Today’s post is written by Antonio Gargiulo, MD, Medical Director, Center for Robotic Surgery and a fertility expert in the Center for Infertility and Reproductive Surgery (CIRS) at Brigham and Women’s Hospital in Massachusetts and the Center for Reproductive Care at Exeter Hospital in New Hampshire.
Often my patients experiencing infertility need gynecologic surgery because certain conditions can either cause infertility or impair infertility treatments. Most of these conditions can be treated through minimally invasive surgical techniques, resulting in fewer complications and quicker recovery.
The following post provides information about conditions requiring gynecologic surgery and your treatment options. I recommend that all women of reproductive age that need gynecologic surgery should consult a reproductive surgeon (infertility specialists who practice gynecologic surgery). These physicians have received highly specialized surgical training, which is critical in successfully treating gynecologic conditions that may affect your fertility. I also remind patients that obtaining a second opinion before agreeing to any surgical plan is an essential step of their care.
Uterine Fibroids
Fibroids are very common in women of reproductive age, and most do not need to be treated. However, fibroids that cause significant symptoms (pain, anemia, urinary problems) and some asymptomatic fibroids may need to be removed in women with infertility. Hysterectomy is NOT indicated in women of reproductive age except in the rare cases where uterine cancer is present.
The procedure that removes fibroids and leaves the uterus intact is called myomectomy. Computer-assisted surgery (robotic surgery) has revolutionized myomectomy, allowing nearly all women to be treated with minimally invasive, laparoscopic techniques. The most current laparoscopic technology allows removal of fibroids without the use of morcellators, which have been banned by the Food and Drug Administration. Computer-assisted surgery and single-incision laparoscopic techniques are offered almost exclusively at specialized reproductive surgery centers.
The majority of patients in our infertility program at Brigham and Women’s who need a myomectomy undergo computer-assisted surgery. Our surgeons have pioneered a robotic technique that enables them to perform myomectomies through a single site, resulting in nearly invisible scars.
Endometriosis
Endometriosis is a chronic inflammatory condition of the pelvis that occurs when the cells that normally line the inside of the uterus (endometrial cells) are found in other parts of the body. Its origin is not known, and it can be difficult to treat and manage. Women who have endometriosis may experience significant pain, infertility or both.
For patients with ovarian and deep-infiltrating endometriosis, surgical removal of the endometriosis can help with fertility. Advances in computer-assisted laparoscopy have made open surgery for endometriosis largely unnecessary. Procedures should be performed by a reproductive surgeon who has performed a high volume of surgeries using these techniques.
Ovarian Cysts and Tubal Disease
Surgery is not usually recommended for women with ovarian cysts or tubal disease. Ovarian cysts are usually diagnosed by ultrasound. Radiologically “simple” cysts and most “complex” cysts should be observed by ultrasound for several weeks since they may resolve on their own. Cysts that are suspected to be cancerous should be removed via laparoscopy.
With the availability of safe and effective In-Vitro Fertilization, reconstructive surgery is rarely performed in women with tubal disease. In some cases, your doctor may recommend that a tube that has become blocked and filled with inflammatory fluid (known as hydrosalpinx) be removed. This is a simple laparoscopic operation, but it too should be left to reproductive experts, as removal of a tube, if not well done, can result in injury to the ovary and loss of eggs. Computer-assisted laparoscopy, while of limited use in such simple tubal surgeries, can offer advantages for ovarian surgery. These include the possibility to perform the entire surgery through a single incision at the belly button.
Uterine Anomalies
Birth defects involving the uterus are common, and often remain hidden until a woman experiences fertility issues. Congenital anomalies of the uterus are either untreatable or can be treated with minimally invasive hysteroscopic surgery, in which surgeons reach the inside of the uterus through a natural orifice (the cervical canal).
In rare cases, where the uterus is either absent or otherwise not functional, couples can consider parenting through a gestational carrier volunteer.
In the future, transplantation may be a treatment option. In October 2014, the first birth from uterine transplantation was reported in Sweden.
In closing, these recommendations are intended as a starting point for a constructive discussion between you and your fertility specialist; they should not be a substitute for specific expert advice.
March is Endometriosis Awareness Month
