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Surgical Infertility – anatomic causes of female infertility that lend themselves to surgical repair

2 April 2009

This term denotes anatomic causes of female infertility that lend themselves to surgical repair. With the ascent of IVF (in-vitro fertilization), fewer indications for surgical infertility exist today than a decade ago. Nevertheless, there are still many occasions where competent surgery can make a difference. Examples are myomectomies (the surgical removal of fibroid tumors from the uterus), ovarian cystectomies (the surgical resection of ovarian cysts), tuboplasticies (the surgical correction of abnormal fallopian tubes) and many other procedures.

Surgical Treatment of Infertility

Infertility can be caused by problems in the pelvic anatomy – birth defects, fibroids and polyps, and adhesions are among these. Medical treatment, while sometimes available, often does not fix the problem, and repair must be undertaken directly – a surgeon must go in and remove the problem or restore the anatomy. Treating these problems is highly individualized and depends on the patient’s age, medical problems, and patient wishes. The available procedures are:

Hysteroscopy: Hysteroscopy involves looking inside the uterus with a small camera. The cervix is dilated with a smooth dilator about the diameter of a pencil. The hysteroscope is placed through the cervix into the uterus. The uterus is gently opened with CO2 gas or a fluid. The inside of the uterus then can be seen through the hysteroscope or, more commonly, on a television screen. A normal uterus has a smooth glistening appearance. The glands that line the uterus can often be seen as small white dots on the surface of the lining.

Laparoscopy: Laparoscopy is the classic procedure to evaluate and treat tubal disease. Under anesthesia, an incision is placed in the belly button, and a small television camera is placed through the incision. The doctor can look at the pelvic organs, investigating for signs of endometriosis, scar tissue, and cysts. Problems can be treated with scissors, cautery, or a laser. Most of these instruments can be introduced through tiny incisions, about ¼ inch in diameter.

Tubal cannulation: Devised for the treatment of cornual occlusion, a tiny wire is placed through the cervix and uterus and into the tube. The wire gently opens the tube and may relieve an obstruction in this area. Tubal cannulation can be performed in the X-Ray department under fluoroscopy or via a hysteroscope. A physician who is experienced in the techniques is essential.

Laparotomy: Used less commonly for fertility procedures, laparotomy involves making a larger incision in the skin (1 ½ to 4 inches) so that the internal organs can be directly investigated and seen. While the view is quite good, pain after surgery and recovery time can be quite long. Some studies show a higher long-term complication rate after laparotomy. Laparotomy is generally undertaken only when necessary. The most common indications for laparotomy today are for tubal reanastomosis, repair of the fallopian tubes after tubal ligation, and for removal of fibroids from the uterus (myomectomy). Most adhesions, cysts, and tubal blockages can now be treated laparoscopically.

Devising a treatment plan requires a close relationship with a physician with experience in these areas. A few common scenarios follow:

Hydrosalpinx: A hydrosalpinx is a fallopian tube that is filled with fluid because it is blocked at its end. The blocked tube can communicate with the uterus, and the fluid in the tube can be expressed out the tube into the uterus. This fluid is probably somewhat toxic to early embryo development, and certainly provides an unfavorable environment. Standard fertility treatments and evaluations, such as HSG and insemination, may cause an infection in a hydrosalpinx. Fertility drugs may cause the fluid to build up in the tube, since the tubes are responsive to the ovarian hormones produced during fertility drug therapy.

Hydrosalpinx can be repaired in carefully selected cases, but pregnancy rates remain quite low. Hydrosalpinx can be treated laparoscopically, a procedure known as neosalpingostomy. In neosalpingostomy, an incision is made in the end of the hydrosalpinx and the edges of the incision are folded or flowered back, leaving an open tube. Unfortunately, the tube often closes back up, and pregnancy rates are relatively low.

Repair of a hydrosalpinx works best in women who are young and who have a very small hydrosalpinx, as measured on ultrasound or HSG. A hydrosalpinx can have adverse effects on pregnancy rates with in vitro fertilization. Basically a small hydrosalpinx in a young woman might be repaired, with the understanding that further surgery might be necessary if the repair is unsuccessful; a larger hydrosalpinx should be removed.

Bipolar Disease: Bipolar disease refers to the situation in which there exists injury to both the cornual and the ampullary or fimbrial portion of the tube. It is very difficult to get a satisfactory repair when problems are present at both ends of the fallopian tubes. Most patients with bipolar disease should proceed to in vitro fertilization.

