Surgical Fertility Procedures at Troché Fertility Centers
For women who have tubal damage the treatment options are tubal reconstructive surgery (tubal reversal) and In Vitro Fertilization (IVF). Over the last 25 years the pregnancy rate associated to IVF has markedly increased and now far exceeds those that could be achieved with tubal reconstructive surgery. As a result, IVF is the treatment of choice for most couples with tubal damage. Nevertheless, tubal reconstructive surgery is still an appropriate option for certain cases of tubal damage, and when moral, ethical, or religious objections, or financial pressures prevent IVF.
Laparoscopy
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The diagnostic laparoscopy probably is the most common surgical procedure performed as part of the infertility evaluation. It is generally regarded as the definite test for the evaluation of tubal factors. It is usually performed under general anesthesia and involves the thorough exploration of the pelvis organs (uterus, ovaries, fallopian tubes and peritoneal surfaces) and documentation of tubal patency.
At laparoscopy suspected abnormalities such as tubal obstruction, pelvic adhesions or endometriosis can be confirmed and documented. In many cases during the diagnostic laparoscopy tubal surgery or endometriosis treatment can be performed. The types of tubal procedures that can be performed will depend on the skill of the surgeon.
Common Laparoscopic Procedures
- Division and or removal of scar tissue
- Re-opening of an obstructed fallopian tube(s)
- Destruction of implants of endometriosis
- Removal (cystectomy) or incision and drainage of ovarian cysts
The more severe the abnormality treated at surgery the lower the expected pregnancy rate associated to the procedure.
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Hysteroscopy
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Two types of uterine surgery are commonly performed, the hysteroscopy and the myomectomy. The hysteroscopy consists of the inspection of the uterine cavity with a small optical instrument inserted through the cervix. A liquid solution is used to distend the uterine cavity and facilitate its inspection. The hysteroscopy can be performed in the doctor’s office or in a hospital or outpatient surgery center.
Hysteroscopy at the Doctor's Office
At the doctor’s office minimal or no sedation is employed and the procedure is only diagnostic. The uterine cavity is inspected, findings documented, and if a surgical correction is needed it is performed later at the hospital.
Hysteroscopy at the Hospital
The hysteroscopy is frequently performed at the hospital or outpatient surgery center under conscious sedation or general anesthesia. In this setting operative procedures such as the removal of polyps, fibroids (submucosal) and scar tissue (adhesions) can be performed. In addition, operative hysteroscopy is performed for the treatment of a congenital malformation of the uterus called a septum. This malformation creates a wall or partition within the uterus and has been associated with miscarriages. The repair by hysteroscopy of this anomaly improves the reproductive outcome of women with frequent miscarriages associated with uterine septum.
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Myomectomy
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The myomectomy is a surgical procedure for the removal of uterine fibroids.
Three types of myomectomy can be performed:
- Abdominal myomectomy - The abdominal myomectomy requires an abdominal incision usually of the “bikini” type, and through the incision the fibroids are removed from the uterus. This abdominal approach is the best procedure when fibroids are large, numerous, and or located deep within the muscle of the uterus.
- Laparoscopic myomectomy - Fibroids can also be removed by laparoscopy, and this type of myomectomy is best when fibroids are few in number, superficial in location and small in size.
- Hysteroscopic myomectomy - Hysteroscopic myomectomy is recommended when most of the fibroid is located within the cavity of the uterus (submucosal). A myomectomy is a relatively safe procedure that results in few serious complications.
Postoperative adhesion formation is a common complication and good surgical technique combined with adhesion-prevention barriers should be routinely used at myomectomy.
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Tubal Sterilization Reversal
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Elective tubal sterilization (ligation) is one of the most common forms of contraception in the United States. The objective of the tubal sterilization is to create an interruption in each fallopian tube that will prevent conception.
This can be achieved by:
- removing a segment from each fallopian tube;
- applying an occlusive device (clip, ring, band) to each fallopian tube; or
- burning (coagulating) part of each fallopian tube.
Because of its destructive nature, the tubal sterilization is considered a permanent form of contraception. Approximately 1 million women have an elective tubal sterilization procedure in the U.S. each year. Many regret their decision and about 1% will later request a reversal. As a result, surgical techniques have been developed to reverse most forms of tubal sterilization.
The sterilization reversal is a major surgical procedure performed under anesthesia (epidural or general) through an abdominal incision. The re-connecting of the fallopian tubes is performed with meticulous microsurgical technique, including the use of an operating microscope and very fine sutures. Because of the delicate nature of this operation, the sterilization reversal usually takes about 3 to 4 hours. The woman is usually discharged home after a 23-hour hospital stay. She continues her recovery at home for 2 to 3 weeks. Surgical complications with sterilization reversal are rare.
Tubal Sterilization Reversal Success Rates
The likelihood for a successful pregnancy is affected by the age of the woman, the type of sterilization procedure, and the final length of the reconnected fallopian tubes. Younger women whose sterilization procedure was performed with clips, rings, or bands have the best prognosis. While older women or those with more destructive procedures such as burning or coagulation do worse. In properly selected candidates, the pregnancy rate seen after a sterilization reversal is quite good and usually between 40 to 80% with an associated 5 to 10% incidence of tubal (ectopic) pregnancy. Most patients who conceive do so in the first 12 months following the operation.
Unfortunately, not all tubal sterilization procedures are reversible. Some procedures can be quite destructive to the fallopian tubes such as burning or when removal of a large amount of the tube leaves too little tube to be re-connected. To determine if your particular tubal sterilization is reversible or not, a copy of the operation report of the sterilization is needed. This report describes the sterilization operation in detail, and usually gives all the information necessary to determine if a reversal is possible or not. A copy of the operation report can usually be obtained by writing to the hospital where the operation took place. When the operation report is not available, or it doesn’t give enough information to decide if the reversal is possible or not, a diagnostic laparoscopy is recommended. At laparoscopy the fallopian tubes are visualized and inspected to see if they can be re-connected or not. When reversal is not possible, In Vitro Fertilization is then the only alternative available to achieve a pregnancy.
We want you to understand what all your options are (including IVF) in order that you might make an informed decision. Ultimately, our goal is to match you with the best treatment option consistent with your personal goals.
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Last updated:
February 8, 2012
Reviewed by Dr. Vladimir Troché and his medical staff