What went wrong?

Alarmingly high doses of medication given to the woman inadvertently resulted in the above mishap. The same medication, when used in correct doses, yields good favourable results like egg release at the right time. In a normal fertile woman who is ovulating normally and regularly, the egg is released on the 14th day (in case of a regular cycle of 28 days). This is documented in a scan called follicular tracking. Hence, the couple is made aware of the probable fertile days to plan conception.

The group of women who have irregular or delayed cycles with non-documented egg release require the ovulation induction drugs. These drugs enable ovulation to happen which is again documented by the follicular scan and accordingly the couple is advised for conception. This prescription of drugs at Zoi is done in a very meticulously, in low doses tailored according to each woman’s need. We start with the lowest dose and slowly escalate according to the need while doing the follicular scan each month. When prescribed in the right way, there are no side effects.

The Zoi Approach:

On evaluating her, we knew that she was given very high doses of medication used normally to induce ovulation earlier in the menstrual cycle.
We ran her through various examinations and investigations, found that her ovaries were hyperstimulated with ovulation of multiple follicles i.e., multiple eggs released from the ovary at a time causing ovarian rupture and blood collection in the abdomen. We did a laparoscopic surgery and to our astonishment saw the blood collection of about 300cc to 500cc in the pelvis and ovaries grossly enlarged floating in the blood. We cleared the ovaries of the huge follicles and dealt with whatever was needed at that time and saved both her ovaries. She was relieved from severe pain such that she did not feel even a little pain after surgery. We discharged her with a smile and a sigh of relief the very next day.

We have achieved successful pregnancies and deliveries. This involves detailed counselling, investigation of the couple by the gynaecologists. We also have diagnostic/ therapeutic hysteroscopy and laparoscopy to perform fertility enhancing surgeries for women who require intervention.

We at Zoi, are assertive in making decisions as a team which give fruitful results to anxious couples waiting for a newborn.

Causes Of Infertility:

Infertility is defined as the inability to conceive a pregnancy after 12 months of unprotected sexual intercourse. According to a 2018 report, around 27.5 million couples in India suffer from infertility. Causes of infertility are many and varied and involve male, female or a combination of factors. This includes problems with the production of sperm or eggs, the structure or function of male or female reproductive systems; and/or hormonal and immune conditions.
In 40% of couples, the cause of infertility is attributed to a sperm factor, in another 40% the cause is found within the female reproductive system, and a third will have a combination of male and female factors.

Pre-Conception Counselling:

The Centers for Disease Control and Prevention defines preconception care as a set of interventions aimed at identifying and modifying biomedical, behavioural, and social risks to a woman’s health or pregnancy outcome through prevention and management. The goal is to ensure that the woman is as healthy as possible before conception to promote her health and the health of her future children. Preconception care is integral to primary care for women in their reproductive years.

Ovulation Tracking:

A simple process of ovulation cycle tracking can help you identify which days you’re most fertile. We do this by tracking your hormone cycle to predict when ovulation is going to take place. Ovulation is triggered by a surge of hormones from the pituitary gland (Luteinising Hormone). This usually takes place 24 hours before ovulation.
By carrying out simple blood and ultrasound tests to detect this hormone surge, we can advise you of the ideal days to have sexual intercourse that gives you the best chance of conception. It doesn’t require a consultation with a fertility specialist or any invasive fertility treatments or medicines and is more accurate than the home ovulation prediction kits.
Also, only the female partner needs to come into the clinic for tracking the cycle.

The Ovulation Induction Process:

Ovarian hyperstimulation is a serious complication of overenthusiastic infertility treatment

Assessment:
Your fertility specialist will assess your ovulation cycle with blood tests to measure hormone levels at specific stages of your cycle, and an ultrasound to see the development of follicles in the ovaries and thickness and appearance of the uterus lining.

Timed Intercourse Or Artificial Insemination:

Around the time of ovulation, your specialist will advise the most appropriate days to have sexual
intercourse to maximise your chance of pregnancy or perform intrauterine insemination where prepared sperm is inserted into the uterus.

A 32-year-old lady who has conceived after a prolonged infertility treatment came to Zoi Hospitals for safe confinement as soon as she missed her period. For all the 9 months of her pregnancy, she underwent regular antenatal check-ups with us. At the beginning of her pregnancy, she was 95 kgs and after the full term, she was 103 Kgs and developed Hypertension (Pre-Eclampsia). Since she crossed her due date, she was induced for labour which failed and hence, she was taken up for C-section.

The Challenge

While we were performing the C-section, we noticed that the lower segment from where the baby is delivered was occupied by a fibroid, roughly about 6cm X 6cm in size.

The Treatment

For delivery, we had to remove the fibroid. This procedure was discussed with the couple during the surgery as it was undiagnosed in the antenatal scans. We explained to them that missing fibroids in antenatal scan is common as the uterus expands and gets bigger in size during pregnancy.
We also made them aware that it is a risky procedure which involves additional blood but also a necessary procedure as this can be combined with the C-section and help the mother escape from a second surgery just to remove the fibroid.

After understanding the condition, a decision to do Myomectomy was taken in the interest of the patient so that she could escape from a second surgery. We successfully performed a Cesarean Myomectomy without a lot of blood loss. The mother delivered a healthy baby. Post surgery, there was a 1.5GM drop in the hemoglobin which suggests that there was a moderate amount of blood loss.

Myomectomy during cesarean was practically absent in the literature until the last decade. It is always advised to postpone and perform before the second delivery in order to prevent unnecessary blood loss and hysterectomy during a cesarean. However, in the modern era of Obstetrics, in the hands of an expert, myomectomy during a cesarean is actually an opportunity to combine both surgeries.

A 27-year-old woman came to Zoi Hospitals, Somajiguda, to meet the gynaecologist.
Her younger baby, who was just one year old, passed away in an unfortunate accident. Six months ago, she underwent a Tubectomy which is a permanent sterilization surgery in another hospital.

In 2017, the patient came to us because she wanted another child. We told her about Recanalization surgery which is a microsurgery to reverse the sterilization in the patient. We also explained to the patient about the risks involved as the surgery could have resulted in a Tubal Ectopic Pregnancy which is an emergency situation. After understanding the procedure and the risks involved, she bravely underwent the surgery.

The Challenge

We faced a challenge during recanalization. Both the tubes were badly damaged by the previous sterilization surgery. With utmost diligence, we recanalized both the tubes successfully.

Current Concern

Post surgery, we had instructed her to wait for 3 months to assess the success of the surgery. But within a month, she came back to us as she had missed her period. Hence, we were not able to conduct tests as planned to check the tubal function before the pregnancy.

The treatment

We gave her good antenatal care for those precious 9 months. Since she had a cesarean previously, this time too she underwent an elective C-section on 6th September 2018. She delivered a healthy baby boy weighing 2.6 KG.

Summary Of The Procedure

The outcome of tubal microsurgery depends on 3 factors:
A woman’s general and reproductive health
The effect of sterilization procedure on the tubes
The technique and surgical skills used to anastomose the tube.

Apart from these factors, we found out that the age of the patient, the type of anastomosis, the length of the remaining tube after sterilization, the time period between sterilization and reversal procedure, all played a crucial role in the success of the operation.