Reproductive disorders are frequently due to anatomic problems of the reproductive tract that require surgical correction for optimal reproductive outcomes. Many of these abnormalities can be treated with minimally invasive surgery, using laparoscopy and/or hysteroscopy. Laparoscopy is the placement of a small camera through the belly button under general anesthesia. Using this camera and 1 to 3 other 0.5 to 1 cm incisions, surgical correction of reproductive disorders can be performed. The advantages of minimally invasive surgery are that patients can go home the same day and resume normal activities within 1 to 2 weeks in most cases. Hysteroscopy is the placement of a small camera and other surgical instruments into the uterine cavity. Recovery from hysteroscopic procedures is typically 1 to 2 days.
Surgical procedures for women include diagnostic hysteroscopy, diagnostic laparoscopy, tubal reversal, assisted reproductive technology procedures (GIFT and ZIFT), and reconstructive pelvic surgery. Highly trained and experienced doctors can often use minimally-invasive surgery instead of abdominal surgery to minimize pain, scarring, and recuperation time.
Procedures for men, usually performed by a urologist, include vasectomy reversal, removal of obstructions, sperm aspiration, and varicocele repair.
Several surgical procedures can help you improve your chances for pregnancy. Abdominal surgery was the traditional way to gain access to the internal pelvic organs. Now, most procedures can be done using laparoscopy or hysteroscopy.
Diagnostic hysteroscopy
Your doctor may use a hysteroscopy for diagnosis if your ultrasound exam suggests problems inside the uterus or gives incomplete information. A hysteroscopy allows your doctor to examine the uterus for scar tissue, polyps, or fibroids. A telescope-like device is passed through the cervix. Hysteroscopy requires no incision, and patients usually recover quickly.
If any problems are found, your doctor may be able to correct them during the initial hysteroscopy. Follow-up may be necessary with a separate operative hysteroscopy or other surgical procedure.
Diagnostic laparoscopy
With a few small incisions, your doctor can see inside your abdomen to the outside of the uterus, the fallopian tubes, the ovaries, and the bladder. A viewing device (the laparoscope) is passed through one of the incisions.
The laparoscope can help your doctor diagnose uterine fibroids (in the wall of or outside the uterus), endometriosis, ovarian cysts, and other fertility problems. These problems can often be treated during the laparoscopy. In some cases, follow-up surgery may be required.
Most women recover within a few days. The small incisions are normally made at the navel and at the pubic hair line and rarely leave noticeable marks.
Tubal reversal
Some women who choose sterilization for contraception later wish to become pregnant. A new marriage, other life change, or a new outlook may prompt this change of heart. Tubal ligation, a "permanent sterilization" procedure, can be reversed. In other cases of female sterilization, IVF is usually the best option.
In tubal reversal, the surgeon uses laparoscopy or abdominal surgery to repair the tubes. It is an outpatient procedure. Scar tissue is removed, the ends of each tube are prepared, and the tube is reconnected with tiny sutures. Since the fallopian tubes are extremely delicate, success - and future fertility - depend on the ability of the surgeon. After a successful reversal, youÕll have up to a 75 percent chance of pregnancy.
Dr. Donald Galen of the Reproductive Science Center® of the Bay Area performed the first robotic computerized tubal reversal. Robotics allows meticulous control and even the possibility of remote surgery, with the patient and surgeon thousands of miles apart.
ART procedures
In some cases, your doctor may recommend an assisted reproductive technology that requires surgery. For example, your cervix may be scarred in a way that prevents success with standard embryo transfer after IVF.
Your doctor may use a laparoscopy to place the embryos or a sperm/egg mix into your fallopian tubes. In ZIFT (zygote intrafallopian transfer) the doctor places embryos into one of the tubes. In GIFT (gamete intrafallopian transfer). the unfertilized eggs and sperm are transferred into a tube.
Recovery normally takes a week or less.
Reconstructive pelvic surgery
Some women are born with an improperly developed uterus. These problems occur naturally in a small percentage of women, and some of them lead to infertility or miscarriage. Surgery may correct them.
Nonsymmetrical development of the uterus - When a female fetus develops, the two sides of her uterus begin to form, then fuse together from the bottom up. Sometimes, they don't fuse, resulting in an abnormal cervix or a closed-off portion of the uterus, called a blind horn.
For women born with this condition, menstrual fluid can't get out of the blind horn and pregnancy rates are lower. A laparoscopy or hysteroscopy can be used to remove the blind horn or open it up to the uterus so that it can function normally.
