{"paper_id":"c237d9dc-07f7-4717-a001-382018fb32f4","body_text":"Volume 4 • Issue 2 • 37\nJ Obst Gynecol Surg,\nISSN: 2583-5912\nThe Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances \nin Technology: A Comprehensive Narrative Review        \nKulvinder Kochar Kaur1*         , Gautam Nand Allahbadia2, Mandeep Singh3\n1Scientific Director, Dr Kulvinder Kaur Centre for Human Reproduction, Jalandhar, Punjab, India.\n2Scientific Director, Ex-Rotunda-A Centre for Human Reproduction, Bandra, Mumbai, India. \n3Consultant Neurologist, Swami Satyanand Hospital, Jalandhar, Punjab, India.\nReview Article \nCorrespondence to: Kulvinder Kochar Kaur, Scientific Director, Dr Kulvinder Kaur Centre for Human Reproduction, Jalandhar, Punjab, India.\nReceived date: September 26, 2023; Accepted date: October 23, 2023; Published date: October 31, 2023\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nCopyright: ©2023 Kaur KK, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted \nuse, distribution and reproduction in any medium, provided the original author and source are credited.\nPage 25 of 36\n       ABSTRACT\n Earlier we have reviewed the role of surgery in need for fibroids removal prior to In Vitro Fertilization (IVF) in \nimproving success rates, management of inoperable recurrent endometrioma presenting as severe incapacitating \npain following leuprolide acetate depot by aspiration, recurring again at 2 years subsequently for sclerosing \ntherapy presented as a case report updated advances in classification along with reproductive surgeries in \nmullerian anomalies. Updated management of oncofertility-does the use of vsels appear practical in the near \nfuture in human malignancies replacing cortical tissue and testicular tissue, autologous Platelet Rich Plasma (PRP) \nprobability of it becoming a revolutionary therapy in the field of gynaecology and reproductive endocrinology \nand infertility, role of surgery in endometriomas and endometriosis, adenomyomas, tubal surgery. Here we have \ntried to outline how prior to the invention of IVF, reproductive surgeries which were believed to be fertility sparing \nwere properly acknowledged, role of reproductive surgeons became obsolete. With the plateauing of IVF result \ninterest has got rekindled with considerable advantages of reproductive surgeries is this field. Additionally, newer \ninstrumentation as well as surgical procedure has evoked and made it attractivefor reproductive surgeons for \nimprovementof their expertise with regards to conservation of future fertility as well as train future Reproductive \nEndocrinology and Infertility specialist (REI) in view of solidifying this field of yielding pregnancies to maximum of \ninfertile cases even in patients having cancer surgeries or earlier cryopreservation of oocytes in say patients with \nturners syndrome etc.\nrepetitiveness reproductive surgery is promoting fertility \npreservation at the time of considerable impact or damages \nto the ovarian reserve leading to Diminished Ovarian Reserve \n(DOR) as well as is influencing the probability of capacity of and \naiding in continuation of pregnancy in addition to escalating \nthe probability of a pregnancy in the cases of Mayer-Rokitansky \nKuster Hauser syndrome with congenital lack of uterus. In view \nof the drastic escalation of outcomes obtained following ART \nhave started reaching a plateau over the last 10 years, the part \nof reproductive surgeon is undermined in the form of being \nkey for maximization of outcomes for the patients having a \ntrial for conception, along with preserve this probability for \nfuture. Here we have attempted to review the historical aspect \nof reproductive surgery in addition to emphasizing the part of \nsurgical strategy for the treatment of patients with infertility.\nSurgery for Uterine Fibroids \n The detailed description of historical aspect is available \nin refernce 2. Only brief talk about subsequent to vaginal \nhysterectomy in year 120 and the abdominal hysterectomyin \n1843 [3] came followed by myomectomy with the idea of \npreservation of fertility in 1845 [4]. Nevertheless, in preantibiotics \nera in addition to lack of blood transfusion escalation of \nmortality along with morbidity it took numerous decades \ntill in 1922 Bonney made the invention of the uterine artery \nclamp which aided in the reduction ofmorbidity (Figure 1) [2]. \nKeywords:  \n Reproductive surgeries, Fertility, Hysteroscopy, Laparoscopic \novarian drilling, Robotic surgery. \nIntroduction\nThe Origination of Reproductive Surgery\n Prior to the invention of In Vitro Fertilization (IVF), reproductive \nsurgeries which were believed to be fertility sparing were \nproperly acknowledged. To start with fertility sparing surgeries \nlike myomectomy was initiated. Subsequent to that surgery \nin the form of primary treatment for infertility (for instance \ntubal surgery) along with ultimately moved towards surgery \nfor escalating fertility (for instance septoplasty). Once Assisted \nReproductive Technology (ART) was introduced greater \nexpansion of our capacity of tackling diseases of structural \netiology was substantially escalated. This was followed by \nfurther evolution regarding treatment of non structural \netiologies of infertility which has considerably resulted in the \nimprovement of effectiveness of human reproduction.With the \nenhancement of efficacy in addition to ease of accessibility to \nART, the part of reproductive surgeon was appearing to become \nredundant, with certain infertility specialists pointing that we \nshould pay obituary to this topic [1]. Luckily advancements \ngot attained apart from in case of instrumentation, as well as \nstrategy in addition to in the scope. In case of its maximum\nJournal of\nObstetrics and Gynecological Surgery \nKaur KK, et al. J Obst Gynecol Surg 2023, 4:2\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\nPage 26 of 36\nadvantageous surgery in case of a germane young woman \nstopping need for loss of lady’s womb in a young woman getting \nutilized. \n Gradually with the enhancement of survival in 1970’s came \nthe era of microsurgical techniques by Victor Gomel as well \nas Celso Ramon Garcia correlated with utilization of smaller \nbore sutures, carefull tissue tackling in addition to heparinized \nsaline-all of which aided in remarkable escalation of clinical \noutcomes. These all enhanced the acceptability of these fertility \nsparing surgeries in the form of safe along with efficacious \nstrategies in correct choice of patients. Moving from abdominal \nmyomectomy towards minimally invasive myomectomy then \nbecame the acceptable surgical approach in broad group of \nwomen from reproductive age. \n The initial laparoscopic myomectomy was revealed by the \nGerman Kurt Semm in 1979 [6]. Subsequently came the \nintroduction of the experience robotic assisted laparoscopic \nmyomectomy in Michigan United States [7]. This minimally \ninvasive strategy is correlated with substantially diminished \nhospitalization, lesser incidence of postoperative readmission, \nlesser surgical morbidity in contrast to abdominal myomectomy \n[8]. Although there are advantages still no clarification exists \nover the impact of fibroids on the reproductive capacity as well \nas if their removal does result in improvement of reproductive \nresults.\n Generally it has been acknowledged that the fibroids which \nare distorting cavity (FIGO 0,1,2 as well as 3) possess a negative \ninfluence over the reproductive results (Figure 2) [9].\n Following this invention Bonney performed greater than 700 \nmyomectomies with remarkable reduction of mortality(7;1.1%) \n[5]. Despite,the fame of Bonney was with regards to his \npioneering work of fertility sparing radical surgery in case of \ncervical cancer he further gave recommendations apart from \nearly myomectomy but further for Ovarian cystectomy for \nfertility preservation.. Bonney advocated utilization of this \nFigure 1: Courtesy ref no. 2: Bonney clamp for uterine artery clamping.