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Surgery

Overview

The prospect of surgical intervention arouses feelings of uncertainty in most people. If surgery is related to a fertility disorder, then there is a unique emotional element. Couples that undergo surgery related to infertility treatment sometimes feel immense pressure because so much can depend on its outcome. They may be placing all their hopes in surgery to solve their problem and overcome their infertility. This is a natural reaction, but not always realistic. Try to remember that the treatment of infertility sometimes involves time and often requires more than one treatment.

Diverse fertility problems, in both males and females, can be treated surgically. For male disorders, surgery normally involves the repair of structural abnormalities that are related to the transport of sperm and/or seminal fluid out of the body. Female disorders that might require surgery are more varied in nature and include endometriosis, fallopian tube abnormalities and fibroids. It is important to note that these and other disorders can sometimes be treated medically, that is with drug therapy, instead of surgically. As usual, you must discuss these options with your doctor.

In this section, those female and male disorders that can be treated surgically are reviewed. You can find information regarding the procedures, side effects and so on, as well as results. Every surgical intervention carries risks. Because of this, you must carefully weigh up the risks against the desired goal of the intervention. These are fortunately rare, but the patient must still be made aware of the chances of them occurring.

Decisions and choices play a large role in surgery aiming to restore fertility. That is why it is important that you discuss all the advantages and disadvantages of any procedure extensively with your doctor before any decision is made.

01. Laparoscopy
02. Hysteroscopy
03. Tubal Surgery
04. Surgical Treatment Of PCO
05. Vasectomy Reversal Procedure

Laparoscopy

Laparoscopy is a keyhole surgery technique for examining the exterior of the uterus (womb) and the fallopian tubes. While this surgical procedure is often performed as a diagnostic examination, it can also be used for the treatment of blocked tubes, endometriosis, adhesions, ovarian cysts, ectopic pregnancies or fibroids. Hydrosalpinx, a disorder whereby fluid collects in the fallopian tubes, can also be diagnosed and sometimes treated with laparoscopy.

How It Works:

A laparoscope is a telescopic instrumn normally be covered with a plaster. Using the laparoscope, the doctor can literally see the reproductive organs of a woman and correct any abnormalities such as a blockage, endometriosis, or adhesions (scar tissue) with the help of laser surgery or electrocauterisation. (For women with serious fallopian tube disorders, it appears to generally not be worthwhile to try to address the disorder using laparoscopy. They are generally advised to move directly onto IVF treatment.) If the disorders are more extensive than expected during keyhole surgery, it might be necessary for treatment to be performed through an abdominal operation (laparotomy) either there and then or at a subsequent date. If there is a chance of immediate surgery, it will be discussed with the woman beforehand.

Risks:

A woman will be put to sleep for this operation, which requires a day in hospital. The following side effects may occur:

  • Abdominal pains after the operation, sensitivity of and bruising to the abdomen.
  • Shoulder and abdominal pains as a result of the carbon dioxide.
Nausea or headaches as a result of the anaesthesia

Possible Complications:

  • Damage to internal organs (intestine, bladder, urinary tracts), which require emergency surgical intervention (this is very rare occurring in 2-4 operations out of 1000).
  • Lung oedema (fluid in the lungs, occurs rarely).

Heavy blood-loss and high temperature are signs that a doctor must be consulted.

Results:

The success of laparoscopy can vary dramatically, depending on the reason for the procedure.

 

Hysteroscopy

Hysteroscopy is used to examine the cavity or the lining of the uterus (womb). It can be used for diagnostic examination, or treatment of blocked fallopian tubes, endometriosis or adhesions. Sometimes, examination and treatment occur at the same time. Hysteroscopy is applied to the treatment of uterine fibroids, scar tissue, polyps and congenital disorders such as a uterine partition.

How It Works:

This procedure occurs under either local or general anaesthesia. While diagnostic hysteroscopy can take place in the offices of your doctor, treatment is usually carried out in an operating theatre. The hysteroscope, an illuminated tube, is introduced into the uterus via the cervix. The procedure is normally carried out at the beginning of a womans menstrual cycle. Before the hysteroscope is introduced, the cervical canal is widened (dilated). In addition to the hysteroscope, carbon dioxide or a fluid is also introduced into the uterus in order to enlarge the cavity and to remove blood and mucus that might be present. During surgical (as opposed to diagnostic) hysteroscopy, a larger hysteroscope is employed so that surgical instruments can be introduced into the uterine cavity via the hysteroscope. After the operation, a Foley catheter (flexible tube) or spiral can be placed in the uterus to ensure that the walls do not stick together or form scar tissue. The catheter or spiral is removed after a few days.

