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terminal tubal block developed in between previous HSG and present laparoscopy; and (6) pedunculated fimbrial cysts which can block the fimbrial opening of respective fallopian tube, like a ball valve, causing temporary tubal block. Combination of above pathologies was most common. 10.5005/jp-journals-10006-1163 Fertility Promoting Laparoscopic Surgery: Our Experience Journal of South Asian Federation of Obstetrics and Gynaecology, January-April 2012;4(1):12-16 13 JSAFOG The surgical procedures are summarized by Chatterjee et al.2 To recapitulate, the kinked tubes are corrected by SMH technique to regain their normal lengths. The stretching of IP ligament to correct the C-tube is not always successful. Fimbrial pathologies were corrected by fimbriolysis and fimbrial combing. Everted fimbriae were released by combing with palpating rod against the lateral pelvic wall or by cutting thick membranous adhesions. Sometimes, ostial dilatation by endoscopic forceps (Merryland) was necessary. Peritubal adhesions and bands or membranes were separated either by blunt or sharp dissection, taking precaution not to injure intestines. Bleeding may be controlled by saline wash or bipolar cautery. In case of cornual block, cornual massage with palpating rod or squeezing with special forceps aided by pushand-pull technique might be successful. Pedunculated fimbrial cysts were easily excised, using diathermy or scissors. Tuboovarian relation is very important for conception to occur. It is observed that TOR might remain disturbed, causing infertility. Chatterjee et al2 have detailed about TOR in their study. TOR was divided into four categories. TOR 4 position was most favorable position for pregnancy to occur. The surgery for endometriosis is a controversial subject, required to alleviate pain or to treat infertility. In advanced endometriosis, the aim of surgery is to bring the pelvic structures back to normal anatomically. The extent of adhesiolysis is always controversial. Too much of release of adhesions may impair vascularity of vital organs and requires the use of diathermy, impairing blood supply further. Extensive raw area and depritonization may invite reformation of adhesions. During the era of assisted reproductive technology (ART), functional integrity of pelvic organs is more important than structural normalcy. Surgery on the ovaries in endometriosis may lead to diminution of ovarian function or folliculogenesis. Surgical adhesions are more avascular than endometriotic adhesions. Hence, paucity of blood supply resulting in less availability of stimulating hormones leads to improper folliculogenesis. So, it is of utmost importance to perform surgery in endometriosis with great care. It should be peritoneal, sparing minimal adhesiolysis, to bring back effective TOR. If adhesions are extensive, IVF and ET are better choice. The use of medical treatment as an adjuvant has long been denied, as it does not promote fertility during its use.3,4 Many centers use post-operative medical treatment for few months to delay recurrence and to increase the chance of conception during recurrence free period.5,6 Preoperative medical treatment helps in effective adhesiolysis due to diminished vascularity or neovascularity of the pelvic organs and less use of diathermy. Another advantage of GnRH—a use preoperatively is if the pelvic adhesions indicate the requirement of ART procedure, controlled ovarian hyperstimulation (COH) can be undertaken in immediate postoperative period, as the patient is already down-regulated. This procedure may be of choice, when complex chocolate cysts are removed before IVF. Operations on the chocolate cysts also have become subject of controversy. We take the cyst wall out, if the dissection is easy. In some occasions, it is difficult to find the plane between cyst wall and healthy ovarian tissue, when cyst wall is removed as much as possible and superficial diathermy is applied on the remaining cyst wall. If the cyst is more than 10 cm in diameter, removal of the cyst wall may lead to destruction of large amount of healthy ovarian tissue, hence deroofing,7 followed by immediate initiation of COH for IVF and ET treatment is helpful.8 Uterine fibroids, if cause infertility or produce symptoms should be removed. We consider uterine fibroid in infertile women according to the following points: (1) Whether the tubes are patent; if not, whether fibroid is responsible, (2) length of the uterine cavity if it is more than 10 to 12 cm, implantation of embryo becomes difficult, (3) whether the fibroid is distorting the uterine cavity and (4) huge size of fibroid causing cosmetic problem or pressure symptom. So, also during pregnancy, that can cause respiratory embarrassment or further pressure symptoms. If difficulty in oocyte recovery for IVF program is anticipated due to fibroid, it is removed before hand. Moreover, large fibroid is better removed before ART procedure, as those can impair vascular supply to uterus and developing embryo. Laparoscopic or open myomectomy is to be decided according to situation. Large fibroids, as we feel, are better removed by open procedure, as repair of uterus can be performed more accurately than laparoscopic procedure. In case of moderate to large fibroid, even if it is removed laparoscopically, sometimes repair is performed by small laparotomy opening for better repair. Dubuisson et al9

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