When cost effective methods have failed or the couple are married fpr more than 1yr or when there is a visible pathology in the scan the women should be taken for key hole surgery or endoscopy surgery.

There are 2 parts, one hysteroscopy and the other laproscopy. Most of the surgeons like to combine both for infertile patients. Primary infertility where a woman has never conceived can be due to ovulatory dysfunction or tubal pathology.

Secondary infertility can be due to pathology inside the uterine cavity, like a septum inside the uterus, a submucus fibroid or an incompetant cervix.

Ovulatory dysfunction is first assesed by blood hormonal studies and by ultra sound scanning. Polycystic ovarian disease is the one which is commonly seen, especialy in Kerala. This disorder is treated medically first and if it is not successful, by laproscopy, doing selective drilling of the follicles. A hyperinsulinaemic disorder is first treated with an insulin sensitiser, if it is not corrected, then laproscopy is the alternative.

Endometriosis is another disease commonly seen. It can affect the ovaries producing ovarian cyst, sometime causing ovulatory disorder. It can be in one ovary or both ovaries and cause adhesions. Laproscopically the cyst can be removed and adhesions released. If done properlythis may result in conception in 50 - 60% of patients.

Septal resection, polyp removal and submucus myoma removal, help patients with repeated abortion, to have ter babies. In competent OS tightening is done for patients who need it by 16th week of pregnancy.

These abnormalities can be simultaneously treated by hysteroscopic surgery. This is totally minimally imvasive approach. This surgery doesn’t require incision (wound) on the abdomen. The conditions mentioned above are very elegantly treated by hysteroscopic surgery.