Most surgical pages in this field are organised around equipment. Laparoscopy. Hysteroscopy. Keyhole. That tells you what will be done to you, not whether it will help.
This page is organised the other way round: by what is actually wrong, and by what the evidence says about whether operating on it improves your chance of conceiving. For some conditions the answer is a clear yes. For others it is genuinely uncertain, and for at least one it is no.
Dr. Munaganuru Niharika holds an MCh in Reproductive Medicine and Surgery, awarded at Sri Aurobindo, Indore, in 2018. That super-specialisation is the surgical training that sits behind this work. She consults in Financial District, Nanakramguda, Hyderabad.
What fertility-sparing means
The surgical objective is not simply to remove what is abnormal. It is to correct the problem while protecting the three things that fertility depends on: ovarian tissue, tubal function, and the integrity of the uterine cavity.
That constraint changes the operation. Removing an ovarian cyst is straightforward if the ovary does not matter. It is a considerably more careful operation when the ovary has to keep working afterwards. The same is true of the uterine cavity, where over-treatment causes the scarring that the surgery was meant to address.
It also changes whether to operate at all. In fertility surgery, the decision not to operate is part of the same skill set.
Fibroids
The single most useful thing to know about fibroids and fertility is that where the fibroid sits matters more than how large it is.
Submucosal fibroids, which sit in or distort the uterine cavity, are the ones with the clearest anatomical case for removal — and the trial evidence is weaker than that case sounds. Cochrane grades the evidence that removing them improves pregnancy rates as very low quality, and in unexplained subfertility the result does not exclude no effect at all. Live birth was not reported in either review. So the anatomy is a good reason and the trials have not settled the question, which is a different sentence from the one most surgical pages will give you.
Intramural fibroids, within the muscle wall and not distorting the cavity, are genuinely contested. Cochrane’s 2020 review rates the evidence that removing them improves fertility as very low quality. ASRM is more favourable where an intramural fibroid also distorts the cavity. Those two positions do not fully agree, and this page is not going to pretend they do. It means the decision needs to be individual, and it means anyone who tells you the answer is obvious is not reading the same literature.
Subserosal fibroids, on the outer surface, have no established fertility benefit from removal. Surgery is not advised for that reason alone.
On approach: Cochrane found no clear superiority of laparoscopic over open myomectomy for live birth, clinical pregnancy or miscarriage. Keyhole surgery has real advantages in recovery. Better fertility outcomes is not a claim the evidence supports.
Endometrial polyps
A randomised trial found that women who had a polyp removed before intrauterine insemination conceived considerably more often than those who did not. The striking detail is that most of those pregnancies happened spontaneously, before the treatment cycle even began.
Cochrane grades that evidence low certainty, citing reporting risk and the absence of live-birth data. So the effect looks real and worth acting on, and the certainty behind it is lower than a single trial result suggests. Both of those are true.
Polypectomy is a day procedure through the cervix, with no incision.
Intrauterine adhesions
Scar tissue inside the uterine cavity, sometimes called Asherman’s syndrome, usually follows a previous procedure or infection. It can reduce or stop periods and can prevent implantation.
Hysteroscopic division of adhesions is standard practice, and the AAGL and ESGE recommend it as the approach for symptomatic adhesions. The same guidelines are candid about the evidence behind it: there are no randomised trials comparing surgery with simply waiting, and none comparing the different surgical methods with each other. The stated purpose of the operation is to restore the normal shape and volume of the cavity and the passage between the cavity, the cervix and the tubes. So it is done because the anatomical problem is clear and correctable, not because a trial has proven the fertility outcome. That distinction is worth having before you consent.
Uterine septum
This is the honest one.
A septum is a wall of tissue dividing the uterine cavity. Resecting it was standard practice for years. Then the TRUST trial, an international randomised trial, compared resection with leaving it alone and found no improvement in live birth. The trial authors recommended against routine resection. It was a small trial, designed to detect a large difference rather than a small one, and that limitation belongs with the result: it does not show that resection never helps anyone, it shows there is no evidence it reliably helps.
Practice ran ahead of the evidence here, and the evidence has now caught up in an uncomfortable direction. Septum surgery may still be right in particular circumstances, discussed individually. It should not be presented to you as an established fix, and if it is, that trial is a fair thing to ask about.
Ovarian cysts and endometrioma
Where surgery on an ovarian endometrioma is needed, removing the cyst wall reduces recurrence of the cyst and of pain compared with draining and coagulating it. ESHRE recommends it.
The same guideline, in the same section, requires specific care to minimise damage to the ovary, because cystectomy measurably reduces ovarian reserve. Pooled AMH data show the fall.
Which means the real question is rarely how to remove the cyst. It is whether removing it serves you, given your age, your reserve, whether both ovaries are involved, whether you have had this surgery before, and what you are trying to achieve. For a woman heading to IVF, ESHRE recommends against routine endometrioma surgery beforehand, because it does not improve live birth and is likely to cost reserve.
Repeat ovarian surgery compounds this. Reserve does not regenerate.
Tubal surgery, and when IVF is the better route
Hydrosalpinx, a fallopian tube blocked and filled with fluid, reduces the chance of an embryo implanting. Cochrane’s 2020 review found that removing the affected tube before IVF probably improves the chance of a clinical pregnancy: across four trials and 455 women, if the chance without surgery is taken as 19 in 100, the chance after removing the tube was between 27 and 52 in 100. That is moderate-certainty evidence. Blocking the tube rather than removing it may also help, on lower-certainty evidence from two trials.
Two things are worth knowing about those numbers. The range is wide, which is what moderate certainty across small trials looks like. And no trial in the review reported live birth at all — so the strongest available evidence stops short of the outcome that matters most. ASRM states that removing a severely damaged tube restores IVF outcomes to levels similar to women without the problem.
