Pelvic Reproductive Surgery: diagnostic and therapeutic.
Diagnostic surgical procedures are performed to evaluate the integrity of the woman’s reproductive organs as well as their relationship to other pelvic structures and incorporate the following procedures:
- This ambulatory procedure (outpatient surgery) is usually performed under general anesthesia. It involves making an incision in the woman’s belly button through which a narrow telescope-like instrument is passesd into the pelvic-abdominal cavity in order to permit visualization of pelvic structures. Fine surgical instruments can be passed through a side channel in the laparoscope or via separate puncture sites in the lower abdomen to perform a variety of therapeutic procedures (see below). Diagnostic laparoscopy has become an important part of evaluating female infertility when organic pelvic disease is suspected. Dye also can be infused via a catheter in the cervix and be visualized exiting from the end of the fallopian tube to assess tubal patency. The advantage of laparoscopy over hysterosalpingogram (HSG) is that HSG can only assess patency of the of the tubes. Laparoscopy can also give information about the mobility of the tube and the quality of the fimbraie, both of which are key in egg pick-up into the tube where fertilization occurs. If the tubes are not free, they can be repaired in the same setting.
- Hysteroscopy is a procedure where a thin telescope-like instrument is passed via the vagina through the woman’s cervix into the uterine cavity in order to evaluate its inner structure for the presence of disease or congenital malformations. The procedure can safely be performed under local anesthetic as an outpatient but is often combined with diagnostic laparoscopy. As with the latter, fine surgical instruments can be passed via the hysteroscope for the performance of corrective surgery.
Dilatation and Curettage (D&C)
- This is usually a therapeutic procedure but in some cases it is used to obtain a sample of tissue from the uterine lining for diagnostic analysis. It is usually conducted under local anesthesia but can also be performed in conjunction with laparoscopy and hysteroscopy under general anesthesia.
- This procedure is performed at a specific time of the menstrual cycle as an outpatient with or without local anesthesia. Its purpose is to assess the hormonal influence on development of the endometrium in cases of infertility and/or recurrent miscarriages.
Pelvic reproductive surgery and in vitro fertilization and embryo transfer (IVF/ET) are the two options that must be considered in evaluating the treatment of infertility secondary to organic pelvic disease. The decision as to which option is best suited to a particular case requires an understanding of the relative success rates that can be anticipated for either approach.
Therapeutic reproductive surgery can be performed through laparoscopy or laparotomy where a relatively large incision is made in the lower abdomen enabling the surgeon to have direct access to the pelvic structures or it can be conducted through endoscopy. Endoscopy involves the use of a laparoscope and/or hysteroscope. Today, most therapeutic pelvic reproductive surgery is performed on an outpatient basis through the laparoscope or hysteroscope. In fact, with the exception of tubal reconnection (reanastomosis) after previous tubal ligation, the removal of large uterine fibroids (myomas) and the surgical management of severe pelvic endometriosis, almost all infertility procedures are performed endoscopically. The adage that “if it can’t be fixed through the endoscope, the patient probably requires IVF/ET” is appropriate.
Currently most reproductive surgeons employ microsurgical (use of an operating microscope or loops) techniques and the use of laser technology. Accordingly, patients submitting themselves to pelvic reproductive surgery should carefully select a surgeon with appropriate expertise. Moreover, the first attempt at surgical treatment of infertility offers the best and probably the only realistic chance of optimal outcome, further underscoring the importance of selecting an experienced surgeon to perform the first procedure.
Available statistics suggest that when surgery is performed to the ends of the fallopian tubes (to open the fallopian tube or repair the little finger-like projections, ie, the fimbraie, which pick up and collect the egg(s) from the ovary), pregnancy rates vary from 10-60% depending on the following factors:
Whether the Woman has Undergone Previous End-Tubal Surgery
The first attempt at corrective tubal surgery offers by far the best chance of success. Should the first attempt fail to result in pregnancy, then subsequent attempts are less likely to result in a healthy pregnancy. In other words, women who have undergone a previous failed attempt at tubal surgery have a very much reduced chance of success following a second or third attempt at surgical correction.
The Type of Surgery Performed
Women with blocked tubes in whom the small, finger-like fimbrial projections cannot be reconstructed microsurgically, requiring that the end(s) of the fallopian tube(s) be opened and stitched back or folded back through the use of laser surgery, can expect a low success rate following the performance of this procedure (referred to as salpingostomy). The average chance of a clinical pregnancy occurring following the performance of a salpingostomy in optimal circumstance is 20% within three years of the surgical procedure. In cases where surgery is capable of reconstructing the fimbrial projections of the fallopian tube(s) and mobilizing the ovary(ies) so as to restore the normal anatomical relationship between the end(s) of the fallopian tube(s) and ovary(ies), the average clinical pregnancy rate following the performance of this procedure (referred to as fimbrioplasty) is about 30-35% within three years of the patient undergoing surgery.
