Question 1

Should we go for hysteroscopy plus laparoscopic chromopertubation, or repeat HSG, for a patient diagnosed with bilateral proximal tubal blockage?

Dr. Shelly Singh · Accepted Answer

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.

Question 2

What is the success rate of IVF, and what are the cost implications?

Dr. Shelly Singh · Accepted Answer

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.

Question 3

Could you explain more on the size of fibroid that must be surgically removed, and on medical management of fibroids generally?

Dr. Shelly Singh · Accepted Answer

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.

Question 4

What about the status of the uterine lining, especially after correction of uterine-related infertility, before proceeding to IVF?

Dr. Shelly Singh · Accepted Answer

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.

Question 5

After a myomectomy, what is the minimum period before conception?

Dr. Shelly Singh · Accepted Answer

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

Question 6

Is there an age limit for women to go for IVF at your hospital in India?

Dr. Shelly Singh · Accepted Answer

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.

Question 7

How long does it take for the endometrium to completely regenerate following estrogen and progesterone therapy?

Dr. Shelly Singh · Accepted Answer

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.

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