For pregnancy to occur, the entire system has to work perfectly – egg has to release; it is picked up by the fallopian tube where it meets the sperm which has wriggled its way up from the vagina; the fertilized egg then re-enters uterus where it grows to a full sized baby. Problems can occur anywhere in this system causing infertility. Medicines can help when hormonal problems prevent pregnancy. However, there are many cases where relief can only be obtained by surgery. These are known as Fertility Enhancing Surgeries and are best by a hysteroscopist – gynaec laparoscopist surgeon. These are minimal access surgeries and are extremely fascinating in what they can achieve with least discomfort to the patient and maximum results.
Hysteroscopy deals with problems inside the uterus. Cervix or mouth of the womb: narrow; does not allow the sperms to ascend up into the uterus. Magnified vision obtained by hysteroscope allows fibre by fibre sniping of this blocked area and the cervix opens up. Tubes: Debris blocking the near end can be removed by placing tubing under direct view (Cannulation of the tubes). When the dye test (HSG) indicates block, each tube can be separately tested (Selective salpingography). Success rates in opening blocks hysteroscopically is 74-90%. Congenital abnormality like a septum inside the uterus is more associated with repeated pregnancy losses than infertility but considering successful pregnancy of 87.5% with surgical removal versus 5% when not removed, it is better to excise this septum in infertile patients. Hysteroscopic septum surgery is a simple, short procedure compared to major open surgery. Similarly, scarring inside the uterus (adhesions) released under direct vision increases pregnancy rates 4 times compared to blind D&C. Adhesions outside the uterus require Laparoscopy for effective treatment. Similarly endometriosis, chocolate cysts, simple cysts of ovaries, blocked tubes for excision/re-canalization are excellently treated with laparoscopic surgery. Fibroids, if removed by Hysteroscopy or Laparoscopy depending upon the location, double the pregnancy rates. In fact, so valuable are these procedures that no infertility and IVF management is complete without a diagnostic hysteroscopy-laparoscopy and for many gynaecological conditions causing infertility these are ‘gold standard’ techniques.
Dr. Nirja Chawla, Director, Obstetrics Gynaecology, Infertility, Hystero-Laparoscopic Surgery, Paras Bliss Hospital, Panchkula