Surgical Infertility Treatment
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Diagnostic assessment of the pelvis:
This involves both a hysteroscopy and a laparoscopy. A hysteroscopy is a short procedure usually taking 5 minutes or so, where a telescope is inserted into the womb cavity to check the shape, and to exclude the presence of polyps and fibroids that might prevent pregnancy or increase the risk of miscarriage. A biopsy of the womb lining is often taken.
A laparoscopy where a small telescope is inserted at the umbilicus to view the entire abdominal and pelvic contents. A second tiny incision is made along the bikini line to insert an instrument that will lift the structures to allow a complete assessment. The upper abdomen including the liver and gall bladder are inspected as a matter of course. The womb, tubes and ovaries are each carefully examined in turn. The procedure is usually combined with a dye test, where blue dye is inserted upwards through the womb cavity and can be traced as it finds its way into the abdomen through the fallopian tubes. It is easy to see if the tubes are blocked and where the blockage is.
Treatment to endometriosis:
Mild or moderate endometriosis is easily amenable to laparoscopic treatment that may involve:
The removal of endometriotic (chocolate) cysts in the ovary, the division of adhesions (scar tissue that limits mobility of the pelvic contents), and diathermy or laser treatment to destroy obvious endometriotic deposits in the pelvis. Occasionally larger nodules of endometriosis, usually found over the ligaments at the back of the womb, or between the womb and the bowel, can be excised laparoscopically, but clearance of severe endometriosis usually warrants a major open operation that takes time and is associated with significant risk of damage to adjacent structures. These procedures are reserved for women with pain, and are rarely required to improve fertility alone. Most laparoscopic procedures take between 30 and 60 minutes and involve an incision at the umbilicus for the telescope, and one or two small incisions along the bikini line. The procedure is often completed as a day case, or will require a stay overnight only.
Treatment to adhesions (scar tissue)
Adhesions are a bit like cobwebs that stick structures together that can normally move freely against each other. They arise because of previous inflammation, often as a result of surgery, infection or endometriosis. Diathermy is used to easily divide most adhesions, restore normal anatomy, and to improve fertility and pain symptoms. The treatment involves a straightforward laparoscopic procedure
Failure to ovulate every month will reduce fertility considerably, and when this is due to polycystic ovary syndrome, ovarian drilling can restore normal function, or make the ovaries more sensitive to the more routinely used medical treatments. It is in fact a simple laparoscopic treatment where excess hormone producing tissue deep in each ovary is destroyed by diathermy. Drilling takes about 5 minutes to complete, and is easy to perform during a routine laparoscopy if required. It should cause no long term side effects.
A myomectomy will improve fertility if fibroids are large or if they impinge on the womb cavity. The operation can sometimes be done laparoscopically, and if the fibroid is inside the womb cavity it can be resected using a hysteroscope, but most large fibroids are removed through a bikini line incision in the abdomen. The risks depend on the number, size and position of the fibroids to be removed, and the surgery may mean that a caesarean section is required in a subsequent pregnancy. The operation itself normally takes about an hour, and a 3-5 day stay in hospital afterwards with six weeks off work in total. Trying for pregnancy should be deferred for three months.
Hysteroscopic removal of uterine scarring or a septum:
Previous womb surgery including late terminations may cause scar tissue inside the womb, resulting in patchy lining that will significantly reduce the chance of pregnancy. A division inside the womb cavity is called a septum, and when this is present it can reduce fertility and increase the risk of miscarriage. Both scar tissue and a uterine septum can be removed using an operating telescope inside the womb where abnormal tissue is removed using a specialised diathermy instrument. Sometimes a coil (intrauterine contraceptive device (IUCD)) is inserted at the end of the procedure to reduce the chance of scarring as the womb heals, and oestrogen supplements encourage regeneration of a healthy womb lining. The IUCD(s) are usually removed after 6 weeks when you see the Doctor. The operation is usually a day case procedure.
Hysteroscopic removal of fibroids:
A special operating hysteroscope is used to remove fibroids inside the womb cavity. Occasionally they can be removed in one piece, but usually a diathermy loop is used to remove the fibroid in pieces, and the pieces removed through the cervix and sent for examination. The procedure takes about 30 minutes and is usually performed as a day case, but a stay in hospital overnight may be required if the fibroid is very large, or if there is significant bleeding afterwards. A special injection to reduce the size of the fibroid is sometimes given a month before surgery. A second operation may be required three months after the first to ensure the fibroid has been completely removed.
Tubal reconstruction / surgery:
Tubal blockage commonly occurs as a result of pelvic infection, and in many cases the damage to the tubes makes repair and restoration of tubal function impossible, but in selected cases when the blockage is close to the wide ovary end of the tube, surgery can provide a permanent cure for an infertility problem that can only otherwise be overcome by repeated IVF attempts. A hysterosalpingogram (an xray tube test) is useful before surgery to demonstrate the position of the blockage, but the potential success of the procedure can only be accurately predicted during the surgery itself, which is always laparoscopic, and usually performed as a day case.
The most common type of tubal reconstruction follows previous sterilisation, when normal tubes are blocked in one small portion by the sterilising clip. Reversal of sterilisation is very successful and can be performed laparoscopically in some cases.