From social stigma to blessed motherhood

A married couple with wife age being 34 years and husband age being 42 years, visited Indira IVF , Bhubaneswar in 2019 with a dream of bearing a child. Little did we know it would be one of the most challenging and most satisfying case to treat. The wife was not having menses for last 20 years. On history taking , it was found that the female had not a ttained her puberty till 15 years of age for which she had attended a gynaecologist , who on abdominal ultrasound discovered a rudimentary uterus and abnormally small gonads. The vagina was very narrow on examination.

She was planned for lapascopy to diag nose the anomalous condition. On laparoscopy, it was seen that the girl had both male testis and female ovary as her gonads , making her a true hermaphrodite. The gonads were removed due to potential risk of future malignancy in them. As she was reared as a girl, her vaginal canal and clitoris were reconstructed. She was advised for lifelong hormone replacement therapy to continue having menses, which she discontinued thus becoming amenorrhoic. On growing up , she married the person whom she loved , who als o took up the challenge of completeing their family despite several social hurdles. When we evaluated her, her uterus was rudimentary due to lack of hormones, having minimal muscle mass which made it look infertile.

Apart from having no gonads, all other t est were normal including her husband tests. Our major target was to bring back her uterus to normal shape and strength to be able to carry a pregnancy. For this it took almost a year of hormonal therapy and a hysteroscopic surgery . We went with donor oocy te IVF program due to absence of eggs in her. The embryo transfer was very difficult due to the previous vaginoplasty surgery making cervix very high to reach. Her first single embryo transfer was a success with an unfortunate miscarriage at 8 weeks. We again took a 6 months hormonal therapy to make her uterus stronger. The next transfer was double embryo which again resulted in a successful pregnancy, but with twins. Management of twin pregnancy in a otherwise normal pregnancy is trick with potential pre gnancy complications but this case with a previously rudimentary uterus made it all the more a high risk pregnancy. With a very strict and close follow up we crossed 3 months where a cervical encerclage was planned owing to the potential risk of prematu re delivery in such cases.

But the major problem was the route the surgery as the most preferred vaginal route was impossible for her due to the distorted anatomy caused by previous surgery. We planned for an abdominal laparoscopic route which is a rare method but done successfully. Following her up for the next 5 months was a herculean task, but with great team effort from obstetrician, fetal medicine specialist and IVF specialist, we completed 32 weeks after which Doppler abnormalities appeared in babie s. With strict monitoring, LSCS was one at 33 weeks , delivering a baby girl 1600 grams and a baby boy 1400 grams . The happiness new no bounds as they were returned by several doctors who denied the possibility of a successful pregnancy but here they were with not one but two healthy babies with healthy mother. IVF is a boon in disguise to several such couples who have been trying hard for conception but failing with basic infertility management. The right guidance and evidence based management in a truste d and technologically advanced centre with infertility experts can definitely bring success to the most challenging cases as well.