Fertility Surgery: Hysteroscopy, Laparoscopy, Myomectomy
Reproductive surgery can be a good option for the evaluation and treatment of infertility. Indications for surgery could include abnormal findings on initial testing, failed treatments with oral medication, inability to assess fertility factors with less invasive diagnostic testing, recurrent pregnancy loss or a strong suspicion for a pelvic factor such as endometriosis. The risks and benefits of proceeding with surgical investigation and treatment will be discussed prior to proceeding with these treatments.
Hysteroscopy is a telescopic procedure to evaluate and treat abnormalities of the uterine cavity. This procedure is done under local anesthesia, conscious sedation or general anesthesia. Hysteroscopy can be performed in the office, surgery center or hospital setting. This procedure can readily diagnose uterine abnormalities, such as endometrial fibroids, polyps or a uterine septum. During this procedure, the hysteroscope is passed into the uterine cavity after cervical dilation. Using fiber optic video and fluid distension a diagnostic evaluation of the uterine cavity is performed. These findings can also be treated at the same session with a combination of minimally invasive surgical techniques. Risks for hysteroscopy include standard surgical risks, such as bleeding, infection and anesthetic complications. A rare complication could also include perforation of the uterus, with associated injury and need for additional surgery. These risks, however, are minimized through good surgical technique, safe anesthetic monitoring and prophylactic antibiotics. Postoperative, women can experience generally minimal cramping or vaginal bleeding.
Laparoscopy is also a minimally invasive telescope procedure, which is used to evaluate and treat abnormalities of the pelvis. This procedure is performed with a laparoscope, which is inserted just beneath the navel, or umbilicus, to be able to see the uterus, fallopian tubes and ovaries, as well as other pelvic structures. Abnormalities such as ovarian cysts, endometriosis, pelvic scar tissue (adhesions), and ectopic (tubal) pregnancies can be readily seen and treated with this technique. The ability to know if the fallopian tubes are open can also be tested with a dye injection through the tubes during this procedure. Laparoscopy does require general anesthesia and is performed in a surgery center or hospital setting. During laparoscopy, carbon dioxide gas is used to distend the abdominal cavity, to adequately see and safely perform the operative component of this procedure. Risks for laparoscopy can include bleeding, infection and anesthetic complications, which again are rare and can be avoided with good surgical technique, adequate monitoring and prophylactic antibiotics. The high resolution video used in laparoscopy also is a critical factor to avoid injury to adjacent pelvic structures. Postoperatively, some women can experience mild abdominal discomfort and shoulder pain, generally related to retained carbon dioxide, can also be experienced postoperatively. Great attention, however, to remove the gas is done immediately after the procedure to minimize these effects. Incisional discomfort and risk of infection is generally minimal given the small incisions that are used in laparoscopy. Postoperative pain is well treated with Acetaminophen, or a Non-steroidal anti-inflammatory medication such as Ibuprofen.
The removal of large fibroid tumors is sometimes necessary as part of the reproductive treatment approach. The standard approach is the abdominal myomectomy, performed with either a bikini style or midline vertical skin incision. This procedure involves general anesthesia and is performed in the hospital setting. This procedure generally takes 1-2 hours of surgical time and generally requires a 2-3 day hospitalization. During this operation, the uterus is opened surgically, the fibroids are removed and the uterus is reconstructed with a multi-layer surgical reconstruction technique. Similar to other procedures, bleeding, infection, injury to adjacent structures and anesthetic complications can be minimized with good surgical technique, safe surgical monitoring and prophylactic antibiotics. Risk of postoperative adhesions is minimized with good technique, gentle handling of tissues and specialized anti-adhesion barriers that are placed intra0peratively on the uterine incision. Postoperative discomfort is controlled initially with IV pain medication, which is changed over to oral medication by day 1 after the surgery. Early ambulation and compression devices help to minimize the risk of postoperative blood clot formation. Generally a 2-4 week home recuperative time is necessary after these procedures. Robotic myomectomy is also being increasingly performed, which can help to lessen postoperative discomfort and recovery times. A wait of three months prior to conception is generally recommended after myomectomy to ensure adequate uterine strength. Future pregnancies may also require Cesarean Section based on the location of the fibroids and degree of surgical process required for the myomectomy.