\nFigure 2: Courtesy ref no-2: FIGO Fibroid Staging System (From Munro, et al. [96] IJGO 2018. (Used with permission of the author)\n\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\nPage 27 of 36\nescalate uterine contractility as well as cause modification \nof local hormonal along with paracrine environment of the \nendometrium [16] (Figure 3).\n Of the outcomes obtained whichcorroborate their resection is \nthe enhancement of quantities of Transforming Growth Factor-β \n(TGF-β) liberated by large intramural fibroids which possesses \nthe capacity of changing bone morphogenetic protein-2 (BMP-\n2), along with HOXA 10 (member of the homeobox gene \nfamily) expression [17]. HOXA 10 portrays a key messenger in \ncontrolling endometrial receptivity continues to be persistently \nlesser once there is existent a submucosal fibroid pointing \ntowards large intramural fibroids despite not distorting cavity, \nmight bepossessing inimical actions. Requirement of greater \nstudies is there for attaining insight over the advantages of \ninvasive myomectomy of non cavity distorting uterine fibroids.\nIn the latter part we describe the more innovative in the form of \nnon abating alternative to invasive myomectomy. \nSurgery for Endometriosis Along With Adenomyosis\n The isolation of endometrial glands with ectopic placement \ngot initially observed in 1860 as well as got revealed by the \npathologist Carl von Rokitansky in 1860 [18]. Subsequently in \n1920 inimitable naming in addition to descriptions were made \nby Sampson along with Frankl respectively. In the same time \nperiod Cullen, et al. conducted surgeries for pain treatment for \nsituations believed to be endometriosis along with adenomyosis \ncurrently; nevertheless, with considerable risks of mortality. \nDespite, a diagnostic laparotomy comprised the single approach \nto diagnose endometriosis in that era standardized therapy \nconstituted of Total Abdominal Hysterectomy (TAH) with bilateral \noophorectomy. Cullen failed to have realization dawned with \nregards to restricted resection are efficacious in case of milder \ndisease. Furthermore, the 2 advances in these 100 years have \nbeen the advent of Combined Oral Contraceptives (COC) pill in \n On achieving pregnancy on the existence of fibroids which are \ndistorting cavity possess a correlation with escalation of aberrant \nplacement of placenta, Early Pregnancy Loss (EPL) abruptio \nplacentae, malpresentations or Intrauterine Growth Restriction \n(IUGR) as well [10]. Retrospective studies pointed that removal \nof the fibroids encroaching the cavity by hysteroscopic strategy \nprimarily might abrogate these risks [11]. \n The hysteroscopic myomectomy got generated subsequent \nto adapting urological instruments meant for resection with \nregards to treatment of prostate hyperplasia accessibility \nhas been there since 1980. Neuwirth RS, along with Amin HK \nconducted first hysteroscopic myomectomy [12]. Subsequent \nto tackling initial problems advancements with regards to \nfluid management systems,shifting from monopolar to bipolar \nelectrosurgery in addition to utilization of media which is \nisotonic possessing media meant for distension ensured events \nthat had safety along with were efficacious [8]. Greater advances \nin instruments for instance hysteroscopic tissue morcellators, \nhave aided the surgeons in being comfortable regarding taking \nplace at the time of resection of large sized FIGO 0, as well \nas 1 kind uterine fibroids. In contrast to instruments meant \nfor resection, morcellators aided in persistence of fragment \nremoval for maximization for observing without utilization of \nelectrosurgery that has the capacity of complications resulting \nin hands having lesser experience.\n With regards to FIGO 3 or greater, minimally invasive strategy \nis usually believed to be the maximum accessible surgical \nroute. Despite introduction of laparoscopic strategy, by Kurt \nSemm from Germany, Cameron Nezhat’sadding of video with \nlaparoscopy was the major reason of broad utilization of this \napproach in view of the other observers in the room having \nactive part in the surgery. Additionally, utilization of diuted \nvasopressin, barbed surgical sutures in addition to power \nmorcellation with regards to extracting tissues correlated with \nconsiderable reduced Operation Room (OR) time along with \nsubstantially diminished depletion of blood in contrast to earlier \nreiteration of this method [13]. \n As per its part in conservation of fertility apart from fertility \nescalating management, numerous uncontrolled studies have \nindicated with regards to laparoscopic myomectomy for fibroids \nwhich are distorting cavity has been correlated with lesser \npregnancy loss in contrast to no surgery . Moreover , different \nlarge systematic reviews have revealed pooled pregnancy \nrates of 49-57% subsequent to laparoscopic myomectomy \n[14]. Nevertheless, no Randomized Controlled Trial (RCT), have \nbeen conducted for assessment of part of minimally invasive \nmyomectomy regarding escalation of fertility. The heterogeneity \nof the uterine fibroids in addition to patients features present \nbotheration for acquisition of the influence of fibroids on \nfertility. As long as RCT are fashioned in addition to conducted \nwe can just presume with the causal interpretation regarding \nthe resection of fibroids which are distorting cavity is a probably \npromising for women attempting to attain a pregnancy [15].\n A matter which remains controversial is the partof myomectomy \nin case of FIGO 3 to 4 fibroids determined to be over 3-4 cm \nin size for escalating fertility. Despite, when fibroids are not \ndistorting cavity, intramural fibroids might result in dysfunctional \nendometrial in addition to myometrial blood supply, \nFigure 3: Courtesy ref no-2: Mechanisms that link uterine fibroids and \ninfertility. (From Dolmans, et al. [15]. Reprinted by permission of the publisher.)\n\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\nhysterotomy scar [27].\nSurgery for Adnexa \n Polycystic Ovary Syndrome (PCOS)-ovaries: Another fertility \nsparing surgery not involving the uterus is conducted on the \novaries. Of the maximum previous ovarian techniques were \ninclusive of ovarian wedge resection in addition to drilling of \novaries. The goal of both of these surgeries was disturbance of \nthe intraovarian androgen generation along with restoration \nof folliculogenesis in a substantially lesser androgenic milieu \n[29]. Stein as well as Leventhal originally detailed Ovarian \nwedge resection in their pioneering work over 7 patients whose \npresentation was having amenorrhoea as well as Polycystic \novaries [30]. On realization with regards to this strategy leading \nto remarkably escalated incidence of post surgical adhesion \ngeneration (in greater than 90% of patients) that could not be \naccepted, thereby ovarian drilling replaced it. The initial ovarian \ndrilling got conducted in 1984 [31]. \n Ovarian drilling comprises of creation of numerous holes \nover the ovarian cortex with the utilization of electrosurgical \ninstruments has been acknowledged tobe the second line \nstrategyfor patients with resistance to agents meant for induction \nof ovulation [32]. To start with it was advocated to make 10-20 \nholes/ovary, in view of the illustration of the following ovarian \nfailure, their was modification to creation of holes not more \nthan 4/ovary with the utilization of particular electrosurgical \nfashion of energy delivered [33]. Patients having earlier failure \nof induction of ovulation, ovarian drilling portrays an efficacious \nmanner with regards to restoration of ovulation function in \naddition to normalization of androgen quantities along with \ncorrelated symptoms with PCOS. Furthermore, pregnancy \nrates were apparently akin to those observed subsequent to \ngonadotropins treatment; however with considerably lesser \nrisk of multiple pregnancy as well as Ovarian Hyperstimulation \nSyndrome (OHSS) [34].