infertility
INFERTILITY

Infertility is the failure to achieve pregnancy after a year of unprotected regular intercourse or therapeutic donor insemination in women <35 years old or within 6 months in women >35 years old.

It can be primary if no pregnancy has ever occurred or secondary if pregnancy has occurred irrespective of the outcome.

Ovulation induction is part of the patient's management for polycystic ovarian syndrome which aims to achieve development of a single follicle and subsequent ovulation in a woman with anovulation.

Surgical Intervention

Polycystic Ovarian Syndrome (PCOS)

Laparoscopic Ovarian Drilling with Diathermy

  • May be used to induce ovulation in Clomifene-resistant PCOS
  • Creates several surface lesions on the ovary that may trigger endocrine changes and induce ovulation
  • Cumulative pregnancy with this technique was found equivalent to ovulation induction with gonadotropins but is not associated with increased risk of multiple pregnancy

Cervical Factors

  • Infertility due to stenosis of the cervical canal can be managed with dilatation
  • Removal of cervical polyps by polypectomy and abrasion of the cervical canal

Endometriosis

  • Laparoscopy is the surgical approach of choice in treating infertility secondary to endometriosis
    • Aims to remove endometriotic lesions, restore normal anatomy with adhesiolysis, and optimize ovarian and tubal preservation
    • Improves pregnancy rate of patients with minimal or mild endometriosis regardless of treatment modality
  • Laparoscopic excision of >3-cm ovarian endometrioma may improve fertility
    • More effective than simple drainage and ablation of cyst wall
  • Removal of deeply infiltrating endometriosis may unfavorably affect fertility
    • Patient should be advised to undergo IVF after an initial unsuccessful surgery for endometriosis-associated infertility rather than reoperation unless pain is still a concern

Tubal Dysfunction

  • If tubal surgery is effective, it may allow patients to conceive naturally without further intervention
  • Outcome depends on severity of tubal damage, duration of infertility, associated infertility factors, training and experience of the surgeon

Fimbrioplasty and Neosalpingostomy 

  • Surgical procedures for improving patency of distal tubal obstruction
  • Should be done via laparoscopy only due to reduced risks and comparable results with laparotomy
  • Salpingostomy performed before IVF may improve the subsequent likelihood of success of IVF in older women with mild hydrosalpinges, in male factor infertility or other infertility factors

Tubal Microsurgery and Laparoscopic Tubal Surgery

  • Tubocornual anastomosis is the standard procedure for proximal tubal blockage
  • In centers with appropriate expertise, tubal surgery offers higher pregnancy rates in patients with tubal infertility
  • Surgery is more effective in those with mild tubal disease than no treatment
  • Laparoscopic adhesiolysis is equally effective as microsurgical adhesiolysis in improving pregnancy outcome

Tubal Catheterization or Cannulation

  • Tubal catheterization or cannulation is a procedure that uses either a radiographic approach (selective salpingography with tubal cannulation) or a hysteroscopic tubal cannulation
    • Preferred procedure for women with proximal tubal obstruction
    • Selective salpingography with tubal catheterization or hysteroscopic tubal cannulation may improve the chance of pregnancy in women with proximal tubal obstruction

Uterine Abnormalities

  • Surgical correction of polyps, adhesions, fibroids, or septa appears to improve pregnancy rates 
  • Fibroid removal is not clearly associated with improvement of fertility treatment outcomes
    • Please see Leiomyomas disease management chart for further information
  • Hysteroscopic adhesiolysis is likely to restore menses and improve chances of pregnancy in amenorrheic women with intrauterine adhesions
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