Did you know that 85% to 90% of infertility cases are treated with conventional medical therapies such as medication or surgery? In order to improve your chances of pregnancy, reproductive surgery may be necessary. In women, this surgery is used primarily to treat pelvic pain, tubal disease, endometriosis, congenital anatomic abnormalities, uterine fibroids and pelvic adhesions.
A patient with pelvic adhesions could opt for one of two treatment options: a surgical approach or in vitro fertilization (IVF). IVF bypasses the pelvic adhesions by retrieving the eggs directly. The number of IVF cycles in the U.S. has increased from 64,274 in 1996 to 142,241 in 2009, according to the Society for Assisted Reproductive Technologies (SART). With the increased use of IVF to overcome tubal disease, you might expect the use of surgery to decrease. As it turns out, of the annual 6.2 million U.S. infertile women, only about 1 in 100 undergo IVF to conceive. In the U.S, nearly twice as many reproductive surgeries are performed annually as compared to IVF. At the Fertility Centers of New England, we often use reproductive surgery in tandem with other IVF or assisted reproductive technologies.
For example, one case in which a surgical approach is complementary to IVF is in the patient with hydrosalpinges. “Hydro” means water, and the “salpinge” is the fallopian tube. In this condition, the end of the tube is blocked, and the tube itself fills with cellular water. If a patient with a hydrosalpinges undergoes IVF, the fluid in the tube may pass within the uterine cavity contaminating the environment for embryo implantation. By surgically sealing the proximal fallopian tube prior to an IVF cycle, this contamination is avoided. The surgery is done in a hospital operating room setting, and a small telescope or laparoscope is placed through the umbilicus (belly button) to permit surgical access to the fallopian tube. Incisions are very small (5 mm), and the patient typically returns home a few hours after the procedure. Several studies show that the live birth rate achieved with IVF among women with hydrosalpinges is approximately half of that observed in women without hydrosalpinges. The American Society of Reproductive Medicine concluded, “preliminary laparoscopic salpingectomy or proximal tubal occlusion improves subsequent pregnancy and live birth rates.”
A healthy uterus is required for pregnancy whether you are trying to conceive with IVF or with intercourse. It does no good to transfer of a hard-earned embryo via IVF to a uterine environment that is not optimal. Much of current reproductive surgery focuses on fixing the uterus for future embryo implantation. Some uterine abnormalities, such as a uterine septum, are congenital, having existed since birth. The uterine septum is a fibrous band that is attached to the uterine wall and prevents embryo implantation or subsequent growth of the implanted placenta, often resulting in a miscarriage. A uterine septum can be surgically removed using a hysteroscope. A hysteroscope is a telescope that is placed through a dilated cervix. Saline fluid is passed through the hysteroscope under low pressure to enlarge the uterine cavity and optimize visualization of any pathology. Like laparoscopy, this is a day surgical procedure with discharge to home within hours of the surgery.
Fibroids, known as “leiomyomas,” is a benign tumor of the uterine muscle that may hurt an embryo’s ability to implant and grow within the uterus. Fibroids may run in a patient’s family or may be affected by hormonal changes. In one recent study of infertile women, 11% of women with fibroids conceived without intervention, compared with 42% of women who had surgery to remove their fibroids. Fibroids may reduce chances for pregnancy by deforming the uterine cavity, obstructing the fallopian tubes or impairing blood flow to the uterine endometrial lining. Surgical removal of small fibroids within the uterine cavity may be possible with the hysteroscope alone. Larger fibroids often require an abdominal incision or laparotomy to enable removal. Recovery after a laparotomy is more prolonged and requires overnight hospitalization. You will have to weigh the rigors of laparotomy surgery with the potential impact of the fibroids on reproductive function.
Endometriosis is a relatively common disease, where the inner lining of the uterus (the endometrium) inappropriately travels and implants near other reproductive structures. This implantation often causes bleeding and adhesions, which affect the reproductive function of these pelvic organs. Endometriosis is more prevalent in infertile women. The severity of endometriosis can vary and is staged from mild Stage I to severe Stage IV disease. Controversy exists regarding the positive impact of surgical intervention for endometriosis. Randomized double-blinded studies have reported that laparoscopic treatment of endometrial implants was associated with an improvement in pregnancy rates. Endometriosis within the ovary itself (an endometrioma) reduces pregnancy rates in IVF cycles. One study compared outcomes in patients who underwent laparoscopic endometrioma removal to patients who had endometriomas and no treatment. In this particular study, there were no differences in pregnancy or miscarriage rates between the surgery and control groups.
Laparoscopy and/or hysteroscopy are also used as diagnostic tools to define the cause for a couple’s infertility and guide effective future treatments. Sometimes treatment stops with the laparoscopy itself, and couples conceive on their own after surgical treatment. In other cases, the operation can help define future options and avoid wasted time on ineffective treatments. For example, a patient with a laparoscopic diagnosis of dense pelvic adhesions should avoid ineffective ovulation induction protocols with intrauterine inseminations (IUI) and proceed directly to IVF. In one published study of 229 couples, laparoscopy was used in cases of otherwise unexplained infertility (normal ovulatory cycles, normal hysterosalpingogram and normal semen parameters).The resulting laparoscopic examination showed abnormal findings in 75% of these surgical patients.
Reproductive surgery not only can help diagnose infertility issues, but also can complement other assisted reproductive technologies, including IVF. Before undergoing surgical intervention, you should get a thorough evaluation and balance the risks with the potential benefits. The staff at the Fertility Centers of New England would be happy to discuss your individual surgical requirements and assist you in making your decision.