\n Endometriomas-ovaries: William Wood Russell was the person \nwho firstly detailed the existence of endometrial tissue amongst \novaries-alias ovarian endometriomas [35]. Subsequently \nconsiderable knowledge has been attained in the context of the \nmanner by which endometriomas influence ovarian reserve.\n The chronic inflammatory injury which results secondary to \nendometriomas leads to propagation of tissue fibrosis that might \naddition to laparoscopic surgery [19]. Now surgeons possess \nthe capacityof treating pelvic pain or in case of tubal factor \ninfertility with utilization of a minimally invasive strategy.\n With regards to pelvic pain in view of endometriosis, despite the \nstrategy in addition to techniques conducted have undergone \nadvancements, surgery persists to be a significant part in \nthe treatment of endometriosis. Regarding superficial areas \ndestroying these damaged areas involved ablating such lesions \nin contrast to excisingwas illustrated to possess akin efficacy \nfor treating pelvic pain in a Randomized Controlled Trial (RCT), \nnevertheless, in case of deep infiltrating endometriosis full \nexcision is needed with it getting acknowledged with regards to \ndepth of the lesions in addition to their usual intricate association \nwith adjacent organs [20,21]. In the context of infertility fraction \nin view of endometriosis, the advantages of surgical diagnosis \nas well as destroying the disease is not clear. Marcoux, et al. \n[22], randomly enrolled patients with mild endometriosis into 2 \ngroups 1 group for diagnostic laparoscopy/surgical ablation along \nwith observations were that removal of disease by any means \nescalated pregnancy rates with regards to pregnancy which was \nunassisted. Nevertheless, on combination of outcomes obtained \nin an akin fashioned randomized study that was revealed 2 years \nlater the patients number in an acknowledged endometriosis \npointed that requirementfor surgical ablation for achieving Live \nBirth Rates (LBR) unassisted was 12. Nevertheless, for patients \nwho were having asymptomptomatic unexplained infertility \nwith the presumption of 30% incidence of endometriosis \nobserved at diagnostic laparoscopy were required to have \nlaparoscopy for a single extra unassisted LBR, a quantity that \nhas led to advocate no laparoscopy in such patients with In \nVitro Fertilization (IVF) being given preference in the form of \nalternative for maximization of fertility [23-25].\nSurgery which is fertility sparing with regards to dysmenorrhoea \nin addition tomenorrhagoea in view of adenomyosis started \ngetting escalatingly used subsequent to displaying successful \nwedge resections got revealedin 50’s to 1960’s [26]. Surgery \nwhich is fertility sparing gets lesser used in contrast to in other \npathologies, partially in view of the restrictions imposed for \nprecise diagnostic methodologies despite recent advancements \nin imaging modalities might aid in greater isolation of correct \nsurgical subjects. Additionally, the absence of precise planes \ncorrelated with focal as well as diffuse kinds of this problem \ncauses a greater complex resection in contrast to that with \nmyomectomy. Although, there are such hurdles surgical \ninnovations by Japanese surgeons generated numerous \ninnovative strategies over last certain decades for maximization \nof the quantities of adenomyosis resected with concurrent \nfertility conservation. 2 noticeable approaches which have been \nposited having the aim of total adenomyosis getting excised are \ninclusive of asymmetrical dissection methodology in addition to \ntriple flap one (Figure 4) [27].\n Long term following of 2123 uterine adenomyomectomies which \ngot reported from 13 Japanese centres was 449 pregnancies \nleading to361 live birth delivery rates [30]. Nevertheless, the \nlarger incision essential with thesesurgical strategies escalates \nthe risks of uterine rupture in a subsequent pregnancy to \n3-6% in contrast to baseline of 0.005% in case of a nonscarred \nuterus along with <1% of subsequent to a prior myomectomy/\nPage 28 of 36\nFigure 4: Courtesy ref no-2: Representation of the steps of the Osada \nprocedure for resection of diffuse adenomysosis. (From Osada uterine \nadenomyosis and adenomyoma: the surgical approach) (Reprinted by \npermission of the publisher.)\n\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\nmisfortune no success was attained however 8 years later \nit turned out to be the fortune of numerous infertile women \n(Figure 5) [48].\n Additionally combination with surgical strategies for reduction \nof acute inflammatory response along with avoidance of \npostoperative adhesions adhesions initiated by Gomel V as \nwell as Garcia C, there was drastic escalation of successful \nanastomosis. In case of modern date minimally invasive \nstrategies in women amongst 18-30 years, 30-33 years in \naddition to 34-49 years might anticipate pregnancy rates of \n73%, 64% as well as 46% respectively [49]. Besides, the kind \nof the sterilization done (84% with utilization of clips vis a vis \nwith 41% using bipolar electrosurgery) in addition to the extent \nof the residual tube (≥ 4 cm vs ≤ 4 cm) portion both factors of \nsignificance with regards to prognosis of reproductive success \n[50]. \n Just till 1990’s tubal operations were believed tobe treatment \nstrategies for getting over tubal disease at the timewhen \nescalation of IVF success rates with regards to LBR moved \nfrom 14% to 31.6% [51]. In case of this time period of Assisted \nReproductive Technology (ART), it is significant to take into \naccount various factors for instance ovarian reserve,coexistent \ndiagnosis for infertility, number of children wanted, apart from \npatients preference, religious thought processes along with \naccessibility of  ART.\n In contrast to IVF cumulative Live Birth Rates (LBR) over time \nperiod of 5 years were commensurate to ones having undergone \ntubal reanastamosis (52% vis a vis 60%) other than women \n<37 years who had >cumulative LBR with tubal reanastamosis \n(72.2% vis a vis 52.4%) [50]. The ART results in 2001 given by \nAmerican Society of Reproductive Medicine (ASRM) in 2001 \nregistry [51].\nMullerian Abnormalities \n Other than the tackling of the uterine leiomyomas, \nendometriosis, as well as adnexal disorders reproductive \nsurgeons have to tackle complicated mullerian abnormalities. An \ncause displacement in addition to reduction of ovarian follicles \nfollowed by reduction in oocyte quality in addition to ovarian \nreserve [36]. Moreover, endometriomas might further result \nin diminished ovarian reserve by evoking premature follicular \ngeneration along with atrophy, thus causing augmentation of \novarian insufficiency. Kitajima, et al. [37], recently illustrated \nthat endometriomas might result in premature activation of \nGranulosa Cells (GCs) resulting in escalated follicular atresia \nwith resultant diminished qualityof remnant Primordial Follicles \n(PF).\n Numerous methodologies have been detailed with regards \nto annhilation of ovarian endometriomas. Differentially from \nother cysts endometriomas being invasive possess a significant \ncorrelation with tissue fibrosis beneath its presence. Thereby \nlaparoscopic drainage along with ablation portray early surgical \nstrategy however were correlated with substantially greater \nrate of recurrence. Cystectomy, which implicates stripping of the \ncyst wall,partially or in its entirety portrayed a natural evolution; \nhowever in which significant expertise was the need of the hour. \nOn contrasting with ablation, cystectomy was correlated with \nsignificant inimical influence over antral follicles count as well as \nAntimullerian Hormone (AMH) quantities [38]. What comprises \nof remarkable significance is the decision making with regards \nto initial surgical attempt is total excision of the ovarian \nendometrioma in view of repeated surgeries for recurrent cyst \ngets correlated with significant depletion of ovarian reserve \nin contrast to a single lone surgery [39]. Innovations by the \nlaparoscopic surgeon with the utilization of hydrodissection \nin addition to laser vaporization have been illustrated tobe \nsafe with ovarian conservation strategies [40,41]. Earlier \nsclerotherapy utilizing ethanol or lidocainehas been considered \nan option in infertile cases who present with pain as an option \n[9] portrays another minimally invasive surgical attempt \nwhich might be attempted transvaginally by a Reproductive \nEndocrinology and Infertility specialist (REI) represents who \nare already accustomed to performing transvaginal needle \nprocedures. Nevertheless, its part is restricted apparently to \npatients that represent poor surgical candidates whose cysts \nprevent safe oocyte recovery [42,43].