Surgical interventions to optimize fertility

Reproductive surgery is commonly performed to diagnose and treat anatomic abnormalities of the pelvis and alleviate symptoms of gynecologic conditions associated with infertility. The decision to pursue surgery in a patient desiring pregnancy should be guided by data on efficacy relative to expectant management or assisted reproductive technology (ART), as well as by careful consideration of the patient's age, symptoms, disease severity, ovarian reserve, and family-building goals. The evidence on whether specific surgical interventions improve fertility, including fecundity, pregnancy, and live birth, is often limited and varies greatly by indication and patient-related factors. High-quality comparative studies are scarce, and most expert recommendations therefore rely on small observational studies or trials with heterogeneous inclusion criteria, nonstandard surgical techniques, and conflicting findings. This review summarizes the available data on reproductive outcomes after surgery for several common indications: endometrial polyps, uterine fibroids, endometriosis, tubal occlusion and hydrosalpinx, uterine septum, and unexplained infertility. Because the results of surgery may differ depending on whether conception is attempted with or without the use of ART, both scenarios are discussed. This review provides concise guidance on best practices for counseling and managing patients with infertility who have conditions that may be amenable to surgery.