When the end(s) of the fallopian tube(s) are normal, and the main factor responsible for infertility relates to the presence of immobilizing adhesions around the fallopian tube(s) of the adhesions are minimal, freeing of such adhesions may result in a relatively impressive pregnancy rate of between 40-60% within three years.
As with salpingostomy and fimbrioplasty, the first surgical procedure provides by far the best chance of a successful outcome.
It should be realized, however, that pelvic inflammatory disease most often attacks the inner lining of the fallopian tube(s), and that, regardless of outside appearances, which might suggest that only one tube is affected, both fallopian tubes are usually involved to some degree. Accordingly, women who conceive following pelvic reconstructive surgery where the cause of the infertility relates to chronic pelvic inflammatory disease have a relatively high incidence of a tubal pregnancy. The reported incidence of subsequent tubal pregnancy ranges between 8 and 17% in such cases. The incidence of tubal pregnancy following surgery in cases of endometriosis is significantly lower.
Based upon the above statistics, it is our policy to consider women with pelvic disease as candidates for fertility surgery when they are eligible for fimbrioplasty or freeing of pelvic adhesions, provided that the surgical procedure represents their first attempt at correcting the infertility problem and provided the anatomic abnormalities are not extensive. Women who require salpingostomy, especially if this is associated with a thickened and diseased lining or wall of the fallopian tube(s) or women who have undergone a previous unsuccessful attempt at tubal reconstructive surgery are likely to have a far better chance of conceiving following IVF/ET performed in our setting.
Women Who Have Undergone Previous Tubal Ligation
Patients who have undergone previous tubal sterilization are candidates for tubal reconstructive surgery in preference to IVF/ET. The most ideal candidates for tubal reconnection are women in whom investigations reveal that the subsequent total tubal length following reconnection will be greater than 4 cm., and cases where the tubes have been divided relatively close to the uterus. The statistical chance of ideal candidates for microsurgical tubal reconnection subsequently becoming pregnant within two years is in the range of 60-75% with a subsequent tubal pregnancy incidence of about 10%.
Women who have undergone previous sterilization and desire to conceive would, under the following circumstances, be deemed eligible for IVF/ET in preference to microsurgical reconnection:
- If they previously have undergone a failed attempt at reestablishing patency of at least one fallopian tube.
- When it is concluded that the surgery cannot ensure that at least one fallopian tube will have a postoperative length of 4 cm.
- Cases where other tubal or pelvic disease coexists.
- Where it is the preference of the patient that IVF/ET be performed rather than tubal surgery.
This procedure involves burrowing a hole in the uterus, removing the blocked segment(s) of fallopian tube(s), and implanting the remaining open portion of the tube into the burrowed hole which extends into the cavity of the uterus. The chance of a clinical pregnancy occurring within one to three years of surgical tubal re-implantation is about 20%. In our setting, IVF/ET offers such patients significant advantages over tubal re-implantation.
Both pelvic reproductive surgery and IVF/ET represent alternative approaches to the treatment of infertility due to female organic pelvic disease. However, it must be recognized that even in the most ideal circumstances, pelvic reconstructive surgery offers no more than a 50-60% success rate within two years (less than 2% per month). In our setting at NCCRM, women under the age of 41, whose infertility is exclusively due to organic pelvic disease, can anticipate a clinical pregnancy rate of better than 40% per IVF/ET procedure and a birth rate of about 25%. Based upon this statistic, these women will usually conceive within four completed IVF/ET cycles of treatment (within one year).
PROTECTION FROM INFECTION
At NCCRM, we are committed to your health and have these steps in place to help prevent you from getting a post surgical infection
The following steps should be taken to reduce chances of infection at your incision site:
- Do not shave or wax hair at the area where your incision will be at least 2 days before your scheduled surgery. Razors cause small cuts in your skin that can lead to infection.
- If your doctor wants any hair removed from the operative site, it will be removed at the hospital using clippers, not razors.
- Your healthcare providers should clean their hands with soap and water or an alcohol hand rub before examining you. If you do not see them clean their hands, please ask them to do so.
- To remove as many germs from your skin as possible, the skin at and around the area where the surgeon will make your incision will be cleaned with an antiseptic Chlorhexadine (CHG) disposable cloth. This will be done after you arrive at the hospital.
- Your doctor may order an IV antibiotic to be given to you before your incision is made. This is usually done once you arrive in the operating room.
- The doctors and nurses in the operating room will clean their hands and arms up to their elbows with an antiseptic solution just before your surgery and they will wear hair covers, masks, gowns and gloves during surgery.
- Before the surgery begins the skin around the operative site will be cleaned again using an antiseptic solution.
Printable Sheet: PROTECTION FROM INFECTION
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