\n Tubal operations: In 1896 the first fallopian tubes reconstruction \ngot attempted [44]. Nevertheless, not till introduction of \nmicrosurgical strategies in 60’s and 1970’s this procedure came in \nmodern use. Previous attempts for salpingostomy used Mulligan \nhood-a silastic device which was sutured to the opening of \ntubes for sustenance of patency, however the requirement was \na second look laparotomy 3 months subsequently to its removal \n[45]. In view of the production of considerable adhesions \nfrom the originating laparotomy as well as need for invasive \nmethodologies, temporary tubal patency methodologies \nwere not accepted. In 1967 Sweden’s Swolin K subsequent \ntohis observations of intraperitoneal delivered hydrocortisone \ndiminished postoperative adhesions, with him conducting 33 \nsalpingostomies through laparotomy for restoration of fertility \n[46]. 10 intrauterine pregnancies (30.3%) were revealed \nby him in addition to12.1% rate of ectopic pregnancies. 3 \nyears subsequently Leslie Brown who bore the First IVF child \nLouis Brown further underwent bilateral salpingostomies for \nattenuatation of tubal blockade [47]. Nevertheless, to her \nPage 29 of 36\nFigure5: Courtesy ref no-2: Tubal reanastomosis demonstrating the use of \nstay sutures forreapproximation (blue arrow) followed by serial interrupted \n10-0 sutures to complete anastomosis. (From Gomel, et al. [48].Reprinted \nby permission of the publisher.)\n\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\nolive with its placement in the perineum using an abdominally \ntensioning gadget with application of cranioventral tension \nat the time period of 4-7 days. Besides stretching techniques \nneovagina generation is feasible by utilization of replacement \ntissues [64]. The McIndoe in addition to Davydov techniques \nare dependent on either a split thickness skin graft or use \nof peritoneum respectively. Innovative strategies implicate \nuse of novel tissues like buccal mucosa, tilapia skin fish or \nuse of placental membranes that aid in augmentation of the \ntissues present in the manner which further escalates tissue \ncharacteristics as well as their functional working.\nEctopic Pregnancies\n Apart from escalating surgeries reproductive surgeons possess \nthe part in surgical treatment of ectopic pregnancies, particularly \ncervical in addition to caesarean scar implantation pregnancies. \nupdated classification of mullerian abnormalities was given by \nthe American Society of Reproductive Medicine in 2021 (ASRM) \n[52]. This newer gadget with correlated interactive website \ngives a useful clinical gadget in aiding in differential diagnosis \nwith regards to these abnormalities. In future this gadget would \nbe aiding in surgical videos for aiding in better detailing of the \nsurgical of these complicated mullerian abnormalities.\n Presumably one of the most common abnormalities which we \nin the form of the REI specialist have to tackle is the uterine \nseptum. Presentation of women having uterine septum is an \nescalation of risk of infertility, recurrent miscarriage as well \nas preterm birth [52]. Retrospective outcomes obtained have \npointed that an incision might escalate pregnancy rates [53]. \nA recent multicentre Randomized Controlled Trial (RCT), The \nRandomized Uterine Septum Transaction Trial (TRUST) was \nnot able to illustrate any escalation of successful reproductive \noutcomes in case of women who underwent septum excision \n[54]. Substantial restricting factors of their study was wide \ninclusion criteria , definition of uterine septum was considerably \nliberal, with significant time consumption in enrolment for \ninstance 8 years for 80 patients getting enrolled were believed to \nbe the significant restricting factors in view of generalization of \ntheir outcomes. Till trials that have been fashioned vigorously we \nhave persistence of uncertainty with regards to the advantages \nin our thought perception of septum incision. Managing greater \ncomplicated abnormalities by surgical means are canonically \nconducted for abrogation of pain in addition to conservation \nalong with restoration of fertility in case of obstructive \nabnormalities. Having the acknowledgement regarding broad \nkinds of pathologies are present with mullerian abnormalities, \nthis newer classification would aid in diagnostic assessment \nalong with surgical management of these complicated mullerian \nabnormalities (Figure 6) [55].\n Furthermore vaginal abnormalities might be present alone \nor correlated with uterine aberrations for instance Mayer \nRokitansky–Kuster–Hauser Syndrome is the diagnosis for an \nindividual presentingwith lack of mullerian development in a \npatient presenting with primary amenorrhea and no apparent \nvagina [56].\nRegarding the patients with vaginal agenesis,neo vaginal \ngeneration by stretching thevagina, its replacement or \napproaches regarding its augmentation. Generation of a \nneovagina through its stretching with the utilization of \ndilators was first detailed by Frank Rin (1938) a reproductive \nendocrinologist in NewYork [57]. To start with one begins inthe \nposterior direction and then after 2 weeks changingdirection \nupwards towards the usual line of vaginal axis, pressure is \napplied with dilators available commercially for 20’/day to the \npoint of modest discomfort. Gradually utilizing larger dilator \na functional vagina can be createdin several months [58-62]. \nPlastic syringe covers can beused instead of the expensive \ncommercial glass dilators. A very easier and effective technique \nis to hold the dilatorin place with a tight garment, maintaining \npressure by sittingon a running bicycle seat (mounted on a \nspecial stoolor even a bicycle) [63]. In case of women having \nunsuccessful dilation surgical vaginal stretching by utilization \nof Vecchietti technique is remarkably successful obtaining a \nvaginal length of 8-9 cm in routine. Its basis is utilization of an\nPage 30 of 36\nFigure 6: Courtesy ref no-2: Wide range of surgical findings at the time \nof laparoscopic management of noncommunicating rudimentary horns. \n(From Fedele, et al. [55]. Reprinted by permission of the publisher.) UU ¼ \nUnicornuate uterus; RH ¼ rudimentary horn.\n\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\n Despite, the first uterine transplantation was conducted in \nSaudiArabia in the year 2000 (a patient who had a hysterectomy \nin view of Post Partum Haemorrhage (PPH), practically 14 years \nsubsequently the first live birth was obtained in Sweden by \nBranstrom M, et al. [72]. Subsequently it has been attempted \nto decline surgical morbidity to living donors by obtaining \norgans from either demised or brain dead both of which have \nyielded live births [73]. It has been determined that greater \nthan 60 uterine transplantations have been conducted leading \nto greater than 20 live births as detected by May 2020 [74]. \nUterine transplantations in US (n=33) one year survival of the \ngraft had been 74% (23/31 recipient) of which 58% (19/33 \nrecipient) had borne 21 live births [75]. The average GA at birth \nof neonates was 36 weeks 6 days (30 ± 1-38 weaks) as well as \naverage birth weights 2860 (1310-3940), median (range) (58th-\n6th-98th) percentile. Once the morbidity the recipient as well \nas obstetrical/neonatal results escalate it has been pointed that \nenhanced interest would be evoked in utilization of uterine \ntransplantations in aiding in chance for pregnancy in case of \nAUFI as well as those who had a hysterectomy, patients having \npresentation in the form of androgen insensitivity syndrome, \nrobust Ashermanns Syndrome in addition to transgender \nfemale patients.