This dissertation is aimed at improving the effectiveness of conservative plastic operations in infertile women of childbearing age that have uterine fibroids and congenital uterine anomalies. A complex investigation before and after surgery was performed on 150 infertile women of reproductive age, 110 of which had uterine fibroids (group 1) and 40 - congenital uterine anomalies (group 2). The investigations included anamnesis, general medical and gynaecological examinations, blood picture and biochemistry, coagulogramme and urinalysis. All the patients had an ultrasonographic examination of the internal genital organs, plain pelvic X-ray, hysterosalpingography, bicontrast gynaecography, and where indicated, endoscopy (hysteroscopy and laparoscopy). Morphological, histochemical and electronmicroscopical studies of the specimens (fibroid tissue and adjoining myometrium, and uterine septal tissue) obtained during surgery were carried out. Investigations before surgery showed that 29.1% of the women in g roup 1 and 60.0% in group 2 had a normal menstruation. Women in group 1 had predominantly hypermenstruation while those in group 2 - metrorrhagia. Ovarian function was characterized in 43.6% and 45.0% of the women in groups 1 and 2 respectively, by an insufficiency of the luteal phase, while in 17.3% and 17.5% respectively, anovulatory menstrual cycle. The following conditions contributed to infertility in the women studied: tubo-peritoneal factors (73.3% of women), endocrine factors (16.7%), polycystic ovaries (14.7%), ovarian cysts (6.7%), endometriosis (4.7%) and adenomyosis (2.0%). The period of infertility was from 2 to 18 years. 65.5% of group 1 women and 52.5% of group 2 had primary infertility, while 34.6% and 47.5% respectively - secondary. Only 31.6% of the women with secondary infertility in group 1 and 5.3% in group 2 carried their pregnancies to term and delivered viable babies. Uterine fibromyoma was diagnosed in all the women in group 1, with uterine size ranging from 11 to 24 weeks of pregnanc y in 95.5%. In 72.7%, uterine cavity was asymmetrical, deformed. 35.0% of the women in group 2 had bicornuate uterus, 65.0% - septate. Myomectomy and metroplasty were performed in groups1 and 2 women respectively, and where indicated, concomitantly with plastic surgery on the fallopian tubes and ovaries. Histology, histochemistry and electron microscopy of the tissues obtained at surgery showed severe structural and ultrastructural cellular changes in the fibroid nodes as well as the adjoining myometrium, and in the uterine septum. The genesis of infertility in the women studied could be ascribed to these changes, hence surgical intervention was indicated and justified. Long term postoperative results showed that menstrual flow normalized in 82.7% and 80.0% of women in groups 1 and 2 respectively, menstrual cycle - 67.3% and 50.0%, uterine size - 97.3% and 92.5%, uterine mobility - 90.0% and 87.5%, shape of uterine cavity - 96.4% and 95.0%, and uterine topography - 91.8% and 92.5%. Fallopian tube patency was restored in 91.8% and 92.5% of groups 1 and 2 women respectively. The pregnancy rate in group 1 women increased from 34.6% to 54.6%. 93.3% of the women carried their pregnancy to term with a successful delivery of live children, as opposed to 31.6% before operation. Metroplasty in group 2 women led to an insignificant increase in pregnancy rate from 47.5% to 52.0%. 85.7% of the women, however, carried their pregnancy to term and delivered live children, as against 5.3% before operation. We conclude, therefore, that infertility in women with uterine fibroids and congenital uterine anomalies has a multifactorial genesis. A detailed investigation is mandatory in these women groups to identify all the factors involved and make adequate plans for surgery. Specialized gynaecological investigations should be started with non-invasive methods (roentgenology and ultrasonography), and where indicated, ended with invasive (hysteroscopy and laparoscopy). Conservative plastic operations are justified for the complex trea tment of infertility in women of childbearing age that have uterine fibroids and congenital uterine anomalies, and indispensable for the normalization of the anatomical features of the uterus. They have a favourable influence on reproductive function - pregnancy rate, progress and outcome. We recommend a more liberal use of these operations in these women groups.