Tubal adhesions: Some patients with an otherwise normal evaluation, including a normal hysterosalpingogram, can have subtle adhesions over the fallopian tube and ovaries. These adhesions appear like cobwebs over the surface of these organs, and can prevent eggs successful ovulation, prevent the tubes from picking up eggs, and limit the mobility of the tubes. Patients at special risk for these problems include those who have used IUDs, had abdominal problems, such as appendicitis or an ovarian cyst removal. Limited adhesions benefit from laparoscopy. The adhesions can be removed with scissors, cautery, or a laser. Age is a significant factor in who will respond to these procedures – younger women benefit more than older women.

Fibroids (Myomas): Fibroids are muscle tumors that result from uncontrolled cell division within the uterus. They can take many forms, but most result in balls of cells, raging in size from pea-sized to grapefruit or even cantaloupe sized. Myomas love hormones, and tend to grow larger and larger throughout the reproductive years, in which high levels of estrogen are produced from the ovaries. After menopause, the myomas tend to decline, and may disappear entirely.

Size is not really the important criterion in assessing myomas: position is. A myoma that is located on the outside of the uterus tends to have little effect on pregnancy outcomes. Those that affect the endometrial lining and compress the cavity of the uterus, or that cause problems with menstrual bleeding are much more significant. If a myoma affects the location of embryo implantation, the inside of the uterus, it is likely to have an effect on pregnancy outcomes.

Assessment of the myoma is best done on ultrasound. Ultrasound will reveal the size and location of myomas and their impact on the endometrial lining. Sonohysterogram, a procedure in which fluid is placed into the uterine cavity to outline the margins of the uterus, sometimes is helpful in assessing size and location. HSG is occasionally helpful. More complex evaluations like MRI and CT scans are sometimes done, but add little to the knowledge gained from ultrasound.

Myomas inside the uterus can often be treated hysteroscopically. A hysteroscope is placed into the uterus under sedation or general anesthesia. Using forceps, scissors, or an electrical blade, the myoma can be removed or shaved off. The resectoscope is a special type of hysteroscope that contains an electrical blade that can be especially useful in removing myomas. The type of procedure used depends on the size of the fibroid and how deeply it is into the wall of the uterus. Fibroids with a very narrow stem-like base and that are small are easily removed, with high success rates. Those that are deeper in the wall of the uterus with a broader base are more difficult to remove and carry a higher risk of injury to the endometrial lining. Fibroids that are very deep in the wall should not be approached hysteroscopically.

Myomas in the wall of the uterus require removal through an abdominal incision. Myomectomy can be performed laparoscopically, but concerns remain over the quality of healing with laparoscopic removal. The technique requires an experienced surgeon. Laparotomy is often preferred. It can be done through a small incision with fast healing and minimal risk. The traditional risks of infection and blood loss with myomectomy can be minimized by new techniques that limit blood flow into the fibroid. Other techniques such as freezing or cautery of the myoma are under investigation.

Tubal Reanastomosis:

Women who have had their fallopian tubes tied sometimes request reversal of this procedure. Fortunately this can be highly successful. If the tubes were tied in an optimal manor, removing minimal tube and limiting use of electro-cautery, the procedure can generally be reversed.

Success rates are determined by the patient’s age, the amount of tube remaining after tubal ligation, and ovarian and sperm health. Evaluation should include review of the tubal ligation operative notes, an ultrasound of the pelvis, a semen analysis, and baseline cycle day 3 FSH and estradiol.

Tubal reversal involves a mini-laparotomy with removal of the damaged portion of the tube and the use of delicate sutures to tie the tubal ends together. While the procedure is highly successful, it does require an experienced surgeon. It is best to find the physician in the area who does the most of these procedures.

Ovarian Cystectomy:

This is usually not done as a fertility procedure, but is often done by a gynecologist for definitive evaluation and treatment of a persistent cyst. From a fertility standpoint, should these cysts be removed?

The answer is not always clear. The issues are – is the cyst life threatening? Is there a possibility of serious disease like cancer in the cyst? Will the cyst grow over time and is there a risk of enlargement and rupture, resulting in further problems during fertility therapy and pregnancy? Will repair of the problem hurt the ovaries and injure the available oocytes?

Assessment includes measurement of the size of the cyst, the mobility of organs around it, the growth rate of the cyst, and its ultrasound appearance. Not all cysts need to be removed, and if the cyst is removed, the remaining ovarian tissue needs to be managed to optimize later fertility. These questions require an experienced physician and must be highly individualized. A physician board certified in reproductive endocrinology is an excellent place to start.