Endometriosis :

Endometriosis is the sole cause of infertility in 7% of infertile couples,and the incidence of endometriosis is much higher in infertile women when compared to fertile women (12-45% vs 2-4%). Endometriosis is a condition where the cells lining the uterus (endometrium) grows in other areas of the body, causing pain, irregular bleeding, and infertility. They bleed and heal and are stimulated again during the next cycle.

This process leads to signs and symptoms of endometriosis i.e it causes adhesions of the tubes, ovaries and surrounding structures in the pelvis and symptoms like severe dysmenorrhoea (painful periods), dysperunia (painful coitus) and chronic pelvic pain. Depending upon the severity of the disease the disease can be staged into 4 stages. Severe the disease more advanced is the stage and may be associated with ovarian cysts, severe pelvic adhesions with blocked Fallopian tubes and in those subjects Assisted Reproductive Techniques may be required to treat the infertility.

As such endometriosis is a progressive disease as long as estrogenic stimulation is there ie till menopause and the surgical or medical treatment will not cure the disease, it will just slows or delays recurrence or progression, also repeated surgery for endometriomas can compromise ovarian function .

Polycystic Ovarian Syndrome :

Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders, affecting approximately 5%-10% of women of reproductive age and is thought to be one of the leading causes of female subfertility. Features are obesity, anovulation, irregular menstruation or amenorrhea, acne and excessive amounts or effects of androgenic (masculinizing) hormones. Insulin resistance, diabetes and obesity are all strongly correlated with PCOS. In 2003 a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if 2 out of 3 criteria are met :

• Oligo- ovulation and/or anovulation
• Excess androgen activity
• Polycystic ovaries (by gynecologic ultrasound)

Metabolic syndrome is associated with 30- 40% of PCOS. So the investigations includes fasting lipid profile GTT, BP Monitoring, Hormonal study. Regular exercise, low calorie diet and weight reduction are the first line management for PCOS. Anovulatory infertility is seen in PCOS, so ovulation induction with drugs may be required and follicular development and ovulation can be noted with serial tracking of the follicle by Ultrasound. The PCOS subjects are at risk for later development of Diabetes, Endometrial hyperplasia, Cardiovascular disease, hypercholestrolemia and hypertension.

Fibroid Uterus :

Fibroids are very common benign (non cancerous) tumors of the uterine smooth muscle and is seen in 20-40 % of women in reproductive age groups and upto 10-15% of infertile ladies and 60% of ladies in the pre-imenopausal age group. Fibriod can be the sole cause for infertility in 2% of infertile couples . The size and location of the fibroid are important. The large majority of them are very small or located in an area of the uterus such that they will not have any impact on reproductive function.

There are three types of uterine fibroids :

1. Subserosal - on the outside surface of the uterus

2. Intramural - within the muscular wall of the uterus

3. Submucous - bulging in to the uterine cavity

This fibriod may be associated with infertility, heavy menstrual flow, dysmenorrhoea, pregnancy complications like recurrent abortions, intrauterine growth retardation, antepartum hemorrhage.
Recent studies have noted that both intramural and submucosal fibroids can decrease fertility.

Management :
Fibriods are estrogen dependent tumors and will have the tendency to grow as long as estrogenic stimulation is there and it regresses after menopause. But it can be symptomatic or can cause complications depending on its rate of growth, location and may be by size also. The fibroids can be treated by surgically (myomectomy by laparotomy, laparocopy or hysteroscopically), minimally invasive surgical techniques (like laparoscopic myolysis, MR focused ultrasound myolysis, Uterine Artery Embolisation) or by medical treatment (eg.GnRH.,analogues, newer treatments like angiogenesis inhibitors, gene therapy are all under trial).

Myomectomy is the procedure to surgically remove fibroids and is not recommended except for extreme cases, as surgery always has the potential for causing adhesions unexpected heavy bleeding leading to hysterectomy, improper dissection of fibroid near cornual area can damage the fallopian tube and so that can further hinder fertility.

Hydrosalpinx :

Hydrosalpinx is a condition where the fallopian tube gets filled with fluids because of chronic inflammation by bacterias like Chlamydia or Neisseria and others or due to Tuberculosis and it may damage the tubal lining and may be associated with tubal block. In acute infection tubes may be filled with pus and is called pyosalpinx.

The presence of hydrosalpinx is known to reduce the pregnancy rate by half even in IVF pregnancies and disconnecting the tube with hydrosalpinx from uterus is found to double the pregnancy rate. The presence of bilaterally damaged or blocked tubes may require IVF for to get conceived.

Ectopic pregnancy :

In about 1%of cases pregnancies occurs outside the uterine cavity and the common location of extrauterine pregnancies are fallopian tube, ovary, abdominal cavity and cervix. The incidence of ectopic pregnancies are much higher in ART pregnancies and the most common cause for ectopic pregnancies are damaged fallopian tube, more no of transferred embryos in ART, previous tubal surgeries etc.

Sometimes both intrauterine and extrauterine pregnancies occurs together in the same cycle and this is called heterotopic pregnancies. The incidence of heterotopic pregnancies are 1/30000 in natural conceptions and is 1/100 in ART pregnancies or it can go upto 1/10 if the transferred number of embryos are more than or equal to four.

Laparoscopy :

Visualization of peritoneal cavity with laparoscope. It is a minimally invasive technique when compared to laparotomy.

Hysteroscopy :

Hysteroscopy is the process of using a viewing scope to examine the interior of the uterus along with the cervical canal. The scope is inserted through the vagina and into the cervical opening. The procedure can be performed as an aid in the diagnosis of problems with the uterus, or it may be combined with simple surgical techniques for treatment purposes.

Folliclogenesis, Ovulation :

Release of egg and pickup by the tubes for transport