Gynecologic Surgeries offered at IVF Phoenix™
Laparoscopic surgery is a minimally invasive surgery that is performed on the abdomen and pelvis with the use of a fiber-optic instrument measuring 5-10 mm in diameter that is attached to a small camera. This provides visualization of all the abdominal and pelvic organs through a small incision measuring 1cm or less. Laparoscopic surgeries can be used for diagnostic purposes but also to perform various surgical treatments.
Laparoscopic surgeries are helpful for diagnosing and treating a number of infertility conditions including:
Endometriosis is a chronic inflammatory condition where the cells lining the uterus (termed endometrium) appear outside of the uterus including on the ovaries, fallopian tubes, bowel, bladder and peritoneum (the membrane lining the cavity of the abdomen). Similar to the hormonal changes that happen with your uterine lining, this tissue can grow, thicken and bleed—however, this shedding is trapped within your abdomen. This process can be very painful for many women and presents with significant pain with periods though some women may be asymptomatic. Unfortunately, endometriosis can result in the formation of scar tissue surrounding your pelvic organs as well as large cysts in the ovaries termed endometrioma.
A definitive diagnosis of endometriosis cannot be made without a biopsy of endometrial implants in the pelvis which is performed laparoscopically. Laparoscopic treatment of endometriosis includes lysis of adhesions, ablation of endometriosis lesions, and in rare cases removal of endometriomas (if causing pain or very large). This may improve symptoms and pregnancy rates, including for patients with previous implantation failure.
Adhesions are fibrous tissue bands known as scar tissue that causes organs to stick together. Normally, the intra-abdominal organs are fairly mobile and can shift positions as you move. Although painless, adhesions can cause infertility if there is the involvement of the fallopian tubes, ovaries, and uterus. Adhesions can be caused by the previous infection, abdominal surgery, ruptured appendicitis, and endometriosis. It can be surgically corrected by laparoscopic lysis of adhesions.
Fibroids are benign tumors of the uterus that vary in size. Fibroids are fairly common and can be observed in as high as 70% of women. Most fibroids are small in size and are completely asymptomatic, however, some women will develop larger fibroids that can cause pelvic pain, excessive bleeding, and infertility depending on its location within the uterus. Fibroids present within the muscle and outer surface of the uterus often will not interfere with fertility treatments and pregnancy, however, can cause a significant amount of discomfort. Other symptoms caused by large fibroids include constipation, urinary incontinence or retention, pain with sex and increased abdominal girth. When present within or in proximity to the endometrial lining, fibroids can interfere with implantation resulting in infertility, miscarriage, and other pregnancy-related complications.
Fibroids that are located within the muscle of the uterus (myometrium) or the outer surface of the uterus (serosa) can be removed laparoscopically. The size and number of fibroids will determine your eligibility for a laparoscopic approach, however in some cases when the fibroids are too enlarged they may need to be removed through an abdominal incision. Fibroids located within the endometrial cavity are removed by hysteroscopy (see below).
After a laparoscopic myomectomy, you will be required to wait 3-6 months prior to conceiving in order to allow the uterus to completely heal. This surgery may increase your risk of a uterine rupture during labor and most women will be required to have a Cesarean delivery to minimize the risk of such complication.
Hydrosalpinx refers to blocked fallopian tubes filled with watery fluid. This is commonly seen in women with a history of a sexually transmitted infection, moderate to severe endometriosis or previous pelvic or abdominal surgery. Women with blocked fallopian tubes can only conceive through IVF, however when a hydrosalpinx is present on ultrasound, the fallopian tubes must be proximally ligated (blocking the tubes where it inserts into the uterus) or surgically removed before the embryo transfer. Many studies have demonstrated increased pregnancy loss in the presence of a hydrosalpinx. This is presumably because the fluid contained within the tubes is toxic to the embryo and can spill into the uterine cavity.
Hysteroscopy is an endoscopic procedure with a similar fiber-optic instrument to a laparoscope that is attached to a small camera to visualize the inside of the uterine cavity. A hysteroscope is entered through the cervix and thus does not require any incisions. Hysteroscopies are outpatient procedures with short recovery time.
Hysteroscopy can aid in diagnosing and treating various intra-uterine pathologies including:
Fibrous tissue bands can form within the endometrial cavity known as synechiae. A scarred endometrium is called Asherman syndrome. Asherman syndrome can vary in severity but even mild disease can causes infertility. Symptoms of Asherman syndrome includes infertility and recurrent miscarriages due to poor vascularity of the scar tissue, abnormal placentation in pregnancy (placenta previa or placenta accrete) and lack of periods (amenorrhea). Common causes include history of a dilation & curettage (D&C), previous intra-uterine infection (endometritis), surgical removal of fibroids (myomectomy), cesarean section, endometrial ablation (a procedure designed to destroy the endometrial tissue to create lighter menstrual bleeds).
A hysteroscopic lysis of adhesion can be performed to cut the scar tissue. In some cases following surgery, a balloon or catheter may be placed inside the uterus to promote healing without new scar formation in conjunction with hormonal therapy to further reduce that risk.
Polyps are small growths of the tissue that lines the uterus. Polyps can result in infertility, recurrent miscarriages and/or heavy/irregular menstrual bleeding. Endometrial polyps often require surgical removal to improve reproductive outcomes by means of a hysteroscopic polypectomy. In rare cases, polyps located in proximity to the cervical opening can be removed in the office without anesthesia.
Fibroids are noncancerous tumors of the uterine that may grow within the uterine cavity. This too can interfere with implantation, cause recurrent miscarriages and heavy menstrual or intermenstrual bleeding. Fibroids located within the uterine cavity can be surgically removed using a hysteroscope. Unlike with a laparoscopic or abdominal myomectomy, when fibroids are hysteroscopically removed, a vaginal delivery is not contraindicated.
A uterine septum is a condition where a band of tissue is found along the top of the uterus. A complete uterine septum extends from the top of the uterus all the way to the cervix, dividing the cavity in half. More commonly, however, the septum is small (termed a partial uterine septum) and only creates a small deformity within the cavity. Uterine septum is one of the most common congenital abnormalities of the uterus and its presence is highly associated with infertility and increased risk of pregnancy loss. The septum can be removed by operative hysteroscopy. Similar to a polypectomy, following surgery, a balloon may be placed within the cavity to minimize scar tissue formation during healing.
With current advances in minimally invasive procedures, abdominal surgeries are less commonly performed. Though rare, some indications for abdominal surgery include:
- Presence of large fibroids
- Significant scarring within the abdomen causing poor visualization during laparoscopy
- Hemorrhage caused by a ruptured ectopic pregnancy, hemorrhagic ovarian cyst that is actively bleeding
- Pelvic inflammatory disease with tubo-ovarian abscess that has not responded to antibiotics and drainage by interventional radiology
- Pelvic mass that is concerning for a possible malignancy