnancy rate. Overall analysis showed that clinical pregnancy rate was higher in the group that received hysteroscopy when compared with the control group (pooled OR, 1.64, 95% CI: 1.30-2.07, p<0.001). There were five studies that provided live birth rate data. Pooled results from five studies showed there was no statistical significance in live birth rate (pooled OR, 1.30, 95% CI: 0.90-1.88, p=0.168). A subgroup analysis of the two randomized controlled trials and the three non-randomized studies showed no significant difference in the live birth rate between the two groups. Four studies provided data regarding miscarriage rate. There was no heterogeneity noted among the four studies. Pooled results revealed no significant difference in the miscarriage rate between the two groups (pooled OR, 0.94, 95% CI: 0.66-1.35, p=0.744). The subgroup analysis of the randomized controlled trials and the non-randomized trials also showed no significant difference in the miscarriage rate between the two groups. The results of this meta-analysis indicated that hysteroscopy improved implantation rate and clinical pregnancy rate, however it did not improve live birth rate or reduce the rate of miscarriage. One limitation of this meta-analysis is the small number of studies included. Also, the authors did not examine whether or not abnormalities were found on hysteroscopy and what effect, if any, they may have had on the outcomes of IVF. It is also noted there were different definitions of recurrent implantation failure among the studies. Further research with randomized controlled trials is necessary to help define the role of hysteroscopy in individuals with recurrent implantation failure.

Adnexal mass: A tumor or mass that occurs on any of the organs next to the uterus.

Bicornuate uterus: A congenital malformation in which the uterus is shaped like a heart instead of pear-shaped.

Dysmenorrhea: Painful menstrual cramps.

Endometrial polyp: A growth that attaches to the inner lining of the uterus.

Hydrosalpinx: A blocked, dilated, and fluid-filled fallopian tube.

Hysterosalpingogram: An X-ray procedure done to view the inside of the uterus and fallopian tubes. It is often used to see if the fallopian tubes are partly or fully blocked. It also can show if the inside of the uterus is a normal size and shape.

Hysteroscopy: A surgical procedure used to diagnose or treat problems of the uterus. A hysteroscope is a thin, lighted telescope-like device that is inserted in the vagina and then into the uterus. The hysteroscope transmits the image of the uterus onto a screen and can assist with diagnosis of uterine problems.

Hysterosonogram: A special, minimally invasive ultrasound technique that provides pictures of the inside of the uterus.

Intrauterine synechia: Scarring inside the uterus.

Myoma: A benign tumor of the smooth cells of the myometrium.

Septate uterus: A congenital uterine anomaly in which a septum (membrane) divides the uterus into two parts.

Submucosal myoma: A non-cancerous, or benign tumor that grows inside the uterus just under the surface of its lining.

Unicornuate uterus: A genetic condition which causes only half of a uterus to form.

Peer Reviewed Publications:

1. Acholonu UC, Silberzweig J, Stein DE, Keltz M. Hysterosalpingography versus sonohysterography for intrauterine abnormalities. JSLS. 2011; 15(4):471-474.
2. Armstrong SC, Showell M, Stewart EA, et al. Baseline anatomical assessment of the uterus and ovaries in infertile women: a systematic review of the evidence on which assessment methods are the safest and most effective in terms of improving fertility outcomes. Hum Reprod Update. 2017; 23(5):533-547.
3. El-Toukhy T, Campo R, Khalaf Y, et al. Hysteroscopy in recurrent in-vitro fertilisation failure (TROPHY): a multicentre, randomised controlled trial. Lancet. 2016; 387(10038):2614-2621.
4. Indraccolo U, Greco P, Scutiero G, et al. The role of hysteroscopy in the diagnostic work-up of infertile asymptomatic patients. Clin Exp Obstet Gynecol. 2014; 41(2):124-127.
5. Mahendra G, Sahana M. Comparative analysis of hysterosalpingography and diagnostic hysteroscopy findings in infertility evaluation. Cureus. 2025; 17(4):e81789.
6. Mao X, Wu L, Chen Q, et al. Effect of hysteroscopy before starting in-vitro fertilization for women with recurrent implantation failure: a meta-analysis and systematic review. Medicine (Baltimore). 2019; 98(7):e14075.
7. Schrager S, Falleroni J, Edgoose J. Evaluation and treatment of endometriosis. Am Fam Physician. 2013; 87(2):107-113.
8. Smit JG, Kasius JC, Eijkemans MJ, et al. Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial. Lancet. 2016; 387(10038):2622-2629.
9. Teka S, Negash M, Zegeye S, et al. Diagnostic and therapeutic hysteroscopy in Ethiopia: a retrospective study on practice and outcomes. BMC Womens Health. 2024; 24(1):656.
10. Wang Y, Tang Z, Wang C, et al. Whether hysteroscopy improves fertility outcomes in infertile women: a meta-analysis and systematic review. Front Endocrinol (Lausanne). 2024; 15:1489783.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Obstetrics and Gynecologists (ACOG). Practice bulletin no. 114: management of endometriosis. Obstet Gynecol. 2010; 116(1):223-236. Reaffirmed 2022.
2. American College of Radiology. Practice parameter for the performance of sonohysterography and hysterosalpingo-contrast-sonography (HyCoSy). 2025. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=100. Accessed on February 2, 2026.
3. American College of Radiology. ACR Appropriateness Criteria^®. Female Infertility. 2019. Available at: https://acsearch.acr.org/docs/3093336/Narrative/. Accessed on February 2, 2026.
4. Kamath MS, Bosteels J, D'Hooghe TM, et al. Screening hysteroscopy in subfertile women and women undergoing assisted reproduction. Cochrane Database Syst Rev. 2019; 16;(4):CD012856.
5. Practice Committee of the American Society for Reproductive Medicine. Fertility evaluation of infertile women: a committee opinion. Fertil Steril. 2021; 116(5):1255-1265.
6. Practice Committee of the American Society for Reproductive Medicine. Definition of infertility: a committee opinion. Fertil Steril. 2023; 120(6):1170.

1. American Society for Reproductive Medicine. Available at: http://www.asrm.org/. Accessed on February 2, 2026.

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