\n Oncofertility: For the female cancer patients having requirement \nfor gonadotoxic chemotherapy or pelvic radiotherapy, various \nsurgical strategies are present for conservation of future fertility \nfurther than oocyte along with embryo cryopreservation. \nDespite, certain are beyond the REI’s, usual practice, procedures \nlike radical trachelectomy however others for instance \ncryopreservation of ovarian tissue, ovarian transpositions \nin addition to uterine fixations,can be well tackled by the \nreproductive surgeons. \n McCall from the Louisiana States University documented the \nfirst patient ovarian transpositions for a patients with Cervical \nCancer in 1958 [76]. It has been well acknowledged that the \noocyte possesses substantial sensitivity to ionizing radiation \nwith just 4-6 Gy sufficient for the depletion of a minimum of \n50% of all ovarian follicles [77]. The degree of injury to ovarian \nreserve is basically based upon the full radiation dosage \ndelivered to the ovary, baseline ovarian reserve as well as age of \nthe patient. in case of ovarian transpositions movement of 1 or \nboth ovaries out of the pelvis has been implicated canonically as \nlateral along with as cephalic the extent the full anatomy aids in \na void of total bulk of the anticipated radiation field of the pelvic \nradiotherapy (Figure 7) [78].\n Subsequent to 1958 patients with colorectal cancer as well as \npelvic lymphomas who are posted for pelvic radiotherapy. In a \nrecent meta-analysis where 892 patients underwent ovarian \ntranspositions with subsequent brachytherapy, 94% illustrated \nconservation of ovarian function following radiotherapy, how \ndiminished to 65% in the ones who had external beam radiation \ntherapy, with/without brachy therapy [79]. Subsequent to \ngonadotoxic therapy ovaries are canonically left back in the \ntransposed localization with regards to ovarian stimulation in \nview of migration back towards the radiated region is correlated \nwith escalated rates of ovarian insufficiency [80]. Although, \nit yields substantial success in conservation gone through of \nfuture fertility less than 10% of women below the age of 35 \nAbout 2% of the total pregnancies in the United States are \nectopic,out of which 10% have implantation in non tubal areas \n[65]. Advancements in Imaging technologies REI’s have produced \ninnovative minimally invasive methodologies for tackling the \npatients who are stable basically by Ultra sonography-driven \nlocal injection. REI’s have sufficient expertisefor performing \nthese techniques in view of routine utilization of Trans Vaginal \nUltra Sonography (TVS) for oocyte retrieval. Injection of \nmethotrexate or potassium chloride have been substantially \ndetailed earlier [66]. Incidence of caesarean scar pregnancy \napparently has been escalating in view of escalation of number \nof caesarean deliveries throughout the world with a study \nquoting an incidence as high as 1 in 531 women possessing \na caesarean scar would generate a caesarean scar pregnancy \n[67]. First line treatment usuallycomprises of direct injection \nof methotrexate or potassium chloride as well as aspirating \nwith a needle with/ without systemic methotrexate delivery. \nOperative removal by a laparoscopic strategy or USG driven \nor vacuum aspiration are believed to be the first line surgical \nstrategies where a gestation sac is present in which case either \nmethotrexate or potassium chloride availability is not there or \nare contraindicated [68]. Furthermore, REI’s possess remarkable \nskills with regards to diagnosis in addition to management of \nearly pregnancies in view of earlier determination of pregnancy \nthrough TVS amongst 5-7 wks is correlated with remarkably \nlesser risk of maternal morbidity to contrast to diagnosis in \naddition to treatment initiation at over 9 weaks GA (5.9 vs \n32.4%, odds ratio 0.14; 95% CI:0.1-0.4) [69].\n On successful resolution of caesarean scar pregnancy is attained \nneed for caesarean scar defect repair is there in case the patient \nwants a further pregnancy. Handling of these kind of patients is \npreferably done by the REI’s in view of their surgical experience \nwith the acknowledged fact of escalated bleeding along with \nneed for hysterectomy occasionally as well. \n Besides, the risk of implantation in the following pregnancy \ncaesarean scars niches have been known to be correlated \nwith a considerably diminished successful IVF along with \nIntracytoplasmic sperm injection (ICSI) cycle (15.9% vis a vis \n23.3% OR:0.6; 95% CI :0.5-0.9) [70]. It has been posited to take \nplace in view of alterations in endometrial receptivity, tough \nembryo transfer, dysfunctional myometrialcontractility as well \nas embryotoxic blood components getting trapped within this \nniche. There is no clarification regarding the revision has any \ncorrelation with escalation of reproductive outcomes, reduction \nin recurrence rates or alterations in placenta accreta spectrum \ncondition.\nReproductive Surgery Future \n Transplanting uterus: Absolute Uterine Factor Infertility (AUFI) \nimpact less than 5% of women are in the reproductive age [71]. \nOf those having presentation in the form of AUFI earlier other \nthan IVF with the utilization of a gestational carrier used to \nbe the exclusive manner of attaining a biologically correlated \nchild. Nevertheless, utilization of a gestational carrier is not \nlegal throughout the world, expensive where legally allowed \nin addition to not aiding the woman to get the satisfaction of \nbearing a pregnancy in her own body. Transplanting uterus \nwas illustrated to be a plausible manner for getting over this \nproblem,giving a newer archetype for patients with AUFI.\nPage 31 of 36\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\nwith utilization of resorbable interrupted sutures with out need \nof the colpotomy in addition to mobilization of pelvic vessels \nmight be possible from technical angle [84].\n Probably the maximum attractive surgical gadget for \nconservation of fertility would be cryopreservation of in \naddition to transplantation. The first frozen thawed ovarian \ntissue transplantation was conducted in 1999 [85]. As detected \nby 2019 it has been determined that greater than 130 live births \nhave been attained [86]. From technical angle this procedure \nimplicates laparoscopic excision of the ovarian cortex strips \nwhich undergo processing followed by cryopreservation. The \ntissue which has been thawed its implantation can bedone \northotopically into the remnant of ovary or other regions \nin the pelvis for instance ovarian fossa or broad ligaments/\nheterotopically. Canonically heterotopic transplantation \nis conducted in the retroperitoneum with in the pelvis or \nabdominal wall with the clearcut benefit of easy accessibility for \nultimate ovarian stimulation or when, robust pelvic adhesions \nor disease is present which results in avoidance of heteropic \ntransplantation. Just 1 live birth has been documented \nsubsequent to heterotopic transplantation in a patient in which \nbilateral oophorectomy had been conducted [87]. One of the \nproblems with heterotopic transplantation is viability of graft  \nwith regards to tissue tension, temperature along with blood \nsupply of the rest.