Tubal repair rather than IVF is still reasonable in selected situations, including a blockage at the uterine end of the tube in a younger woman without other fertility factors, and reversal of sterilisation below around 37, where the surgeon is experienced in the technique.
And sometimes surgery is the wrong answer. ASRM frames this as a straight comparison, favouring IVF where tubal damage is severe or affects both sides, or where the surgical outlook is poor. Offering an operation that will not work, when a treatment that might is available, is not a neutral act.
What surgery does not do
Across fibroids, polyps, adhesions, septa, endometriomas and tubes, no single operation is shown by high-certainty randomised evidence to reliably restore fertility. Several show no measurable reproductive benefit at all. That is the state of the literature, and it is not what most surgical pages will tell you.
Alongside that:
- Surgery causes adhesions. Readmission for adhesion-related problems after open abdominal or pelvic surgery is common. ASRM cites a study in which around a third of people who had open abdominal or pelvic surgery were readmitted, an average of twice each, over the following ten years, and more than a fifth of those readmissions fell in the first year. Among gynaecological procedures, ovarian surgery had the highest rate of readmissions directly related to adhesions. Adhesion severity is inversely related to later pregnancy after tubal surgery.
- Keyhole surgery does not necessarily prevent this. ASRM states laparoscopy does not necessarily produce fewer adhesions than open surgery, because the extent of tissue injury matters more than the size of the incision.
- Adhesion barrier products have no substantial evidence of improving fertility, reducing pain or reducing bowel obstruction.
- Repeat surgery is rarely neutral, particularly on the ovary.
None of this is an argument against operating. It is an argument for operating on a clear indication, once, with the fertility objective explicit from the start.
Before surgery: preserving what you have
Where a planned procedure carries a meaningful risk to ovarian function, freezing eggs or embryos beforehand is worth discussing. That applies particularly to surgery on both ovaries, to repeat ovarian surgery, and to extensive disease.
ESHRE recommends having the discussion in extensive ovarian endometriosis, while stating that the true benefit of fertility preservation in women with endometriosis remains unknown. The guideline says extensive; it does not set a rule for surgery on both ovaries, so that part is a judgement made with you rather than a recommendation to quote at you. It is a considered option, not a routine add-on.
When this needs a different specialist
This service covers benign conditions. It does not cover cancer.
Where an ovarian mass has features suspicious for malignancy, the pathway changes entirely: it needs malignancy risk assessment and specialist referral before any fertility-preserving surgical plan is made. Where a gynaecological cancer or a borderline tumour has been diagnosed and you wish to conceive, the joint European guidelines require joint care by a multidisciplinary team including gynaecological oncologists alongside fertility specialists, pathologists and radiologists.
That is a team, and it is the correct answer to that situation. Saying so is part of practising within scope.
Questions people ask
Will surgery help me conceive? It depends entirely on what is being corrected. Removing a polyp has reasonable evidence behind it; removing a cavity-distorting fibroid has a clear anatomical rationale and weaker trial evidence. Removing a subserosal fibroid has neither. Septum resection did not improve live birth in the randomised trial. The condition determines the answer, not the operation.
Is keyhole surgery better? Better recovery, yes. Better fertility outcomes is not something the comparative evidence establishes, and Cochrane found no clear difference for myomectomy.
Will surgery damage my ovaries? Removing an ovarian cyst measurably reduces ovarian reserve. That is why the decision, and the technique, matter so much, and why repeat surgery on an ovary is approached cautiously.
Do I need surgery before IVF? For a hydrosalpinx, often yes, and the evidence is reasonably good. For an endometrioma, ESHRE recommends against it routinely. For minimal or mild endometriosis, also recommended against routinely.
Can everything be fixed with one operation? Sometimes. But planning several procedures in advance is usually a sign the indication is not clear, and each operation carries its own adhesion risk.
What if my scan shows something suspicious? Then this is not the right pathway, and you need assessment and referral before any fertility-preserving plan is made. That is stated here deliberately.
Speak to Dr. Niharika
To discuss whether surgery is appropriate in your situation, call +91 90149 52872.
BirthRight Fertility by Rainbow Hospitals, 2nd Floor, Survey No 74, Rainbow Children’s Hospital, Financial District, Nanakramguda, Hyderabad, Telangana 500032.
Consultation timings may vary. Please confirm while booking.
References
- Cochrane. Surgical treatment of fibroids for subfertility, CD003857, 2020.
- Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertility and Sterility, 2009.
- ASRM. Removal of myomas in asymptomatic patients to improve fertility or reduce miscarriage rate: a guideline, 2017.
- Pérez-Medina T et al. Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination. Human Reproduction, 2005.
- Cochrane. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities, CD009461, 2018.
- Rikken JFW et al. Septum resection versus expectant management in women with a septate uterus (TRUST). Human Reproduction, 2021.
- ESHRE. Guideline: Endometriosis, 2022.
- Melo P et al. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database of Systematic Reviews, CD002125, 2020 (supersedes the 2010 version previously cited here).
- ASRM. Role of tubal surgery in the era of assisted reproductive technology: a committee opinion, 2021.
- ASRM. Postoperative adhesions in gynecologic surgery: a committee opinion, 2019.
- AAGL and ESGE. Practice guidelines on intrauterine adhesions. Gynecological Surgery, 2017.
- ESGO, ESHRE and ESGE. Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma, 2023, and the companion guideline on cervical cancer, ovarian cancer and borderline ovarian tumours, 2024.
Guidance changes. Where two bodies disagree, this page says so rather than choosing the one that suits a treatment.