While surgery is not always the first line treatment for infertility there are instances where surgical intervention can help. There are a range of potential procedures that can be beneficial. Some of these are described here:
Laparoscopy
This is key hole abdominal surgery where a fine camera is inserted through a small skin incision (cut) at the umbilicus into the abdominal cavity and pelvis. Gas is then used to make space to allow for surgery to be performed. Skin incisions are normally less then 1cm in length. There are usually a total of three or occasionally four incisions made to perform the surgery. Surgeons operate while looking at a screen and pass fine instruments down the incisions.
Laparoscopy allows for diagnoses such as endometriosis, fibroids, ovarian cysts or blocked fallopian tubes to be made. It also allows for treatment such as removal of endometriosis at the same time.
Tubal flushing with either saline or lipiodol can be performed at the same time as laparoscopy. This is in itself can have a positive effect on fertility.
Common reasons to undergo laparoscopic surgery for fertility include:
- Assessment of pain
- Unexplained infertility
- Removal of endometriosis (excision)
- Removal of fibroids (“Myomectomy”)
- Removal of ovarian cysts
- Divisions of adhesions and treatment of scar tissues
- Assessment and possible removal of damaged fallopian tubes (IVF patients)
- Recurrent embryo implantation failure at IVF
Endometriosis laparoscopy and fertility
Endometriosis is a common gynaecological condition that effects 10% of women of reproductive age with a much higher prevalence in those with fertility issues. Endometriosis is a condition where tissue that normally only lines the uterus (the endometrium) is present on other pelvic structures. Endometriosis can affect the ovaries, fallopian tubes, the outside of the uterus, the cervix, the lining of the pelvis, the bladder and the rectum. Very occasionally it is found on more distant structures. The presence of endometrial cells can result in a chronic, inflammatory reaction in the affected tissues which may result in damage.
There is good evidence that laparoscopic surgery and excision of endometriosis can be beneficial for endometriosis related pain. The approach for fertility is not always as clear and should be guided by discussion about the risks versus the potential benefits to the patient.
It is important that before any surgery involving the pelvis and in particular the ovaries that your surgeon seeks a clear understanding of your fertility goals. Where a surgery is being performed for an endometrioma (an endometriosis cyst in the ovary) the benefits of complete removal of the cyst need to be balanced with any potential damage to the ovary. There is a risk of significantly reducing ovarian reserve (egg count/AMH) with ovarian surgeries and patients can be surprised by this without clear counselling prior. Complicating this, sometimes endometriomas can also be problematic during IVF treatment and in particular at egg collection which may actually necessitate removal. A tailored approach should be taken for each patient.
Laparoscopic treatment of endometriosis has been shown to improve the pregnancy rates in patients with mild to moderate endometriosis (ASRM stage I and II disease).
There is no clear evidence of benefit of laparoscopic treatment of more severe endometriosis for fertility outcomes (ASRM stage III and IV disease). While surgery may be beneficial for some of these patients, in others it can actually have a negative effect on their fertility. This is especially the case where there is significant damage to the ovarian reserve.
Always ensure you have a careful discussion about fertility with your treating doctor prior to any laparoscopic gynaecological surgery. There are some instances where you may benefit from proceeding straight to IVF treatment instead of undergoing laparoscopic surgery.
Laparoscopic removal of fibroids
Fibroids are common non-cancerous growth of the muscle tissue that make up the uterus. They arise from a single smooth muscle cell and are responsive to the hormones oestrogen and progesterone.
Reasons for removing fibroids include heavy periods, pain and pressure symptoms, infertility and recurrent miscarriage and recurrent implantation failure at IVF.
Submucosal fibroids (in the uterine cavity) and some intramural fibroids (in the uterine wall) that distort the cavity of the uterus can be associated with reduced fertility and an increased miscarriage rate. These fibroids only account for <5% of cases of infertility and are normally only treated where other causes have been excluded unless the patient also has troubling symptoms that need to be addressed.
Intramural fibroids are normally removed via laparoscopic surgery. Submucosal fibroids are normally removed by hysteroscope (see below).
Hysteroscopy dilation and curettage
This is a minimally invasive procedure that is normally performed under general anaesthetic. The surgeon introduces a very fine camera (scope) via the vagina and the cervix into the uterine cavity. This scope has a light and uses pressurised water allows the surgeon to see inside the uterus and check if there are any lesions such as polyps or fibroids that can affect fertility.
Other structural abnormalities such as uterine septum may also be identified. A curettage can be performed to sample the lining of the uterus to check for pathology such as chronic inflammation or pre-cancerous change for example. Additional surgeries can also be performed at the time of hysteroscopy.
These include:
Hysteroscopic resection of fibroids
Uterine fibroids that significantly impact the uterine cavity are associated with recurrent miscarriage, recurrent implantation failure during IVF treatment and infertility. They can also cause irregular and heavy bleeding. In this procedure the hysteroscope is used to remove these fibroids and normalise the shape of the uterine cavity
Hysteroscopic reception of a uterine septum
A uterine septum is a band of tissues that often runs vertically in the uterine cavity. Depending on their size they can divide the uterine cavity in half. They can be associated with infertility, recurrent implantation failure during IVF treatment, miscarriage, preterm birth and malpresentation in late pregnancy. Surgery is not a first line treatment for the uterine septum but it can be of benefit in certain circumstances. In this procedure the operative hysteroscope is used to divide (cut) the septum and normalise the shape of the uterine cavity.
Hysteroscopic removal of uterine polyps (“polypectomy”)
This is where polyps in the uterine cavity that are identified during hysteroscopy are removed under visual guidance and sent for testing with pathology. Uterine polyps are associated with abnormal bleeding and can also have a negative impact on fertility. Occasionally they are pre-cancerous or cancerous. It is usually recommended that they are removed via hysteroscope when identified on ultrasound during fertility work up.
Hysteroscopic division of adhesions
Some patients will be affected by adhesions within the uterine cavity which is a condition called Asherman’s syndrome. This can result in infertility. Diagnosis and division of these adhesions can be performed at hysteroscopy.
