Evidence-based medicine has demonstrated that the incidence and frequency of infertility is increasing. This is partly due to women deferring pregnancy until a later age (for career, financial or personal reasons), and also from other medical conditions such as pelvic adhesions, endometriosis, tubal occlusion, sexually transmitted infections, sperm abnormalities, genetic and anatomic causes. Fortunately, the treatment options for infertile couples have also been expanding. In this article, I will focus on minimally-invasive, or non-invasive surgical options for the fertility challenged couple.
Initially performed as an in-patient procedure, laparoscopy has evolved and been refined significantly over the past 20 years. Modern laparoscopes now are available in sizes as small as 1.9 mm diameter. High intensity Xenon illumination has been developed, and high-resolution digital cameras are now available. Thus, during the past 15 years, most modern operative laparoscopy employs the use of video monitoring systems, so that the entire operative team can visualize the operative field and assist and be involved in the surgical procedure, in the same fashion that open surgical procedures are done. This has spawned the development of “endoscopic surgical suites” in most surgical facilities. The advantage of videolaparoscopy is that only a few very small (1/2 inch) incisions are required, and most women can go home the same day. Post-operative pain is minimized, scars are minimal, and surgical risks are reduced. Recovery is faster and detrimental effects of adhesions on future fertility are minimized.
Laparoscopy allows gynecologists and reproductive surgeons to diagnose causes of infertility and to determine if a woman’s fallopian tubes are open. Physicians can identify the presence of endometriosis, ovarian cysts, uterine abnormalities such as fibroids, pelvic adhesions and other pelvic pathology.
For a woman to become pregnant, it is necessary that at least one of her fallopian tubes is open and anatomically normal. While another radiology test, called a hysterosalpingogram (HSG) can be used to determine if tubes are open, the laparoscope is more accurate and is the “gold standard” for evaluation of a woman’s fertility status. In addition to visualizing if there is free flow of a blue colored solution through the tube(s), the surgeon can also visualize the quality of the fibria (the end of the tube) and determine, with a high degree of accuracy, if the tubes are likely to function normally to allow for pregnancy. If the tube has adhesions restricting its motion, or if there are adhesions around the woman’s ovaries, these can be removed. Both ovaries are also identified, and again, evaluated for evidence of pathology. Photographs are typically taken for the patient’s records and later reference.
Another important structure is the uterus. This is where embryos implant, and where pregnancies develop and are nourished. The presence of benign uterine tumors called fibroids (myomata uteri), can, depending on their location, number and size, have a significant effect in the ability of the woman to either become or stay pregnant. Fibroids are one of the most common abnormalities seen, and if a women is not trying to become pregnant, may not require treatment. However, when pregnancy is desired, it is very important to consider removal of large (>4 cm) fibroids within the uterine wall, and to remove fibroids located within the uterine cavity, usually via a hysteroscopic approach.
Endometriosis is another commonly seen problem in women during their reproductive years. In some cases, endometriosis does not seem to have a significant effect on becoming pregnant. In others, it can prevent pregnancy and/or implantation via mechanisms that are still not completely understood. Many studies have shown that removal of pelvic endometriosis at the time of laparoscopy may have a beneficial effect on subsequent fertility. Like uterine fibroids, endometriosis may recur even after removal, and patients should be aware of this possibility. Thus the best “window” for pregnancy occurs in the first year or so following treatment or removal of endometriosis.
Ovarian cysts are another common finding in women trying for pregnancy. If these cysts are from normal ovulation, then simply waiting 1-2 months, or possibly using oral contraceptives for one cycle will cause them to regress. In other cases, cysts can be from endometriosis within the ovary (called an endometrioma) or from benign or rarely malignant tumors. Laparoscopy again allows the reproductive surgeon to remove these ovarian cysts, in order to maximize future fertility.
Pelvic and abdominal adhesions (scar tissue) is an additional cause for both pelvic pain as well as infertility. These adhesions can obstruct the ends of the fallopian tubes, can interfer with egg transport from the ovary to the tube, and can distort pelvic anatomy. The impact on fertility can be substantial, and again every effort is made to remove as many of these adhesions as can be safely accomplished. Experience has demonstrated that there is a risk of new adhesions forming following any type of surgery. This risk, however, is minimized with the use of laparoscopy, as compared to an open abdominal approach.