Risks

This procedure is not painful, but the following side effects can occur:

  • Abdominal pain after the operations, sensitivity and bruising to the abdomen.
  • Nausea or headaches as a result of the anaesthesia.
  • Cramps and vaginal secretions can occur.

 

Possible Complications

  • Damage to internal organs (intestine, bladder, urinary tracts), which require emergency surgical intervention (unusual side effect, this occurs in 2-4 operations out of 1000).
  • Lung oedema (fluid in the lungs) as a result of the fluid that is injected into the uterus (occurs rarely).
  • Perforation of the uterus (the opening normally repairs itself naturally).
Heavy blood loss and high temperature are signs that a doctor must be consulted.

Tubal Surgery

A number of operations on the fallopian tubes are possible in an attempt to restore fertility, by restoring the functioning of the tube assuming it is not too badly damaged. If a tube is very stretched and stiff, or the cilia too badly damaged or defunct due to fluid accumulation (hydrosalpinx), then it must sometimes be removed. An operation could also be undertaken on the tubes to reverse previous sterilisation. Depending on the reason for the intervention, surgical interventions can be carried out via an abdominal operation (laparotomy) or through keyhole surgery (laparoscopy). Many couples may still have to undergo in vitro fertilisation (IVF) subsequently, and in view of increasing success rates with IVF, surgical intervention is these days becoming increasingly selective. Below you can find a number of different interventions that can be performed on the fallopian tubes. A rough idea will be given of the chances, as far as is known, of pregnancy after the operation, but because this is dependent on many factors, only your doctor will be able to better assess the chances of success for you.

Adhesions:
Adhesions are a major reason for surgical intervention. If there are adhesions around the ovaries and tubes, an attempt can be made to prise the adhesions loose in the hope that the tube will then be in a better state to accept and transport an ovum (egg). The chance of pregnancy after this intervention is estimated at approximately 50%.

Blockage On The Side of the Uterus:
In the presence of a blockage in the tube close to the uterus (proximal or corneal side), the affected part of the tube may be cut out and the tube then stitched back onto the uterus. Here too the chance of pregnancy after this intervention is estimated at approximately 50%.

Blockage at the extremity near the ovary (distal end):
If only the extremities of the tubes (fimbriae) are partially blocked, they can sometimes be opened again (fimbriolysis). If they are completely blocked, then this intervention is referred to as salpingostomy. Depending on the extensiveness of this intervention, the chance of pregnancy is estimated at 25%.

Restorative Operation Following Sterilisation:
If a woman has been sterilised in the past, then the tubes will have been surgically sealed. The sealed off section can sometimes be removed and the ends stitched together using microsurgery. Whether this is technically possible depends on, amongst other things, the length of the tube that will remain behind after such an operation. In order to assess whether such an operation will be of use, a sperm analysis of your (new) partner will also be undertaken beforehand. The estimated chance of pregnancy is 60-85%.

Removal of A Tube:
If the tube is so badly damaged that there is no possibility of repair then a decision is sometimes made to remove it (tubectomy). If serious blockages are present on both sides due to a hydrosalpinx, then IVF is the only remaining option. In this case, as a preparation for an IVF treatment, both the damaged tubes are sometimes removed.

  • Risks
  • Possible complications

Risks:

The risks depend on the nature of the operation, but are, in principle, the same as with any other type of laparoscopy or laparotomy. The following phenomena can occur after the operation:

  • Nausea or headaches as a result of the anaesthesia.
  • Abdominal pains following the operation, sensitivity and bruising to the abdomen.
  • Pain in the shoulders and abdomen as a result of the carbon dioxide used in a laparoscopy.

An abdominal operation (laparotomy) is a more extensive intervention than diagnostic surgery, with bleeding and bruising and an interrupted healing of the wound being the most serious short-term effects. Recovery after abdominal surgery also takes a little longer (a few days) than with a diagnostic operation (one to a few days). In the long term, there is also often the slightly greater chance of an ectopic pregnancy as a result of these operations and/or the development of (new) adhesions.

Possible Complications:

Possible short-term complications:

  • Damage to internal organs (intestine, bladder, urinary ducts), which require emergency surgical intervention (unusual side effect, this occurs in two to four operations out of 1000).
  • Thrombosis.
  • Heavy bleeding and high fever are signs that a doctor must be consulted.