Uterine septum - Sometimes a dense layer of tissue grows and divides the uterus into two working halves. These women have decreased pregnancy rates and higher miscarriage rates. An operative hysteroscopy can sometimes be used to remove the dividing layer.
Uterine abnormalities
The uterus or womb is the organ where the embryo implants and develops throughout a pregnancy. Uterine abnormalities can contribute to decreased fertilization, miscarriage, or pregnancy complications. Common uterine abnormalities requiring surgical treatment include polyps, scarring, fibroids and septums. Many of these abnormalities can be treated using hysteroscopy and/or laparoscopy, but some may require more extensive surgery depending on the patient’s condition. Uterine fibroids are very common among women of reproductive age and not all fibroids need to be removed in order to achieve a successful pregnancy.
Ovarian Cysts
Ovarian cysts are a frequent finding in women of reproductive age. Many of them resolve on their own and do not require surgery. Cysts that are large or persistent, lasting more than 2 to 3 months may require surgery. Most ovarian cysts are non-cancerous and may be due to endometriosis or other benign processes. Cancer is rarely found in women of reproductive age with simple ovarian cysts, but surgical removal and microscopic examination is the only way to definitively diagnose the type of cyst. Ovarian cysts can typically be removed laparoscopically, and do not require removal of the entire ovary. Other ovarian disorders, such as polycystic ovarian syndrome, can be treated medically and rarely require surgery.
Endometriosis
Endometriosis is a gynecologic condition characterized by endometrial tissue from the inner lining of the uterus, growing outside of the endometrial cavity. Typical symptoms of endometriosis are painful menstrual periods, vaginal bleeding between periods, and infertility; however, some women with infertility associated with endometriosis have no symptoms. Laparoscopy can be used to diagnosis and treat endometriosis in a single procedure. Although the exact mechanism of how endometriosis causes infertility remains poorly understood, the strong association between endometriosis and unexplained infertility exists and many studies have shown that treatment of endometriosis can improve fertility in women attempting to conceive on their own and with fertility treatments.
Fallopian Tube abnormalities
The fallopian tubes are the path that the sperm and egg must take to achieve fertilization and successfully implant in the uterine cavity. Disorders of the fallopian tubes can lead to the inability to conceive, because the sperm and egg cannot meet. Prior pelvic infection, surgery, or endometriosis can lead to blocked fallopian tubes. Laparoscopy is used to diagnose and treat these disorders. In some cases, severely damaged fallopian tubes must be removed to give a woman her best chance to conceive within vitro fertilization because fluid buildup in the fallopian tubes can create a toxic environment for implantation. In other cases, pelvic scaring and endometriosis can be treated to improve a patient’s chances of conceiving naturally or with less aggressive fertility treatments.
Some men don't produce sperm in their ejaculate. This condition, azoospermia, can be caused by a vasectomy, a natural obstruction that traps the sperm, or improper sperm development. In some cases, outpatient surgery can help these men become fathers.
Vasectomy reversal
The urologist makes a small opening in the scrotum. The obstruction is found, scar tissue is removed, and the ends of the tubes are open and reconnected. The procedure usually takes about three hours. You may be sore for several weeks. If pregnancy doesn't occur within a few months, you may wish to pursue further fertility treatment.
Obstructive azoospermia
Some obstructions that trap sperm can also be surgically corrected. For non-operable obstructions or failed vasectomy reversals, the urologist can use sperm aspiration. The urologist locates the obstruction, then uses a small needle to draw out sperm from near the obstruction. If sperm aren't found, the next step is to take a small sample of testicular tissue (a testicular sperm biopsy), which may contain sperm.
The sperm can be used immediately - or frozen - for an IVF cycle. In IVF with ICSI (intracytoplasmic sperm injection), only one sperm is needed for each egg.
Nonobstructive azoospermia
If you don't produce any mature sperm (a condition called nonobstructive azoospermia), a testicular sperm biopsy may help. A small needle puncture is used to remove a tiny portion of the testicular tissue. The sperm are then dissected out of the tissue. If insufficient sperm are found in the small sample, a larger biopsy may be performed. Almost all men have some sperm.
Since IVF with ICSI requires only one sperm for each egg, most of these men have enough sperm to have a genetic child. Pregnancy rates may be lower than for men with obstructive azoospermia.
Varicocele repair
This is becoming a less-used procedure. It is believed that an enlarged vein - essentially a varicose vein - around a testicle can raise its temperature, thus suppressing sperm count. In varicocele repair, the urologist ties off the vein. After surgery, sperm count usually increases within a few months, but pregnancy rates don't seem to improve.
