Advanced Diagnostic and Therapeutic Surgical Procedures

Even after a complete physical examination, X-ray or ultrasound some conditions affecting the female reproductive tract cannot be adequately diagnosed. Therefore, visual examination of the pelvic structures may provide important information about infertility or common gynecologic conditions. Laparoscopy and hysteroscopy allow the physician evaluate the pelvic cavity and to look inside of the uterus. At the same time of the procedures, and if some abnormal conditions are detected, operative laparoscopy or operative hysteroscopy may be performed to correct the disorder. During an infertility evaluation of the female patient, we need to consider that several components of the pelvic cavity may be associated with her inability to conceive. Therefore, several factors have been described. Among them are: Cervical, Uterine, Peritoneal and Tubal Factors. In the following sections we will briefly describe when and how the most common surgical procedures are utilized to deal with some infertility factors. First, we will describe the three most common surgical diagnostic-therapeutic procedures available.

Hysteroscopy.

This is a visual exam of the interior of the uterus. It may reveal the presence of tumors, scars, localized chronic inflammatory processes or congenital abnormalities such as uterine septum, bicornuate uterus, or didelphic uterus. It is done by inserting a device directly into the uterus. If required, the diagnostic hysteroscopy may be converted into an operative if abnormalities are observed. Also, it can be done at the time of laparoscopy or it may be conducted as an office procedure.

Diagnostic/Operative Laparoscopy. This procedure enables the physician to see directly the exterior of the entire reproductive tract (uterus, ovaries, and fallopian tubes) and its association with other organs in the pelvic cavity. This procedure is performed under general anesthesia in a hospital or outpatient surgical center. It is conducted by inserting two long and thin instruments through the abdominal wall. One goes through a small incision below the navel and a second one is inserted through an incision just above the pubis. A lot of information can be gained by looking directly into the exterior of the reproductive tract and several reconstructive procedures may be conducted using this approach. After surgery, the patient may go home the same day provided that no major interventions were conducted.

Hysterosalpingogram. This is an indirect assessment of the structural integrity of the uterus, the fallopian tubes and the pelvic cavity. This is an entirely diagnostic test that consists of inserting a small tube into the cervix and a contrast dye is injected slowly. The flow of dye can be followed using an x-ray study or viewed on a screen or observed directly during a laparoscopy. The test is conducted after menstruation but before the next ovulation. Some discomfort (cramps) may be experienced during and shortly after the procedure is conducted. However, one of the positive side effects may be that the probability of conception appears to increase after the procedure since it may remove some potential obstructive structures.

Tubal Surgery

The oviducts, also known as fallopian tubes or just the tubes are essential for fertilization and early embryo development. They need to be freely floating in the pelvic cavity to enjoy some degree of mobility, need to be healthy and most important open for the gametes and embryos to pass through on their journey from and to the uterus. About one fourth of women infertility problems are associated with the oviducts. In most cases, surgical procedures are the only alternatives to restore oviducts. Most of them are performed using the laparoscopic approach. Some of the reasons for tubal surgery and reconstruction are: ectopic pregnancies, adhesiolysis (destruction of adhesions), blockages or occlusions secondary to salpingitis istmica nodosa, endometriosis and fibrosis, hydrosalpinx, STDs and other inflammatory processes of the pelvic cavity (Crohns Disease, etc) as well as previous tubal surgery.

Uterine Surgery

Uterine defects may be diagnosed by hysterosalpingography and hysteroscopy. The last procedure may be used for corrective purposes. Conditions such as endometriosis, polyps, myomas, intrauterine adhesions, scarring, fibroids and abnormal shaped uterine cavity may interfere with implantation. About 5% of infertility cases may be due to uterine abnormalities.

Peritoneal Surgery

Conditions such as endometriosis, intramural and subserous fibroids, adhesions and scarring may be corrected using the laparoscope. The peritoneal condition as a factor of infertility is found in about 35% of infertile women. Endometriosis. This condition is the most important component of the peritoneal factor as a cause of infertility. Endometriosis is basically, the implantation and development of endometrial cells in other parts of the uterine and abdominal cavities. Since those endometrial cells are responsive to the stimulatory effects of the estrogen circulating during the menstrual cycle they implant and develop very upon the influence of ovarian estrogens. The leading theory explaining how endometriosis begins indicates that retrograde flow of menstrual discharge is deposited in several areas of the pelvic cavity. Endometrial cells may implant on the ovaries or elsewhere in the pelvic cavity. This seems to be a familial condition since women who have relatives (sisters or a mother) with endometriosis have a greater probability of developing the disease. Menstrual cramps, pain during intercourse and abnormal bleeding are some of the early signs of infertility. Oral contraceptives, Danazol, GnRH analogs and progestins may be the first line of therapy for endometriosis. However, advanced cases and its sequel such as adhesions and scar tissue may be removed only by laparoscopic surgery. In some cases, endometriosis leads to infertility directly by way of inducing development of adhesions or indirectly by poorly understood immunology related mechanisms. Conception may be affected in various ways, scar tissue or adhesions may bind or cover the ovaries, fallopian tubes or intestines together. Adhesions may affect the release of eggs from the ovaries and pick up of the egg by the fimbria of the oviducts. Spatial relationship between the ovaries and oviducts may be altered so the eggs may fail to enter the tubes. The inflammatory process by-products such as prostaglandins or other chemicals may interfere with ovulation or entry of the egg into the tube and fertilization. Once pregnancy is achieved, the progesterone rich environment of the pregnant mother appears to negatively affect or inhibit the disease. The condition may often return sometime after pregnancy.