Surgical Treatment Of PCO

If clomiphene does not produce ovulation in women that have polycystic ovarian disease (PCO), surgical treatment of PCO can be considered as an alternative to injections of gonadotropins. Previously, surgical treatment was first developed on the basis of a simple hypothesis; given that the ovary produces too much of the hormone androgen, less of the hormone will be produced if part of the ovarian tissue is removed.

In the surgical treatment of PCO therefore a small piece, or wedge, is removed from the ovary, a procedure that is called a wedge excision. Despite the fact that this procedure was sometimes successful in producing ovulation, it is now rarely used. In some cases, little ovarian tissue remained and, consequently, women were unable to react to subsequent treatment with gonadotropin (injections to stimulate ovulation).

laparoscopic electrocoagulation of the ovaries  (LEO) is now used more frequently. Small holes are burned in the surface of the ovaries, as a result of which the hormonal activities in the ovaries changes. In the first months, particularly, there is a chance of ovulation and therefore a regular cycle. The advantages and disadvantages are not yet fully understood and therefore LEO is not provided in all centres. This method can be used as an alternative to injections of gonadotropins, if clomiphene is not successful.

How It Works:

This procedure can be carried out by laparoscopy and consists of burning small holes in the outer layer or capsule of the ovary using a cauterising needle or laser. Both seem to have the same effect as the previous wedge incision, but crucially much more of ovarian tissue is preserved. Making holes in the capsule appears to be enough to be effective. An increase in the level of follicle stimulating hormone (FSH) observed after the operation and the appearance of a dominant follicle show that the surgery has been successful. Ovulation is permanently restored in some women, while others ovulate for a short time and then return to their previous condition of anovulation. Some women do not react at all.

Risks:

  • In the wedge incision, it is possible that adhesions, a type of scar tissue that can form on the ovaries, will be formed after the operation. These adhesions can cause subsequent fertility problems.
  • Just as with surgery, there is a risk of complications (therefore in practice a drug based therapy using clomiphene is considered in the first instance).

Results:

The LEO method is still not widely used because of the invasive nature of the operation and because little is yet known about the long-term effects of the surgery. However, the percentage of successful ovulation seems to be comparable to that of treatment with gonadotropins..

Vasectomy Reversal Procedure

Vasectomy reversal is used to repair the continuity of the vas deferens in men who have previously been sterilised. Approximately 1% of men who have had a vasectomy subsequently want to have it reversed. Other blockages in the vas deferens or epididymis (where the sperm are stored) caused by breakages or inborn defects can also be repaired in the same way.

  • how it works
  • risks
  • results

How It Works:

There are two different possibilities for a repair operation: re-attachment of the loose outer ends of the vas deferens (vaso-vasostomy) or, if that does not work, connecting one outer end of the vas deferens to the epididymis (vaso-epididymostomy).

In an operation in which the two outer ends of the vas deferens are re-attached (vaso-vasostomy), the surgeon stitches the inner and outer layers of the vas deferens to each other again. In this procedure the continuity of the vas deferens is restored. Vaso-epididymostomy is a bypass procedure in which the innermost and outermost layers of the vas deferens are attached to the epididymis.

Both surgical procedures are carried out on an out-patient basis under local or general anaesthetic. Semen analyses have to be carried out six weeks, 12 weeks and every three to four months after the procedure to see whether sperm cells are present in the seminal fluid. Recurrent checks are needed to be sure that possible scar tissue from the surgery does not itself block the vas deferens or the epididymis.If no sperm has appeared one year after the surgery, the procedure must be viewed as having failed.

Risks:

With both procedures, the repair of the tissue takes almost three weeks. Because the structures are so small, the scar tissue from the surgery can cause a new blockage. Although rare, haemorrhages can occur and cause swellings and infections.

Results:

These surgical interventions do not always have the desired result. Depending on how long the vas deferens and the seminal vesicles have been blocked, it may be that the patients ejaculation still does not contain sperm cells after the surgery. Many men produce anti-sperm antibodies after a vasectomy, which can have an adverse effect on the sperms ability to move through the womans mucous. If a mans vasectomy was performed less than three years ago, there is a good chance fertility is restored. The sperm returns in 95% of such men and the pregnancy rate is 75%. If more than 15 years have passed, the respective percentages are 70% and 30%.

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Dates 2015

4 - 6
Dec

Annual Meeting of the Middle East Fertility Society

Location: Liege, Belgium
More information