Uterine Anomalies and Fertility: Which Need Correction?

After adhesiolysis we give a combination of estrogen throughout the cycle and progesterone added in the last 14 days, and it takes about 3 months for regeneration, confirmed with transvaginal sonography for endometrial thickness before and after. Many patients start to show improvement even after about a month and a half, where the scarring and adhesions are not so severe that they have permanently damaged the endometrium.

A lot of times when an HSG is done without sedation, the patient tenses up so much that there is a tubal spasm, which can appear as a bilateral proximal tubal blockage. One good approach is to give the patient an anti-spasmodic before the procedure, or do it with a little sedation, which removes many of these false positives. But if it still appears to be a genuine proximal blockage in both tubes, it's better to go directly for a diagnostic hysterolaparoscopy with chromopertubation, since that lets you directly visualise the tubes — and most patients also find repeating an HSG very painful.

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.

A septate uterus, where a fibrous band divides the uterine cavity, generally requires correction because it significantly affects fertility outcomes.

No. An arcuate uterus, which shows only a minimal dimple on examination, does not require removal.

For a bicornuate uterus, where two uterine horns are present, correction through a Strassman procedure is only considered if the anomaly is causing significant pain or the cavity is very small.

Uterine anomalies can sometimes be associated with renal, cardiac and vertebral abnormalities, which means these can be tricky surgeries requiring careful case by case judgement, and many anomalies do not require correction at all.