\n Finally, the future endeavour for ovarian tissue transplantation \nwould be the capacity of safe conservation along with \ntransplantation of whole ovaries-specifically in case of \nprepubertal women who usually do not possess enough tissue \nmass for conservation of ovarian cortex strips. Two significant \nproblems that are having requirement for overcoming for its \nviability:\n• we need improvement of our capacity of processing as well \nas cryopreservation of solid organs in the manner which \nensures least tissue injury.\n• requirement for generating greater successful manner for \nensuring revascularization of the tissues at the time of \ntransplantation.The utilization of extracellular tissue matrix \nscaffolds are getting actively evaluated with regards to \nensuring least reperfusion injury in addition to maximizing \ntissue viability as well as growth during transplantation \ntime .\nInnovative Upcoming Procedures Along With Gadgets \n Vaginal natural Orifice Transluminal Endoscopy (vNOTES): \nThe invention of Bonney’s clamp with regards to uterine artery \nligation aided the reproductive surgeons in their capacity of \nsurgical performance in the presence of a considerably vascular \nuterus aided in the generation of numerous innovative surgical \nstrategies. In these modern days innovative minimally invasive \nsurgical approaches have made it further indiminishing the \nalready least scar strategy to a single scar or further no abdominal \nscar. Laparoscopy with a single port in addition to Vaginal Natural \nOrifice Transluminal Endoscopy (vNOTES) represent innovative \nprocedures whose indications are enhancing. Furthermore \nvNOTES possesses remarkable probability in surgical tackling \nof ovarian torsion, Ectopic pregnancies in the tube along with \novarian cystectomy as well.\nhaving gone through pelvic radiotherapy for cervical, anal or \nuterine cancer had gone through ovarian transpositions [81].\n Apart from ovaries the other organs in the pelvis that are \nradiation sensitive are inclusive of injury to the uterus along with \nendometrium in particular myometrial fibrosis, uterine vascular \ninjury as well as endometrial injury that might restrict successful \nimplantation in addition to live birth [82]. The first patient who \nhad uterine transposition as well as fixation was conducted \nin case of a 26 year old patient having rectal adenocarcinoma \nby Ribeiro R of Brazil in 2017 for conferring protection to both \nuterus along with ovaries from adjuvant pelvic radiotherapy \nprior to rectosigmoidectomy [83]. Total mobilization of uterus \nalong with ovarian pedicles, colpotomy in addition to placement \nin the upper abdomen was implicated in this procedure. \nSubsequent to fixation to the anterior abdominal wall, the cervix \nwas anastamosed with the fascia of the umbilicus with regards \nto aiding in the efflux of the menstruation. In this particular early \npatient reported uterus was reimplanted into the pelvis 18mths \nsubsequent to pelvic radiotherapy when her menstrual cycle \nresumption occurred regularly. Despite, this surgical procedure \nmight be out of the realm of REI’s, a simpler procedure where \ninvolvement of uterine fixations tothe anterior abdominal wall \nPage 32 of 36\nFigure 7: Courtesy ref no-2: Demonstration of ovarian transposition in a \nprepubescent girl. (A): Demonstrates the left ovary that is sutured to the \nabdominal wall with a non-resorbable suture; and (B): demonstrated the \novary aftertransposition to the left paracolic gutters. (From Irtan, et al. [78]. \nReprinted by permission of the publisher.)\n\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\nInsufficiency (POI), or conditions like turners syndrome patients \noocyte cryopreservation might help. In view of their angiogenic \nin addition to anti apoptotic characteristics [91]. Besides \nMSC’s therapies for POI, other workers are evaluating thepart \nof Platelet Rich Plasma (PRP) for restoration of the ovarian \nworking along with enhancement of IVF success rates [92-95]. \nRequirement for gaining insight in generating greater safety \nalong with effectiveness of these innovative procedures prior \nto their utilization in the form of therapeutic strategies is there.\nConclusion  \n In the past 2 centuries in addition to Specifically past 20-30 \nyears reproductive surgery used to be the only strategy being \naccessible therapies for patients with infertility however were \nthought to be obsolete with the advent of IVF/ART. Remarkable \nadvancements in these surgeries, procedures, strategies have \ndrastictically escalated both with enhancement of technologies \nas well as greater information sharing. Concurrently there was \nan upsurge in the ART results, thereby our thought process \nwith regards to need for surgery reduced. Nevertheless, at \npresent reproductive surgery has attained newer premature \novarian failure which has again brought reproductive surgery \nto the forefront for tackling patients with infertility. In case of \nreproductive surgeons possessing expertise for performing \nthese techniques might aid in conservation of reproductive \nworking in addition to might aid in enhancement of ART results \nas well. The initiation of reproductive medicine possess roots in \nreproductive surgery, that represents a skill which will continue \nto be an integral part of our capacity of optimizing ART results. \nFurthermore,passing on these skills to our next generations of \nReproductive Endocrinology and Infertility specialists (REI) is \nsignificant.\nConflict of Interests  \n None declared.\nFunding  \n None.\nReferences  \n1. Feinberg EC, Levens ED, DeCherney AH. Infertility surgery is \ndead:only obituaryremains. Fertil Steril. 2008;89(1):232-236.\n2. Bortoletto P , Romanski PA, Petrozza JC, et al. Reproductive \nSurgery:revisiting its origins and role in the modern management \nof infertility. Fertil Steril. 2023;120(3):539-550.\n3. Sutton C. Hysterectomy:a historical perspective. Bailliers Clin \nObstet Gynaecol. 1997;11(1):1-22. \n4. Speert H. Obstetrics and Gynaecology in America:a \nhistory.Chicago.Ill: American College of Obstetricians and \nGynaecologists.1980.\n5. Chamberlain G. The master of myomectomy. J R Soc Med. \n2003;96(6):302-304.\n6. Semm K. New methods of pelviscopy (Gynaecologic \nlaparoscopy for myomectomy, ovariectomy, tubectomy and \nadnectomy. Endoscopy. 1979;11(2):85-93.\n7. Advincula AP , Song A, BurkeW, et al. Preliminary \nexperiencewith robotic assisted laparoscopic myomectomy. J \nAm Assoc Gynecol Laparosc. 2004;11(4):511-518.\n Radiofrequency ablation: Apart from innovative newer \nstrategies, further innovative treatment models for instance \nutilization of Radiofrequency Ablation (RFA) for uterine \nleiomyomas. Additionally, RFA tries to stimulate coagulative \nnecrosis amongst a myoma for attaining reduction in volume \nof the myoma, thereby myoma correlated symptoms [88]. At \npresent 2 gadgets accessibility is in US namely–Acessa (Hologic) \nas well as Sonata (Gynesonics) systems, where utilization of \nlaparoscopic in addition to transcervical strategy respectively. \nNevertheless, these gadgets are just acknowledged for \nutilization in symptomatic fibroids in case of patients who \ndo not want any future fertility. Moreover RFA portrays an \nintriguing procedure, in view of no requirement for myometrial \nincisions/sutures; however in an akin fashion tissue diagnosis \nis also not aided or resection of the myoma tissue. There are \nscarce outcomes accessible with regards to reproductive results \nin reproductive aged women wanting fertility. Recently, Polin, et \nal. [89], conducted a systematic review, where they isolated 50 \npregnancies subsequent to 923 RFA patients (10 transcervical \nas well as 40 laparoscopic). Of these there were 6 spontaneous \nmiscarriages (12%) along with 44 full term pregnancies (88%) \nwith just 2 revealed complications, placenta praevia, along \nwith, Post Partum Haemorrhage (PPH), with degenerated \nmyoma getting expelled. There were no uterine ruptures, \nno invasive placentation or documented preterm delivery. \nGreater outcomes are required for making sure with regards \nto safety in addition to effectiveness of RFA for patients with \nuterine fibroids who want any future fertility. Till we manage \nto get such outcomes, their part in reproductive aged women \ncontinues to be restricted. Their part in case of adenomyomas \nor diffuse adenomyosis also continue to be probable answers \nwhere present surgical procedures are substantially morbid as \nwell as medical treatment inefficacious for women who want \nfuture fertility.