Reproductive Surgeries Explained
“You need surgery” is not what most patients expect to hear at a fertility consult but there are many reproductive conditions that require surgical management, either in addition to or in place of, medical management.
Here we review a few categories of surgery that are common for patients in a fertility practice.
Hysteroscopy involves using a small camera to look inside of the uterus. Imagine looking down the tube of a straw with a magnifying glass. This allows the surgeon to evaluate and treat intrauterine pathology that can interfere with trying to conceive. These are typically same-day surgeries which do not require an overnight stay in the hospital. The most common side effects after surgery are uterine cramping and vaginal bleeding. The benefit of this type of surgery is direct visualization while addressing the intrauterine issue as well as minimal recovery time.
Polypectomy is the surgical removal of endometrial polyps, which are typically benign overgrowths of the endometrial tissue.
Myomectomy is the surgical removal of uterine fibroids within the uterine cavity, or endometrium, termed submucosal fibroids. This is not an effective technique for removing fibroids embedded deeper in the muscle layer or myometrium (intramural fibroid) or those on the outer surface of the uterus (submucosal or pedunculated fibroids).
Lysis of adhesions is the surgical removal of scar tissue from inside the uterus. Scar tissue may form after prior uterine surgeries like myomectomy, cesarean delivery, or dilation and curettage.
Metroplasty is the surgical resection of a uterine septum. A septum develops from failure of the two uterine horns to completely fuse and dissolve in the midline during fetal development and is something one is born with, not acquired or grown over time. The effect is a small wall typically of fibrous or muscular tissue which divides the uterus into 2 halves. The goal is to reduce that division. Think turning a one bedroom into a studio apartment by removing one wall.
Laparoscopy involves using a small camera to look inside of the abdomen and pelvis. Using a camera and laparoscopic instruments, the surgeon can evaluate and treat abdominal and pelvic pathology that can interfere with trying to conceive or affect outcomes of fertility treatment. In some cases, a robot is used to manipulate the instruments during surgery. Depending on the surgery, you may go home the same day or stay overnight in the hospital for observation. The most common side effects after surgery are abdominal soreness and tenderness at the abdominal incision sites. The benefits of surgery are a minimally invasive technique with fast recovery, less pain and infection, and only very small incisions made on the abdomen.
Cystectomy is the surgical removal of ovarian cysts. Types of cysts that may require removal are dermoid cysts, endometriomas, or rapidly growing or large cysts concerning for cancer. Many types of fertility treatment may be possible without cyst removal so it is best to discuss whether surgery is necessary and if there could be an impact on future fertility.
Myomectomy is the surgical removal of uterine fibroids. Laparoscopy may be required to remove uterine fibroids under the serosa (subserosal) or within the myometrium, the muscle layer of the uterus (intramural).
Lysis of adhesions is the surgical removal of scar tissue formed around pelvic structures, like the fallopian tubes or ovaries, or abdominal scar tissue from prior surgeries or infections. This is sometimes necessary in cases of severe endometriosis where chronic pelvic pain is an issue or if the scar tissue prevents mobility of the uterus, fallopian tubes, or ovaries.
Salpingectomy is the surgical removal of the fallopian tubes. The fallopian tubes are necessary for sperm and egg to meet and for the new embryo to grow until it reaches the uterus. However, if there is scarring inside the fallopian tube, fluid or pus can accumulate, resulting in hydrosalpinx which can decrease the success of IVF after embryo transfer. In these cases your doctor may recommend to have the hydrosalpinx surgically removed prior to embryo transfer. Salpingectomy may also occur as a result of gynecologic or pelvic surgery in cases of ovarian masses, torsion, or abscess. If one or both fallopian tubes are removed, a fertility consultation prior to trying to conceive is advised.
Salpingostomy is the surgical opening of the fallopian without complete removal. Either salpingostomy or salpingectomy is done to treat ectopic pregnancies or pregnancies developing within the fallopian tube. In either case, an evaluation of tubal patency of either the opened tube or the remaining tube if one is removed is recommended prior to trying to conceive in the future.
Tubal reanastomosis is the surgical treatment to reverse a tubal ligation. Tubal ligation is done for the purpose of sterilization or permanent contraception to avoid pregnancy. For some, they may consider reversing the ligation with tubal reanastomosis. There are many factors to consider with the chances for success of this surgery, including type of tubal ligation performed, number of years passed since surgery, and whether there are any other contributing factors to infertility, like low ovarian reserve or low sperm count. Given the increased outcomes of in vitro fertilization (IVF), which bypasses the reproductive function of the fallopian tubes, this surgery is less commonly performed than IVF but remains an option for select cases.
Laparotomy or “open” abdominal surgery involves making an incision in the abdomen to access the abdominal and pelvic organs. This is similar to a cesarean delivery for childbirth when vaginal delivery is not possible or safe. Any surgery that can be accomplished via laparoscopy may require laparotomy for safety, access to pelvic organs, or comfort of the surgeon with surgical technique. Using a larger incision is sometimes needed due to the size of a pelvic mass, such as large or multiple uterine fibroids, extensive adhesions in severe endometriosis, or prior pelvic infection. In the event of unexpected injury or difficulty during laparoscopy, there may be a need to convert from laparoscopy to laparotomy. Open abdominal surgery requires more healing time and sometimes 1-2 nights in the hospital. The most common side effects are abdominal soreness, pain along the incision, increased risk for blood loss and infection, and longer recovery time. The benefit of this surgery is the ability to safely complete surgery and begin the process to family building after recovery.
Understanding the complexities and risks of each of these surgeries will better prepare you as you begin your fertility journey. Should any of the above surgeries be recommended to you,
be sure to consult with your physician and create a plan that you feel comfortable with and is in line with your family building goals. If you would like more information on any of these surgeries, please call 212-756-5777 for more information.