Surgeries

Sometimes fertility problems can result from a person’s body structure (anatomy). A physical complication may be something one is born with, such as a blockage of the reproductive ducts in a man or an abnormally shaped uterine cavity in a woman. Fertility challenges can also result from conditions that develop over time, such as fibroids or scarring from endometriosis.

Physical complications can often be successfully addressed by surgical procedures. A doctor may recommend one of the following procedures before advising fertility medication or therapy. See the links below to learn more.

Hysteroscopy

This procedure can often remove uterine polyps or fibroids (myomas) or uterine scarring from prior surgical procedures. Hysteroscopic surgery is also used to correct a congenital ‘septate uterus,’ wherein the uterine cavity is partitioned by a long band of tissue. In this procedure, the doctor looks inside the uterus with a slender, lighted camera called a hysteroscope. The hysteroscope is guided through the vagina and cervix and into the uterus. The uterus is gently opened with CO2 gas or a fluid enabling the doctor to see the uterine lining on a monitor. Next, small instruments are inserted through the hysteroscope to surgically correct the problem. This procedure does not involve any incisions on the skin and is almost always a day surgery procedure. It does require general anesthesia as dilation of the cervix and distention of the uterine cavity with gas or fluid would be very uncomfortable. Recovery times are typically 1-2 days.

Laparoscopy

Laparoscopy is a well established procedure used to evaluate and treat abnormal tissue growth (endometriosis) as well as scar tissue, abnormal ovarian cysts such as teratomas or endometriomas, some uterine fibroids and tubal adhesions (thin bands of scar tissue that cover the surface of the fallopian tubes and ovaries). In rare cases, laparoscopy may be recommended to treat a condition called hydrosalpinx (a fallopian tube that has become filled with fluid). The laparoscope is a thin, lighted viewing instrument, similar to a hysteroscope. The surgeon inserts the laparoscope through the umbilicus (belly button) into the pelvic area in order to view the reproductive area. The laparoscope can also be fitted with attachments to facilitate surgery. Further small incisions (about ¼ inch wide) may be made to enable the use of additional surgical instruments. This procedure does involve tiny incisions on the skin and is almost always a day surgery procedure. It does require general anesthesia. Recovery times are typically 1-7 days, depending on what procedures were performed in the pelvis.

Robotic-assisted laparoscopy. This is an adjunct to routine laparoscopy performed by surgeons specialized in using robotic systems to activate the instruments. It allows for accurate and effective suturing of tissues that are being operated upon. It is very useful in performing myomectomies (removal of uterine fibroids) through the laparoscope.

Tubal Cannulation

This is a delicate procedure that can clear blockages in the fragile area connecting the uterus and fallopian tubes, what is known as a “proximal tubal occlusion.” Proximal tubal occlusion is quite rare so this is an uncommon procedure. This procedure is done in radiology or in the operating room. The radiologist or surgeon places a small tube or very fine wire through the cervix and uterus to remove the blockage. This procedure can be done on an outpatient basis and does not usually require anesthesia.

Laparotomy

A much less common procedure, laparotomy involves making a larger incision in the skin (1 ½ to 4 inches). It may be recommended for removal of very large uterine fibroids or in the repair of fallopian tubes damaged by tubal ligation. As this procedure does involve a sizeable skin incision, a hospital stay of 2-4 days is typical. It does require general anesthesia. Recovery times are typically 2-6 weeks, depending on what procedures were performed in the pelvis.

Tubal Ligation Reversal

Women who have had their fallopian tubes tied sometimes wish to reverse the procedure. A highly successful procedure called tubal ligation reversal uses a mini-laparotomy to remove the damaged portion of the fallopian tube. Delicate stitches then re-connect the tubes. The procedure is usually done by a laparotomy incision (see above), so is a major abdominal surgery. As it is rarely covered by medical insurance, this can be quite expensive, so most women with prior tubal ligations that now wish to conceive most commonly do in vitro fertilization instead of tubal reversal surgery.

Ovarian Cystectomy

For young and healthy reproductive age women, ovarian cysts that appear to be benign (non-cancerous) can usually just be followed with ultrasonograms every six months to one year. Assessment includes observing the size of the cyst, the mobility of organs around it, the growth rate of the cyst, and its ultrasound appearance. Not all cysts need to be removed, and if the cyst is removed, the surgeon must be careful to preserve as much of the normal surrounding ovarian tissue as possible. We recommend that a patient consult a physician who is board certified in reproductive endocrinology if there are concerns regarding a recurrent cyst(s).

Endometriosis

This is a common condition in which tissue that normally lines the uterine cavity (endometrium) is present in the pelvic cavity, where it does not normally belong. Endometriosis is associated with two things: infertility and pelvic pain. If a woman has significant chronic pelvic pain, laparoscopy is indicated to determine if their endometriosis and associated scar tissue is present and can be safely removed. If there is minimal or no pelvic pain, only infertility, there is no reason to do surgery to look for endometriosis. This is because endometriosis is a chronic condition and even if found and removed, will, likely reoccur. Studies have shown minimal improvement in fertility rates following pelvic surgery for endometriosis. In most cases of significant endometriosis, in vitro fertilization is the best course of treatment.