\n Regenerative medicine: Another field which is the attractive is \nthe utilization of regenerative treatment for instance stem cells \nfor abrogating endometrial damage. Intrauterine adhesions \noccur in view of injury to the regenerative layer of the uterine \nlining/endometrium. On robust injury, there is depletion of \nthe capacity of endometrium to heal in addition to lead to \nregrowth of the normal overlying stratum functional is. The \npresent standard of hysteroscopic breakdown of adhesions \ngot generated by REI’s, with the idea of restoration of the \nnormal architecture of theuterine cavity. Stem cell treatment in \ncombination with tissue engineering 3D scaffolds possess the \ncapacityof restoration of thebasalis layer which got injured from \ndilatation and curettage/myomectomy. At present, endometrial, \nmesenchymal, bone marrow, along withumbilical stem cells \nhave been documented to possess a positive action on the \nhealing of the damaged endometrium [90]. It has not been \nacknowledged with regards to use of these therapies would be \nfor primary avoidance subsequent to surgery for patients with \nsusceptibility to adhesions formation or in the form of secondary \navoidance for the ones already having prior disease. Attempts \nhave been made in regenerating other reproductive tissues \nis attractive in restoration of normal reproductive working on \nadvancement of age. Active assessment of Mesenchymal Stem \nCells (MSC’s) in their utilization in case of Premature Ovarian.\nPage 33 of 36\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\n26. Osada H. Uterine adenomyosis and adenomyoma:the \nsurgical approach. Fertil Steril. 2018;109(3):406-417.\n27. Kaur KK, Allahbadia GN, Singh M. Dilemna regarding \npreference of surgery or medical treatment in case of tubal \nblockade ,endometriosis or adenomyosis and pelvic adhesion \nprevention once surgery is contemplated –a systematic review. \nJ Gynaecol Androl Reprod Med. 2020.\n28. Hendricks ML, Ket CF, Hampes PGA, et al. Why does ovarian \nsurgery in PCOS help? insight into the endocrine implications \nof ovarian surgery in Polycystic ovary syndrome. Hum Reprod \nUpdate. 2007;13(3):249-264.\n29. Stein IF, Leventhal ML. Amenorrhoea associated with \nbilateral Polycystic ovary syndrome. Am J Obstet Gynaecol. \n1935:29(2):181-191. \n30. Gjonnaess H. Polycystic ovary syndrometreated \nbyelectrocautery. Fertil Steril. 1984;41(1):20-25.\n31. Bordewijk EM, Ng KYB, Rakic K, et al. Laparoscopic Ovarian \ndrilling for ovulation inductionin women with anovulatory \nPolycystic ovary syndrome. Cochrane Database Syst Rev. \n2020;2(2):CD001122.\n32. Amer SA, Shamy TTE, James C, et al. The impact of \nlaparoscopic ovarian drilling on AMH and ovarian reserve:a \nmeta-analysis. Reprod Camb Engl. 2017;154(1):R13-R21.\n33. Flyckt R, Goldberg JM. Laparoscopic Ovarian drilling for \nclomiphene resistant Polycystic ovary syndrome. Semin Reprod \nMed. 2011;29(2):138-146.\n34. Russell WW. Aberrant portion of the mullerian duct found in \nthe ovary. Am J Obstet Gynaecol. 1979:134:225-226.\n35. Lee D, Kim SK, Lee JR, et al. Management of Endometriosis-\nrelated infertility: considerations and treatment options. Clin \nExp Reprod Med. 2020;47(1):1-11.\n36. Kitajima M, Dolmans MM, Donnez O, et al. Enhanced \nfollicular recruitment atresia in cortex derived ovaries with \nendometriosis. Fertil Steril. 2014;101(4):1031-1037. \n37. Zhang Y , Zhang S, Zhao Z, et al. Impact of cystectomy versus \nablation for endometrioma on ovarian reserve:a systematic \nreview and meta-analysis. Fertil Steril. 2022;118(6):1172-1182.\n38. Muzil L, Achilli C, Lecce F, et al. Second surgery for recurrent \nendometriomas is more harmfulto healthy ovarian tissue and \novarian reserve than First surgery. Fertil Steril. 2015;103(3):738-\n743. \n39. Muzil L, Achilli C, Bergamini V, et al. Comparison between \nthe stripping technique and the combined excisional /ablative \ntechnique for the treatment of bilateral ovarian endometriomas:a \nmulticentre RCT. Hum Reprod. 2016;31(2):339-344. \n40. Zhang NN, Sun TS,Yang Q. An effective water injection- \nassistedmethod for excision of ovarian endometriomas by \nlaparoscopy. Fertil Steril. 2019;112(3):608-609.\n41. Candiani GB, Ottolina J, Posadzka E, et al. Asssessment \nof ovarian reserve after Cystectomy versus’’ one step’’ laser \nvaporization in the treatment of ovarian endometriomas:a \nsmall randomized Clinical trial . Hum Reprod. 2018;33(12):2205-\n22011.\n42. Cohen A, Almog B, Tulandi T. Sclerotherapy in the \n7. Metwally M, Reybould G, Cheong YC, et al. Surgical treatment \nof fibroids for subfertility. Cochrane Database Syst Rev. \n2020;2020(1):CD003857.\n8. Penzias A, Bendikson K, Butts S, et al. Removal of myomas \nin asymptomptomatic patients to fertility and/or reduce \nmiscarriage rates. Fertil Steril. 2017;108(3):416-425.\n9. Coutinho LM, Assis WA, Spagnuolo-Souza A, et al. Uterine \nfibroids and pregnancy: how do they affect each other. Reprod \nSci. 2022;29(8):2145-2151. \n10. Pritts EA. Fibroids and infertility: a systematic review of the \nevidence. Obstet Gynecol Surv. 2009;91(4):1215-1223.\n11. Neuwirth RS, Amin HK. Excision of submucus fibroids with \nhysteroscopiccontrol. Am J Obstet Gynaecol. 1976:126(1):95-99.\n12. Barbosa PA, Villaescusa M, Andres MP , et al. How to \nminimize bleeding in laparoscopic myomectomy. Curr Opin \nObstet Gynaecol. 2021;33(4):255-261.\n13. Parazzini F, Tozzi L, Bianchi S. Pregnancy outcome and uterine \nfibroids. Best Pract Res Clin Obstet Gynaecol. 2016;34(7):74-84.\n14. Dolmans MM, Isaacsons K, Zhang W, et al. Intramural \nmyomas more than 3-4 cm in size should be surgically removed \nbefore invitro fertilization. Fertil Steril. 2021;116(4):945-958.\n15. Kaur KK, Allahbadia GN, Singh M. Need for Removal of \nFibroids Prior to IVF in ImprovingSuccess Rates - A Short \nCommentary. J Gynecol. 2018;3(2):000157.\n16. Rackow BW, Taylor HS. Submucosal uterine leiomyomas \nhavea global effect on molecular determinants of endometrial \nreceptivity. Fertil Steril. 2010;93(6):2027-2034. \n17. Nezhat C, Nezhat F, Nezhat C. Endometriosis: Ancient disease, \nAncient treatments. Fertil Steril. 2012;98(Suppl):S1-S62.\n18. Junod SW, Marks L. Women’s trial: the approval of the first \nOral contraceptives pill in the United States and Great Britain. J \nHist Med Allied Sci. 2002;57(2):117-160.\n19. Goldberg JM, Falcone T, Diamond MP . Current controversies \nin tubal disease ,endometriosis and pelvic adhesion. Fertil Steril. \n2019;112(3):417-425. \n20. Riley KA, Benton AS, Diemling TA, et al. Surgical excision \nversus ablation for superficial endometriosis-associated pain \n:a randomized controlled trial. J Minim Invasive Gynaecol. \n2019;26(1):71-77. \n21. Marcoux S, Maheux R, Berube S. Canadian Collaborative \ngroup on minimal endometriosis. N Engl J Med. 1997;337(4):217-\n222.\n22. Practice Committee of the American Society of Reproductive \nMedicine. Endometriosis and infertility:a Committee opinion. \nFertil Steril. 2012;98(3):591-598.\n23. Practice Committee of the American Society of Reproductive \nMedicine. Fertility evaluation ofinfertile women:a Committee \nopinion. Fertil Steril. 2021;116(5):1255-1265.\n24. Kaur KK, Allahbadia GN, Singh M. Current Role of Surgery in \nEndometriosis; Indications and Progress. Surg Med Open Acc J. \n2018;1(4):1-7.