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Management of Infertility in Females

Dr. Umesh N. Jindal

Page 5


B. Surgical Treatment

Dilatation and Curettage (D and C) – D and C may be done for gynaecological indications and primarily have a diagnostic role. Empirical dilatation and curettage, still widely prevalent, does not enhance fertility and should be condemned. Cervical stenosis acquired after previous curettage for abortion sometimes responds dramatically to cervical dilatation.

Cervical cauterization – The role of cervical erosion and chronic cervicitis is ill understood in infertility. However, any infection should be treated. Cryocauterization of cervix is safe and simple and have a minimal risk of cervical stenosis as compared to conization and thermal cautry.

Tuboplasty – Microsurgical tubal recanalization after sterilization operation has success rates of 60% – 70% in experienced hands. For tubal damage due to other causes, tubal reconstructive surgery can be done in selected cases but with a guarded prognosis. Success rates vary between 10% – 30% and there is a high incidence of ectopic pregnancy. Long standing tubal infertility, bipolar disease, tubercular etiology, badly damaged tubes, previous failed tuboplasty and previous laparotomies have very low success rate; IVF is the preferred method in these cases.

Myomectomy – Relationship of myoma to infertility appears coincidental. However when myomas are big, multiple or positioned submucosally, they do cause infertility and/or abortions and need removal. Post myomectomy pregnancy rates are generally low and other causes of infertility must be looked into.

Hysteroscopic Surgery – With advances in instrumentation, techniques and growing experience, hysteroscopic surgery has become an important tool for an infertility specialist. Sub-mucous myomas, intrauterine synachiae, septae and foreign bodies can be successfully removed transcervically without scarring the uterus. It is safe, can be done as a day care procedure and gives very satisfactory results in experienced hands.

Laparoscopic Surgery – Laparoscopic surgery has now become the primary method of surgical treatment in infertility. Treatment at time of diagnostic laparoscopy is the standard. Adhesiolysis, myomectomy, fulgration of endometriotic implants, removal of cysts and tuboplasties can be done very successfully with good results. In endometriosis, surgery remains the primary mode of treatment. Ovarian drilling and cauterization in cases of PCOD cases have also been used. It has reasonable success rate in inducing spontaneous menstruation and pregnancy rate. Besides being a temporary method, it is fraught with dangers of pelvic adhesions and premature ovarian failure.

Reconstructive surgery for uterine malformation – There is no evidence that major uterine malformations cause infertility. These are more likely to cause abortions and preterm labour. Corrective surgery may be undertaken in selected cases of septate and bicornuate uterii. Certain malformations like transverse vaginal septum or unilateral obstructive lesions may interfere with proper coitus, hamper menstrual outflow and thus need correction.

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