Approximately 2% of pregnancies occur in a woman’s fallopian tube, rather than in her uterine cavity. These tubal pregnancies are also called ectopic pregnancies. Ectopic pregnancies can be a serious problem for women if they rupture, and in fact ruptured ectopic pregnancies are the leading cause of death in early pregnancy. Fortunately, with current technology, most early ectopics can be identified by measuring a woman’s rise in her hCG hormone level. This rate of rise has a close correlation with normal versus abnormal pregnancies. Combined with early ultrasound, most ectopics can be identified before there is a risk of rupture, which allows for these abnormal pregnancies to be either treated by laparoscopy, or by injection of a medication called methotrexate, which dissolves and eliminates the abnormal pregnancy.
Evidence-based studies have demonstrated that patient outcomes are, in most cases, better with laparoscopy than with open incisional approaches. Improved technical innovations (such as radial dilating abdominal access systems, ultrasonic surgical instruments, argon beam coagulation, surgical lasers and adhesion prevention products) have all contributed in making these procedures more effective and safer for women.
Early hysteroscopy was used only for diagnostic purposes, as a means of seeing inside the woman’s uterus to look for causes of infertility, or to diagnose causes of irregular bleeding such as uterine polyps. Again, as instrumentation and experience (and patient demand) increased, modern operative hysteroscopy allows the use of very small or flexible hysteroscopes and video monitoring systems. These procedures do not require any incisions and are performed by using the woman’s cervix for uterine access. Office hysteroscopy is now a common procedure as it requires little or no anesthesia and allows the fertility specialist to view the uterus as well as the openings to the fallopian tubes. There is even a smaller flexible scope that can be placed into the fallopian tubes in order to visualize their lining and quality.
In addition to diagnosis, the operative hysteroscope is used for removal of fibroids within the uterine cavity in order to restore normal intrauterine anatomy prior to pregnancy. Removal of endometrial polyps, and lysis (removal) of adhesions within the uterine cavity also can be accomplished. Uterine anomalies causing recurrent pregnancy loss, such as the presence of a uterine septum, can effectively and safely be removed without the need for a large abdominal incision as was required prior to the development of operative hysteroscopy.
To perfom hysteroscopy, the surgeon uses a continuous flow of liquid to separate the walls of the uterus and provide a “working space” for specialized instruments. Because all hysteroscopic procedures are ambulatory in nature and require no incisions, women can go home either immediately after, or within a few hours of their completion; most women are back to virtually all normal activities later that same day.
Fallopian tubes can be damaged from prior surgery, scar tissue from either prior surgery, from pelvic infections, or from pelvic endometriosis. In many women with damaged fallopian tubes, the end of the tube will seal shut and the tube will fill with fluid and not function. This is called a hydro (water) salpinx (tube). The presence of a hydrosalpinx will not only make the chance of a future pregnancy very unlikely, it will also reduce the chance of a successful pregnancy even using In Vitro Fertilization (IVF) techniques. A number of published studies have demonstrated that if a woman undergoes an IVF cycle, her chance of a successful pregnancy outcome will be reduced as much as 50% with the presence of one or two fluid-filled fallopian tubes. Because of these findings, women interested in pursuing IVF have, in the past, been advised to have their tubes either removed or burned and sealed using a laparoscopic, or in some cases, using an open surgical technique.
More recently, with FDA approval of a transcervical sterilization coil, women now have the option for an “off label” use of this device for sealing their fallopian tube(s) before IVF. This tubal coil is placed using an office hysteroscope, and requires no major anesthesia or any incision. After a three-month waiting period for the tube(s) to occlude, the woman can then proceed with her IVF cycle and have the best chance of a successful pregnancy outcome. Although this coil was developed initially for permanent female sterilization using a no incision approach, this is yet another example of how minimally-invasive surgical techniques can improve the fertility status of women with hydrosalpinges.
