Reproductive Surgery Techniques
by Michael Doyle, M.D. and Shaun Williams, M.D.
From the 2007 ART Resource Directory

An integral part of the fertility evaluation is an assessment of the anatomy of the reproductive tract, as abnormalities of the uterus, fallopian tubes, ovaries, and lower pelvis are common causes of both infertility and recurrent pregnancy loss. Anatomic abnormalities can be identified through the medical interview process, the physical exam, or through specific imaging evaluations, such as the hysterosalpingogram and ultrasound. Surgical treatment of any conditions is an option which is often considered prior to any traditional fertility treatments. Reproductive specialists utilize numerous techniques to correct specific problems while minimally altering surrounding structures in efforts to increase the efficiency of the reproductive organs.
 
Reproductive surgical procedures within the abdomen are usually approached one of two ways, either by a larger incision on the lower abdomen (called a laparotomy), or through minimally invasive means utilizing small incisions and cameras (called laparoscopy.) Most procedures can be performed utilizing laparoscopy, and reproductive specialists typically have greater expertise with this form of surgery than other general practitioners. Many uterine cavity abnormalities can be corrected without any incisions at all, through the use of hysteroscopy. This involves dilating the cervical opening of the uterus and passing an operating camera into the cavity. Both laparoscopy and hysteroscopy are usually outpatient procedures, allowing women the ability to go home the same day with minimal recovery necessary, while larger incisions require at least an overnight hospital stay.
 
During laparoscopy, different instruments are available to help surgeons perform the delicate surgeries often needed when correcting abnormalities. These are specially designed to be passed through small incisions in the abdomen allowing procedures to be performed while observing the monitor image from the laparoscopic camera. Typical surgical instruments such as scissors and scalpels can be modified for this use, but also other means to cut and dissect are often employed. Electrosurgical, laser, and ultrasonic instruments are available to help surgeons perform many procedures with ease. All methods are equally effective in experienced hands.
 
Many procedures can be performed laparoscopically. Laparoscopy is commonly performed in many women for the evaluation of pelvic pain which is often due to endometriosis. It is of particular benefit to be able to closely evaluate the surface lining of the pelvis with the camera in close proximity to diagnose and treat endometriosis, a disease which can cause both pain and infertility. For many women, a laparoscopy following an initially normal evaluation can be of benefit to diagnose pelvic conditions such as endometriosis and pelvic scar tissue.
 
Laparascopy has also been used to repair tubes after a prior tubal ligation, allowing women who have had the tubes “tied” an opportunity to become pregnant. Uterine fibroids can be excised laparoscopically, although this procedure is most commonly performed through a larger incision. Other procedures which have traditionally been performed by laparotomy are now able to be performed through laparoscopy. These include removal of diseased ovaries or tubes, hysterectomy, bladder surgery, and lymph node surgery in cases of pelvic cancers.
 
Hysteroscopy involves the placement of an additional telescope (the hysteroscope) through the dilated cervix, directly into the uterine cavity. No incisions are required for this, and
depending on what is found, hysteroscopy usually takes about 15-45 minutes to perform. This procedure also can be performed as a diagnostic test to help identify abnormalities during an initial evaluation. Defects involving the uterine cavity, such as fibroids, polyps, scar tissue, and developmental abnormalities, can be corrected using hysteroscopy. Additionally, blockages of the fallopian tubes can at times be corrected during this procedure.
 
Even though hysteroscopy involves no incisions, it is usually performed under anesthesia as dilation of the cervix can be uncomfortable. Small, flexible hysteroscopes are available which can be used in the physician’s office using only minor or local anesthesia. This provides a convenient method to identify uterine abnormalities without requiring anesthesia, but if significant abnormalities are present, an outpatient surgery is usually necessary. The recovery from a hysteroscopy alone is generally only 24-48hours, since no incision is required. Risks are minimal, and include very low chances of bleeding, infection, or uterine perforation.
 
Following laparoscopy, 3-4 days of recovery is the average time most patients need to feel basically back to normal. Some amount of abdominal pain often persists for a few days, so patients are advised to take prescribed narcotics to control this pain before it gets severe, rather than letting it get out of control. The anesthesia effect (“feeling washed out”) can also last several days. Most people return to work after 3-4 days, though there is a wide range of variation.
 
Laparoscopy, hysteroscopy and at times laparotomy are excellent tools to assist the reproductive endocrinologist in diagnosing and correcting physical conditions that can impact fertility. With the information provided from this surgery, the physician can also determine which additional non-surgical therapies may also be considered to assist patients in achieving a healthy pregnancy.
 
 
Michael Doyle M.D. is the founder and medical director of the Connecticut Fertility Associates. His specific areas of expertise include
microsurgery, advanced laser laparoscopy and hysteroscopy, treatment of severe endometriosis, management of male fertility, and in vitro fertilization. Shaun Williams, M.D., is board certified in obstetrics, gynecology, and reproductive endocrinology. His interests include recurrent pregnancy loss, ovulation disorders including polycystic ovarian syndrome, and assisted reproductive technologies.
Connecticut Fertility Associates
4920 Main Street
Bridgeport, CT 06606
Phone: (203) 373-1200 Fax: 203-365-6516
http://www.connecticutfertility.com