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Septate uteri are the most prevalent congenital uterine anomaly in infertile women. Women with septate uteri have reduced conception rates and increased risks of first-trimester miscarriage, preterm birth and malpresentation at delivery. The prevalence of arcuate uteri in infertile women is almost identical to that of the general/fertile population. Acquired uterine abnormalities described in the chapter include endometrial polyps, intrauterine adhesions, and uterine fibroids. Hysteroscopic myomectomy is now considered the gold standard treatment for submucosal fibroids. Abdominal myomectomy remains the routine approach for most surgeons faced with multiple or large intramural fibroids. For appropriately trained surgeons, a laparoscopic approach may be adopted. Hysteroscopic resection of submucosal fibroids before IVF treatment is recommended. Although subfertile women who have otherwise asymptomatic fibroids may benefit from a myomectomy procedure, this approach should be individualised given the absence of any good randomised controlled trials (RCT) in this area.
This chapter gives a brief description of the physical principles and the applications of the most commonly used lasers in subfertility surgery. The most common application of laser in subfertility surgery is endometriosis. The role of extensive surgery to treat deeply infiltrating endometriosis is debatable with the exception of endometriomas where excision seems to be superior to ablation regarding spontaneous pregnancy rate. The Nd:YAG laser has been used successfully to treat intrauterine adhesions with encouraging reproductive outcomes. The Nd:YAG laser has been widely used for hysteroscopic myomectomies as one- or two-stage procedure. Interstitial myolysis using a bare optic fiber of KTP, YAG, or diode laser has been reported as resolving symptoms and leaving a uterus capable of child bearing. The KTP or the Nd: YAG is the laser of choice for uterine septums, and the CO2 laser is used for vaginal septums.
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