Pre-IVF Workups and Corrective Surgeries

Success rates of IVF in good centres are now around 60%. Cost depends on the kind of IVF procedure required — sometimes an ICSI procedure, sometimes donor eggs are needed — but it would typically start around 3 to 4 lakh rupees, roughly $3,200 to $4,500 per cycle.

There isn't a specific size used as a strict benchmark — even small fibroids can require removal if they are causing a cornual blockage, and submucous fibroids or polyps will usually require removal regardless of size. But anything bigger than roughly the equivalent of a 12–14 week pregnant uterus is a very large fibroid that definitely requires removal. On medical management: GnRH antagonists such as elagolix are used to help shrink fibroids, as are GnRH analogues/injections like leuprolide, which reduce the size of the uterus. However, submucous fibroids — the main culprits behind infertility — often will not respond well to medical management.

We need a good, plush endometrial lining, and if it isn't good we have medicines that can improve it. For example, in a recent case of severe intrauterine adhesions from a missed abortion managed elsewhere, the endometrial thickness was under 1mm in places and completely scarred. We did adhesiolysis and then gave a combination of estrogen and progesterone — estrogen helps regenerate the endometrium. It takes about 3 months for regeneration, though outcomes depend on how bad the scarring is; in some patients with very severe scarring we may not be able to regenerate a good lining at all.

We generally say at least 3 to 4 months of contraception should be used, and conception should not happen within that window.

There are now government of India guidelines on this. Strictly by those guidelines it is 50 for the woman and 55 for the man, though this used to be more liberal — we used to see people at 60–65 also getting IVF done, before the ethical question of who will care for the children led to the cutoff being tightened.

A pre-IVF workup screens for uterine problems such as fibroids, polyps or adhesions, fallopian tube blockages, ovulation disorders including thyroid disease, polycystic ovarian syndrome and hyperprolactinaemia, endometriosis, premature ovarian insufficiency, and pelvic adhesions that sometimes follow cancer treatment.

Because patients often see their GP before a gynaecologist, a multidisciplinary approach is essential, with GPs playing a central role in treating thyroid disease, PCOS and hyperprolactinaemia early, before infertility care can effectively begin.

The essential tests required before IVF begins are transvaginal sonography, ovarian reserve testing, tubal patency testing and semen analysis.

Corrective surgeries that can improve IVF outcomes include fibroid removal, adhesiolysis for Asherman syndrome, endometriosis surgery, tubal procedures and correction of uterine anomalies.