Fertility Surgery

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 is keyhole surgery 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.

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, but I advise a two week recovery period afterwards.

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 taking about 30 minutes.

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. Drilling sounds awful, but is in fact a simple laparoscopic treatment where excess hormone producing tissue deep in each ovary is destroyed by diathermy. A hot needle is inserted for 5 seconds or so at a number of places in each ovary, and thorough irrigation performed immediately afterwards to cool the tissues. 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.

As many as 3% of women are born with an abnormally shaped womb or vagina which if minor may not affect them at all, but in certain cases can be associated with pain or bleeding during sex, infertility, miscarriage and premature labour. A division of the vagina can be transverse, effectively blocking the outflow of blood from the womb, or more commonly longitudinal, when it may be accompanied by a double cervix, and in some cases a double womb. A transverse septum usually presents with pain associated with the start of periods when the blood accumulates in the upper vagina. A longitudinal septum is often only discovered when a woman presents for a gynaecological exam. Surgery to unify the two portions may be arranged as a day case procedure, and is relatively uncomplicated in most cases, but should only be performed after a complete assessment of the pelvic anatomy for other associated abnormalities of the womb, and in some cases, the kidneys.

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.

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 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.

Dilatation and curettage refers to the stretching of the neck of the womb (cervix) and removal of the womb lining. The procedure is very quick but requires a general anaesthetic. It is indicated in women who have bleeding disturbances, those with polyps inside the womb, and those with repeated miscarriage or fertility treatment failures. The operation is usually combined with a hysteroscopy. The womb lining is sent for histopathological examination. The procedure is increasingly done in women with repeated fertility treatment failures as a means to adjust the immunological environment inside the womb, which may increase the chance of implantation of a pregnancy.