Electropuncture of ovarian follicles (EOF) is the surgical treatment. It was introduced as pelviscopic technique. it can also be done by minilaparotomy which is most suitable for Pakistan & developing countries where expertise and the sophisticated equipment is not available. EOF is useful but one has to be careful not to destroy excess tissue. It is used in cases where there is abundant stroma and high hormones level. It should never be done in unmarried and untested fertility. It is better to try ovulation therapy to help fertility at least once before submitting the case for surgery. With this schedule, there has been 80% success in achievement of fertility in PCO
Ovarian Hyperstimulation Syndrome (OHSS):Women having fertility drugs, often produce excessive number of follicles which can develop in hyper stimulation of ovaries.In its mild form there will be only some abdominal discomfort but in its worst form there is swelling and fluid can accumulate in abdomen and chest which can also lead into thickening of blood. Ultrasonography and high estrogen levels confirm OHSS.
OHSS is mostly seen in polycystic ovaries. It usually develops 5-7 days after hCG injection and is more common if woman gets pregnant. It does not harm pregnancy and slowly subsides.
If OHSS drink plenty of fluids and take extra salt. Take light diet and analgesics. Sometimes if there is excessive vomiting or difficulty in breathing admission is required.
Cervical Hostility Cervix is the only connection between the exterior and the interior. It plays an important role to guard the internal pelvic structures from the external elements protecting the female from infections. It only allows the sperms to swim up to approach the ovum and menstrual blood to come out. In addition at the time of labor, it allows the birth of the baby.
This guard like mechanism is controlled by morphology of cervix and the mucus discharged by its glands with variable characteristics under the influence of the ovarian hormones.
Cervical hostility is detected by Post coital test and is treated with Intrauterine Insemination (IUI). If IUI fails 3 times, IVF is suggested.
Uterine Factor. Uterus is the organ where the pregnancy rests and expands. Any defect in uterus and its function will make it difficult for the conception to implant and grow. In ART, assessment of uterus has become very important. In most of the cases, there is success IVF but the embryo either fails to implant in the uterus or it is weakly embedded. It is discharged at early stages or there is early pregnancy loss.
Uterine walls can be visualized and its size measured by ultrasound. Abnormalities of uterine walls like fibroids and adenomyosis and septa can be seen. It also visualizes the uterine cavity, locates its lesions and observes changes in the endometrium brought by ovarian hormones.
Hysteroscopy is the best method to assess the uterine capacity and the intrauterine lesions. TVS observes changes in uterine endometrium. Thickness of Endometrium is measured at its outer boundaries and its increase observed. It is reflection of its response to the levels of ovarian hormones. Increasing thickness endometrium indicates that hormonal levels are gradually increased and the cycle is proceeding satisfactorily. Changes in the characteristics of the endometrium mean effects of estrogens and progesterone.
At the time of ovulation and after endometrial thickness reaches > 8 mm. Lack of changes indicates hormonal disturbances.
Treatment: Small uterus said to improve by estrogen administration but practically does not make uterus well enough to contain conception. Intrauterine space occupying lesions, septa and adhesions are successfully treated by hysteroscopic surgery.
In cases of abnormal or absent uterus, surrogacy is considered in ART procedures. Some other woman is motivated to harbor couple’s embryo produced by IVF. Surrogacy is not available in oriental communities.