MICROSURGICAL REVERSAL OF TUBAL STERILIZATION (MTR)
Initially, microsurgery was the domain of eye surgeons, ear surgeons, neurosurgeons and plastic surgeons, all using very small instruments, and aided by an operating microscope for achieving precise and exacting reconstructive surgery. Microsurgery has now been developed for women with infertility. One of the first applications of microsurgery was for correction of prior tubal damage, and for women who had been previously sterilized and desired to have their tubes reopened for additional pregnancies. This new field of microsurgical repair involved not only use of the operating microscope and small instruments, but also required surgeons to learn “microsurgical technique” which is quite different and more exacting than standard gynecologic surgery. Benefits to patients include better outcomes, higher fertility, and in the case of tubal reversal, high pregnancy rates. Tubal reversal surgery is now performed in ambulatory surgery centers and office-based surgical centers, with women going home later the same day of their surgery. Post-operative pain is less than with other techniques, and pregnancy rates in the best tubal reversal centers (published literature) averages 60%. This has continued to evolve, such that all tubal reversal procedures performed in our office-based operating room are discharged home within two hours after completion of their reversal surgery. Current pregnancy rates following microsurgical tubal reversal surgery in women under age 38 average 75-80%. Tubal reversal can now even be accomplished remotely with the introduction in 2000 of computerized laparoscopic robotic surgical systems.
One of the known risks of any type of surgery is the subsequent development of scar tissue, more commonly called adhesions. If a person has a mole removed from her skin, the scar tissue formed is minimal and will not cause any other future medical risks. In the case of abdominal or pelvic surgery, any procedure carries with it the risk of adhesions forming as a result of the healing process. These intra-abdominal adhesions can produce subsequent pelvic pain, can interfere or damage fallopian tubes, thus increasing future infertility, and can result in bowel obstruction which necessitates further surgery. Studies have demonstrated that the risk of adhesion formation is higher if an open abdominal incision is used, and if non-microsurgical techniques are employed. The use of minimally-invasive and/or endoscopic surgery has significantly reduced the chance of adhesions forming.
However, even in the best of hands and with the best of surgical techniques, there still remains a risk of post-operative adhesion formation. To address this risk, a number of manufacturers have developed an array of patches, liquids, foams and gels to be applied to the surgical site(s) at the time of surgery in order to minimize or reduce the risk of subsequent post-operative adhesions. To date, these products are partially effective, but more effective spray adhesion barriers are currently undergoing clinical investigative studies in the United States. Early, preliminary data suggests that this new generation of adhesion-prevention product will be easier to apply and more effective at reducing the risks of post-operative adhesion formation.
Ultrasound, while not a surgical technique, has evolved tremendously since its introduction in the late 1960’s. Today, most gynecologists and infertility specialists have one or more high-resolution ultrasound systems, which can view a woman’s uterus, ovaries, and pelvis in a non-invasive, painless and safe manner. The presence and size of ovarian cysts, uterine fibroids, and other pelvic abnormalities are easily seen. Early clinical pregnancies are diagnosed and followed using transvaginal ultrasonography. Ultrasound is also used to remove eggs from a woman’s ovaries, to measure the thickness and quality of her uterine lining, and to guide placement of embryos during In Vitro Fertilization procedures.
In addition to the standard black-and-white ultrasound, there is now color Doppler ultrasound and three-dimensional ultrasound available for specific applications. A special type of examination, termed a saline infusion sonohysterogram (SIS) allows real-time ultrasound to be performed in a physician’s office, with the ability to accurately evaluate the interior of a woman’s uterus for the presence of adhesions, polyps, fibroids or uterine anomalies such as a septate uterus. Since the ability of a woman to achieve and maintain a pregnancy is directly related to the normalcy of her uterus and uterine lining, the presence of these anatomic abnormalities can reduce her fertility. If abnormalities are detected, then an operative hysteroscopic approach can be used for removal or correction of these abnormal findings.
Contemporary medicine allows physicians to provide minimally-invasive surgery, or in some cases, non-invasive techniques for their fertility patients. These methods are used initially for the accurate diagnosis and evaluation of a woman’s fertility status, and to identify probable causes for her reduced fertility. Along with tests to measure sperm function and egg quality, an endoscopic approach for treatment allows the woman to avoid or have minimal incisions, and to reduce the recovery period and discomfort of conventional surgical treatments. In addition, patients have reduced costs, reduced risks of developing post-operative adhesions, reduced pain and recovery times, and a better chance of achieving a successful pregnancy. Ongoing clinical research continues to develop new and better methods for patient care, and less invasive, safer and more effective surgical techniques for the treatment of abnormal findings. Fertility treatment thus remains a dynamic and rapidly evolving field, and an exciting and rewarding specialty in which to practice.
Donald I. Galen, M.D., FACOG is the Endoscopic and Surgical Director, Reproductive Science Center of the San Francisco Bay Area and Assistant Clinical Professor of Ob/Gyn, University of California, Davis