\n25. Van Pragh I. Conservative surgical treatment for Adenomyosis \nuteri in young women: local excision and metroplasty. Can Med \nAssoc J. 1965;93(22):1174-1175. \nPage 34 of 36\n\nVolume 4 • Issue 2 • 37\nCitation: Kaur KK, Allahbadia GN, Singh M. The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\n60. Kaur KK, Allahbadia GN, Singh M. An Update on the \nAdvances in Classification as well as Reproductive Surgeries in \nMullerian Anomalies - A Systematic Review. Am J Surg Tech Case \nRep. 2020;1(1):1002.\n61. Kaur KK, Allahbadia GN, Singh M. An Update on the \nCauses of Primaryand Secondary Amenorrhea alongwith \nAetiopathogenesis and Therapeutic Management. Avid Science \nMonograph Series. 2016;1-87.\n62. Ingram JM. The bicycle seat stool in the treatment of \nvaginal agenesis and stenosis: a preliminary report. Am J Obstet \nGynecol. 1981;140:867-873.\n63. Rall K, Schenk B, Schaffeler N, et al. Long term findings \nconcerning the mental and physical condition, quality of life and \nsexuality after laparoscopically assisted creation of a neovagina \n(modified Vecchietti technique) in young MRKHS (Mayer-\nRokitansky-Kuster-Hauser syndrome) patients. J Clin Med. \n2021;10:1269.\n64. Dolinko AV, Vrees RA, Fishman GN. Non tubal ectopic \npregnancies: overview and treatment via local injection.  J \nMinim Invasive Gynaecol. 2018;25:287-296.\n65. Yamaguchi M, Honda R, Uchino K, et al. Transverse vaginal \nmethotrexate injection for the treatment of caesarean scar \npregnancy: efficacy and subsequent fecundity. J Minim Invasive \nGynaecol. 2014;21:877-883.\n66. Fylstra DL. Ectopic pregnancy within a caesarean scar: a \nreview. Obstet Gynecol Surv. 2002;57: 537-543.\n67. Miller R, Timor-Tritsch IE, Gyamfi Bannerman C. Society for \nMaternal -Fetal Medicine (SFMM) consult series#49 caesarean \nscar pregnancy. Am J Obstet Gynaecol. 2020:222:82-114.\n68. Timor-Tritsch IE, Buca D, Di MascioD, et al. Outcomes \nof caesarean scar pregnancy according to gestation age at \ndiagnosis: a systematic review and meta-analysis.  Eur J Obstet \nGynaecol Reprod Biol. 2021;258:53-59.\n69. Vissers J, Sluckin TC, van Driel Delprat CCR, et al. Reduced \npregnancy  and live birth rates after in vitro fertilization in \nwomen with a previous caesarean section: a retrospective \ncohort study. Hum Reprod. 2020;35:595-604.\n70. https://pubmed.ncbi.nlm.nih.gov/30196945/.\n71. Branstrom M, Johanneson L, Bokstrom H, et al. Live birth \nafteruterus transplantation. Lancet. 2015;385:607-616.\n72. Flyckt R, Falcone T, Quintini C, et al. First birth from a \ndeceased donor uterus in the United States: From severe graft  \nrejection to successful caesarean delivery. Am J Obstet Gynecol. \n2020: 223:143-151.\n73. Ricci S, Bennett C, Falcone T. Uterine transplantation: \nevolving data, success, and Clinical importance. J Minim Invasive \nGynaecol. 2021;28:502-512.\n74. Johanneson L, Richards EG, Reddy V, et al. The first 5 years \nof uterus transplant in the US: a report from the United States \nuterus transplant Consortium. JAMA Surg. 2022; 157:790-797.\n75. McCall ML, Kealy EC, Thompson JD. Conservation of ovarian \ntissue in the treatment of carcinoma cervix with radical surgery. \nAm J Obstet Gynecol. 1958;75:590-600.\n76. Damewood MD, Grochow LB. Prospects for fertility after \nmanagement of ovarian endometrioma: systematic review and \nmeta-analysis. Fertil Steril. 2017;108(1):117-124.\n43. Kaur KK, Allahbadia GN, Singh M. Management of Inoperable \nRecurrent Endometrioma Presenting as Severe Incapacitating \nPain Following Leuprolide Acetate Depot by Aspiration, Recurring \nAgain a 2 Yrs Subsequently for Sclerosing Therapy at Present: A \nCase Report. Sun Text Rev Case Rep Image. 2020;1(1):107.\n44. Surgical treatment of theovaries and fallopian tubes including \ntubal pregnancy. Bristol Medico Chir. 1896;14(54):353-354.\n45. Mulligan WJ. Results of salpingostomy. Int J Fertil. \n1966;11(4):424-430.\n46. Swolin K. Ertilit€atsoperationen. Acta Obstet Gynecol Scand. \n1967;46:234–250.\n47. https://archive.nytimes.com/www.nytimes.com/\ninteractive/2012/12/30/magazine/the-lives-they-lived-2012.\nhtml?view%C2%BCLesley_Brown.\n48. Gomel V. From laparotomy to laparoscopy to in vitro \nfertilization. Fertil Steril. 2019;112:183-196.\n49. Boeckxstaens A, Devroey P , Collins J, et al. 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The Role of Reproductive Surgeons/Surgery has Got Rekindled with Plateauing of IVF Results and Advances in Technology: \nA Comprehensive Narrative Review. J Obst Gynecol Surg. 2023;4(2):25-36. doi: 10.52916/jogs234037\nJ Obst Gynecol Surg,\nISSN: 2583-5912\n87. Luo X, Shen Y , Song WX, et al. Pathological evaluation of \nuterine leiomyoma as treated with radio frequency Ablation. Int \nJ Gynaecol Obstet. 2007;99:9-13.\n88. Polin M, Hur HC. Radio frequency Ablation of uterine \nmyomas and pregnancy Outcomes: an updated review of \nliterature. J Minim Invasive Gynaecol. 2022;29:709-715. \n89. Lv Q, Wang L, Luo X, et al. Adult stem cells in endometrial \nregeneration: molecular insights and Clinical applications.  Mol \nReprod Dev. 2021;88:379-394.\n90. Fu YX, Ji J, Shan F, et al. Human mesenchymal stem cells \ntreatment of premature ovarian failure:new challenges and \nopportunities. Stem Cell Res Ther. 2021;12:161.\n91. Gao M, Yu Z, Yao D, et al. Mesenchymal stem cells therapy: a \npromising method for the treatment of uterine scars premature \novarian failure. Tissue Cell. 2022;74:101674. \n92.  Kaur KK, Allahbadia GN, Singh M. An Update on Management \nof Oncofertility-Does the Use of Vsels Appear Practical in the \nNear Future in Human Malignancies Replacing Cortical Tissue/\nTesticular Tissue. Int J Stem Cell Regenerat Med. 2019;1(1):103.\n93. Kaur KK, Allahbadia GN, Singh M. Autologous Platelet Rich \nPlasma (PRP): A Possibility of becoming a revolutionary therapy \nin the field of Gynaecology and reproductive Endocrinology and \nInfertility- A Systematic Review, Progress in Women's Health \nCare, 2019;1(1):1-13. \n94. Kaur KK, Allahbadia GN, Singh M. Fertility preservation in \nturners syndrome patients-safety issues and problems of the X \nchromosomal content of granulosa cells-will it hinder oocytes \ndevelopment still needs Clarification- A short communication. \nArch Repr Med Sex Health. 2019;2(2):9-12.\n95. Munro MG, Critchley HOD, Fraser IS, et al. The two FIGO \nsystems for normal and abnormal uterine bleeding symptoms \nand classification of causes of abnormal uterine bleeding in \nthe reproductive years: 2018 revisions. Int J Gynaecol Obstet. \n2018;143:393-408.\nchemotherapy or radiation for neoplastic disease. Fertil Steril. \n1986;45:443-459.\n77. Irtan S, Orbach D, Helfre S, et al. Ovarian transpositions \nin prepubescent and  girls with cancer. Lancet Oncol. \n2013;14:e601-e608.\n78. Gubbala K, Laios A, Gallos I, et al. Outcomes of ovarian \ntranspositions in Gynaecological cancers: A systematic review \nand meta-analysis. J Ovarian Res. 2014;7:69.\n79. McLaren JF, Bates GW. Fertility preservation in women \nof reproductive age with cancers. Am J Obstet Gynecol. \n2012;207:455-467.\n80. Seltzer J, Belcht LCG, Huang Y , et al. Utilization of ovarian \ntranspositions for fertility preservation among young women \nwith pelvicmalignancies who undergo radiotherapy. Am J Obstet \nGynecol. 2018;219:415-417.\n81. Critchley HOD, Bath LE, Wallace WHB. Radiation damage \nto the uterus- review of the effects of treatment of childhood \ncancers. Hum Fertil. 2002;5: 61-66.\n82. RibeiroR, Ribolho JC, Tsumanuma FK, et al. Uterine \ntranspositions: technique and. case report. Fertil Steril. \n2017;108:320-324.\n83. Azais H, Canova CH, Vesale E, et al. Laparoscopic uterine \nfixation to spare fertility before pelvic radiation therapy. Fertil \nSteril. 2018;110:974-975. \n84. Oktay K, Karlikaya G. Ovarianfn after transplantation \nof frozen, banked autologous ovarian tissue. N Engl J Med. \n2000;342:1919.\n85. Donnez J, Dolmans MM. Fertility preservation in women. N \nEngl J Med. 2017;377:1657-1665.\n86. Stern CJ, Gook D, Hale LG, et al. First reported Clinical \npregnancy following heteropic grafting of cryopreserved ovarian \ntissue in a woman after bilateral oophorectomy. Hum Reprod. \n2013;28: 2996-2999.\nPage 36 of 36","source_license":"CC0","license_restricted":false}