A 29 year old housewife presented at BACC with complaints of abdominal pain She had sought advise for the same a day prior, at a nursing home. The pain was periumblical and radiating to the right iliac fossa. Clinically she was diagnosed as acute appendicitis. An abdominal scan done there revealed the following findings:

• Uterus normal in size.
• Left ovary cystic, measuring 2.6x2.7 cm.
• Right ovary measuring 1.0x1.5 cm.
• Spleen, liver, pancreas and bladder normal.
• Echogenicity altered in the appendicular region
• Impression - possible appendicitis.

Patient refused treatment and sought another opinion at BACC.
She was married for 4 years and had no conceptions.
She had regular menstrual cycles with congestive dysmenorrhoe; her last menses was 3 days prior.
She had a laparoscopy elsewhere in March 99 with normal findings.
Clinical examination at BACC revealed tenderness over the whole lower abdomen.
Pelvic examination was inconclusive clinically because of the tenderness. Ultrasound showed:

• Normal uterus
• Endometrium 3mm
• Right Ovary - 37x26 mm with chocolate cyst 27x28mm,
• Left Ovary - 35x29 mm with another cyst 18x12mm.
• POD - clear.

She was given GnRh in the form of suprefact twice daily for 1 month, followed by Danazol 200 mg twice daily for 6 weeks. She was posted for laparoscopic surgery for endometriosis.

Operative laparoscopy:

Findings: Bilateral endometriotic ovaries.
Right ovary - endometriotic cyst measuring 4cm, excised.
Dense periovarian adhesions released, both ovaries freed.
Pouch of Douglas adhesions released.
Tubo-ovarian relation restored.
Endometriotic areas were fulgurated.
Chromopertubation positive.
She conceived naturally 3 months later. Her pregnancy was uneventful. She delivered a full term live normal baby.

All that pain is not appendicitis. Endometriosis has diverse clinical presentations. It is an enigma.

A 36 year old primigravida presented with a history of missed period (D36) following intrauterine insemination after ovulation induction with Letroz and HMG. She was asymptomatic. She had undergone a thyroidectomy in 1996 and an ovarian drilling in 2000. Her previous cycles were regular.

Clinical and ultrasonographic evaluation did not reveal a pregnancy either intrauterine or extrauterine. ßhCG showed a value of > 1000 IU. She was sent for a second ultrasonographic opinion, which also revealed negative results for a pregnancy. ßhCG on D38 was 2616 IU. An USS at this stage did not show a pregnancy at any site.

A 39 year old lady presented with secondary infertility of 9 years duration. Husband was diagnosed to have azoospermia. Nine years ago she underwent a left salpingectomy for a left tubal pregnancy following an AID (artificial insemination donor). She had undergone antituberculous treatment 4 years ago elsewhere (no reports available indicating reason).

Mrs. S aged 31 years, approached our center for secondary infertility. She had been married for 6 years. She had undergone three 1st trimester spontaneous abortions, for which evacuation had been done all the 3 times. Her menstrual cycles were regular and normal. There was nothing significant in her past or family history. There were no male factor problems as evidenced by a clinical and laboratory examination.

Mrs. S underwent investigations, which revealed the following: Hormonal profile was normal. Tests for antiphospholipid antibodies were negative. She was not a diabetic. We do not do TORCH tests as routine.

A pelvic ultrasound revealed multiple fibroids in the uterus, and an endometriotic cyst in the right ovary measuring 3 cms. On scan 6 fibroids were seen, all of which were more than 2 cms. The fibroids were located in the fundus, posterior wall, and anteriorly impinging on the uterine cavity.

Patient was counseled to undergo an operative laparosocpy and a hysteroscopy, to which she consented. A 3 cms submucous fibroid was removed via the hysteroscope. At laparoscopy 4 intramural fibroids, one anterior and three posterior were enucleated. The chocolate cyst in the right ovary was drained. Pelvic adhesions were released. Patient did well postoperatvely. She received 3 doses of Zoladex postoperatively at monthly intervals.

After this patient underwent ovulation induction with CC+HMG which was followed by intrauterine insemination at the appropriate time. She conceived in the first cycle of IUI. She is in the 9th month of her pregnancy. Her antenatal period has been uneventful. She is carrying a live normal single fetus.

Recurrent spontaneous abortion (RSA) has many causes, one of which is anatomical i.e. uterine fibroids. The role of fibroids in infertility is not clear. Many women with fibroids have normal fertility and pregnancies with no complications. Spontaneous abortion related to a fibroid may be due to the following.

• Submucous fibroid may be a barrier to implantation or may occupy space in the uterine cavity.
• An intramural fibroid may interfere with the blood supply to an embryo implanting near it.
• A large sub serous fibroid may undergo degeneration or become infected. These may result in uterine irritability, uterine contractions, and a possible pregnancy loss.

• All other causes of the reproduction problem have been evaluated and excluded
• Submucous fibroid
• Fibroids creating a tremendous distortion of the uterine cavity.

In the above patient since all other investigations were normal, it seemed logical to postulate the fibroids as a probable cause for the RSA. Hence a myomectomy was decided upon. Laparoscopy myomectomy was the option. The cavity was not entered into, during the laparocopic procedure. The chocolate cyst was also removed. Patents first line of treatment was ovulation induction with intrauterine insemination. Fortunately she conceived in the first cycle.

Mrs. H, a 30 year old nulligravida underwent ovulation induction and intrauterine insemination for unexplained infertility. She had been married for 7 years. During the monitoring for ovulation induction she had 4 mature follicles. She conceived triplets. There was no family history of twins/triplets.

At 11 weeks of pregnancy she underwent fetal reduction by the transabdominal route. She opted for a twin pregnancy. The pregnancy was closely monitored. Cervical stitch was inserted at 14 weeks. She received prophylactic steroids at 29+ weeks. She did not develop any pregnancy complications. The growth of the twins was monitored b y ultrasound. At 37 weeks she underwent an elective cesarean section. Both babies were extracted by vertex and weighed 2.4 kgs and 2.5 kgs respectively. Both the babies had good apgar scores. Their neonatal period was uneventful. The mother did well postoperatively and in the puerperium.