Diagnostic and Therapeutic Pelvic Surgery
Pelvic Pain
Pelvic pain is an uncommon but significant problem in some women. Careful assessment of pelvic pain with a reasonable diagnosis and comprehensive treatment program is the first step toward relief and return to function.
Learn more about pelvic pain.
Diagnostic Pelvic Surgery
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 may include:
Laparoscopy
This 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 passed into the pelvic-abdominal cavity to permit visualization of pelvic structures. Delegate 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. Diagnostic laparoscopy has become an essential part of evaluating female infertility when organic pelvic disease is suspected. Dye can also 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 evaluate the patency of the tubes. Laparoscopy can also give information about the mobility of the tube and the quality of the fimbrae, 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
Hysteroscopy is a procedure where a thin telescope-like instrument is passed via the vagina through the woman’s cervix into the uterine cavity 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, delicate surgical instruments can be passed via the hysteroscope for the performance of corrective surgery. Learn more about hysteroscopy.
Dilatation and Curettage (D&C)
This is typically 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.
Endometrial Biopsy
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 the development of the endometrium in cases of infertility and/or recurrent miscarriages.
Therapeutic Pelvic Surgery
Pelvic reproductive surgery and in vitro fertilization and embryo transfer (IVF/ET) are the two options considered in the treatment of infertility secondary to organic pelvic disease.
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, except for 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.
Patients submitting themselves to pelvic reproductive surgery should carefully select a surgeon with appropriate expertise. The first attempt at surgical treatment of infertility offers the best and probably the only realistic chance of an optimal outcome, underscoring the importance of selecting an experienced surgeon to perform the first procedure.
Factors that Influence Pregnancy Rates After a Tubal Surgery
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.
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 circumstances 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) 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), with the adhesions being 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 Surgery
Patients who have undergone previous tubal sterilization are candidates for tubal reconstructive surgery in preference to IVF/ET. The ideal candidates for tubal reconnection are women in whom investigations reveal that the subsequent total tubal length following reconnection will be greater than 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 have previously 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 coexist.
- Where it is the preference of the patient that IVF/ET be performed rather than tubal ligation surgery.
Tubal Re-Implantation
This procedure involves burrowing a hole in the uterus, removing the blocked segment(s) of the 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.
Pelvic Organ Prolapse Repair
Pelvic organ prolapse occurs when one or more organs in the pelvis—such as the bladder, bowel, uterus, or the top of the vagina—slip out of their normal position and bulge into the vaginal canal. While this condition is not life-threatening, it can cause discomfort, pain, pressure, and difficulties with bladder or bowel function. Fortunately, pelvic organ prolapse is treatable, with both nonsurgical and surgical options available.
Urinary Stress Incontinence
A related condition, urinary stress incontinence, involves the involuntary release of urine during activities that place pressure on the bladder, such as coughing, sneezing, or lifting. This condition can range from mild to severe; however, effective treatment options are available. One of the most common procedures is the TVT (tension-free vaginal tape) mid-urethral sling. In this procedure, a small strip of mesh or tissue is placed under the urethra (the tube that carries urine from the bladder). Acting like a supportive hammock, the sling helps lift and stabilize the urethra and bladder neck, reducing or eliminating leakage.
Surgical Options for Pelvic Organ Prolapse
When symptoms are more severe or nonsurgical treatments are not effective, surgery may be recommended. Surgical approaches include:
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Reconstructive Surgery: Restores pelvic floor support and repositions organs to their normal location.
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Obliterative Surgery: Narrows or closes part (or all) of the vaginal canal in cases where patients are not candidates for more invasive procedures.
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Additional Surgical Options:
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Vaginal mesh procedures
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Sacrocolpopexy
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Sacrohysteropexy
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Posterior and anterior colporrhaphy
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Sacrospinous ligament fixation
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Vasectomy Reversal
A vasectomy reversal is a surgical procedure that reconnects the vas deferens—the tubes that carry sperm from the testicles to the semen—after a prior vasectomy. The goal of this procedure is to restore fertility so that natural conception is possible. Success rates can vary depending on factors such as the length of time since the vasectomy, the type of procedure performed, and overall reproductive health. While Dr. Sameh Toma does not personally perform vasectomy reversals, NCCRM collaborates with a network of trusted and experienced providers who specialize in this surgery. Our team will guide you through the process, answer your questions, and provide referrals to ensure you receive the highest standard of care. By working closely with these trusted specialists, NCCRM helps patients explore all available fertility options in a seamless and supportive way.
Conclusion
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, your health and safety are our highest priorities. We follow strict protocols to reduce the risk of post-surgical infection and help ensure the best possible recovery. You can also play an essential role by following these steps before and after your procedure:
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Avoid shaving or waxing the area around your incision for at least two days before surgery. Razors can cause tiny cuts in the skin, which may increase the risk of infection.
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If hair removal is necessary, it will be done at the hospital using clippers—not razors—for your safety.
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Hand hygiene matters. Your healthcare team will clean their hands with soap and water or an alcohol-based rub before examining you. If you do not see this happen, it is appropriate to ask them to do so politely.
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Skin preparation at the incision site. Once you arrive at the hospital, your skin will be cleaned with an antiseptic solution (Chlorhexidine, or CHG) to remove as many germs as possible before surgery begins.
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Preventive antibiotics. Your physician may order an IV antibiotic to be given before the incision is made. This typically occurs in the operating room just before surgery.
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Sterile operating environment. Doctors and nurses will thoroughly scrub their hands and arms with antiseptic solution and wear hair covers, masks, gowns, and sterile gloves throughout the procedure.
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Final skin cleansing. Immediately before surgery, the skin around your incision site will be disinfected once again to reduce the risk of infection further.