Other Female Infertility Surgical Treatments

Endometriosis - Surgical Treatment

The object of surgery should be to restore normal anatomical relationships and to excise or fulgurate as much of the endometriosis as possible. Patients with moderate disease can expect a pregnancy success of approximately 60%, whereas the comparable figure is 35% in those with severe disease.

There is support for selective use of medical treatment for 2--3 months following laparoscopy and prior to conservative surgery, especially in patients with pain due to major disease.  Preoperative treatment aids surgery by softening endometrial implants. The highest pregnancy rates following conservative surgery occur in the first year after surgery, and most physicians have been reluctant to use hormones that prevent pregnancy even for a few months. If pregnancy does not occur within 2 years of surgery for endometriosis, the chances are poor that pregnancy will occur.

When the objective of laparoscopic surgery is symptomatic relief and not pregnancy, a return of symptoms is delayed with as little as 6 months of postoperative medical treatment.

The above type of surgery are labeled "conservative", indicating that reproductive function is maintained. Even when radical surgery is performed, an uninvolved ovary can be preserved in some cases if all of the nonovarian endometriosis is removed by fulguration or excision. However, this does provide a risk for recurrent disease.

Surgical treatment might be expected to help to overcome the effects of damage, but not the functional disorder associated with endometriosis. Also, as with tubal surgery, it is necessary to allow at least a year afterwards to get the full benefit of the surgery, if any. Whatever the functional disorder that may be associated with endometriosis, fertilizing ability is generally favorable; therefore IVF treatment would be an appropriate choice in the case of prolonged unexplained infertility.

Uterine Fibroids Surgical Treatments

When a mechanical obstruction of fallopian tubes, cervical canal, or endometrial cavity is present and no other cause of infertility or recurrent miscarriage can be identified, myomectomy is usually followed by a prompt achievement of pregnancy in a high percentage of patients (usually within the first year). Preoperative visualization is important, and mapping of myomas by magnetic resonance imaging (MRI) or ultrasonography. It is difficult to distinguish between submucous myomas and endometrial polyps with ultrasonography.

The short-term recurrence rate after myomectomy (either abdominal myomectomy or hysteroscopic resection) is about 15%. In a series with long-term follow-up, the recurrence rate over 10 years reached 27%. Women who gave birth after myomectomy had a recurrence rate (over 10 years) of 16%, compared to a rate of 28% in those who did not give birth. In an Italian study of recurrence, the rate at 5 years reached 55% in those who did give birth after surgery and 42% in those with no childbirth. Because of the rapid regrowth of myomas following cessation of GnRH agonist therapy, medical therapy for infertility is not recommended. Most myomas do not grow during pregnancy.

Most pregnancies, in the presence of myomas, will, therefore, be uncomplicated (although a higher incidence of cesarean section has been observed). So-called red degeneration of myomas is occasionally observed during late pregnancy, a condition due to central hemorrhagic infarction of the myoma. Pain is the hallmark of this condition, occasionally associated with rebound tenderness, mild fever, leukocytosis, nausea, and vomiting.

Hysteroscopic Myomectomy

With improvements in endoscopic surgical technology, most intracavitary and a substantial number of submucous leiomyomata can be resected via surgical hysteroscopy in an ambulatory setting. If the tumor protrudes completely into the endometrial cavity via a stalk, such as a completely intracavitary myoma, a hysteroscopic resection is by far the most cost-effective method of removal. In this circumstance, extreme caution should be exercised when resecting a submucous fibroid, and resorting to an abdominal procedure should not be perceived as a failure but rather should be considered the safest option. It is inserted through the cervix, the endometrial cavity distended with a nonconductive media, and the leiomyoma resected by electrical loop excision.

The fragments are removed with the effluent of the distending media through an inflow--outflow system. Preoperative atrophy of the endometrium, to provide a clear operative field without resorting to complete pituitary down-regulation, can be accomplished with a 10-day preoperative course of a progestin (20 mg/day of medroxyprogesterone acetate) or an androgen (danazol 800 mg/day).

Laparoscopic Myomectomy

Improvements in endoscopic surgery allow myomectomy to be accomplished via the laparoscope. It is clear that pedunculated, serosal, and superficial intramural leiomyomas can be removed via laparoscopy, and only the most experienced endoscopic surgeons should undertake the surgery. Furthermore, because only clearly obvious leiomyomata can be removed via laparoscopy, this therapy should be undertaken only when a complete laparoscopic myomectomy can be anticipated. Endoscopic closure of the uterine incisions is also technically difficult. A laparoscopic myomectomy performed by an experienced surgeon can be a reasonable option.

Surgical Treatments For Pelvic Pain

Chronic pelvic pain is a common condition with a major impact on health-related quality of life, work productivity and health care utilization. In primary care, the annual prevalence is 38/1000 in women aged 15-73, a rate comparable to that of asthma (37/1000) and chronic back pain (41/1000). An effective treatment for this condition has evaded the medical profession for centuries. Even today only 20-25% patients respond to conservative management. When such treatment fails, a diagnostic laparoscopy is performed. The cause of the pain is not always obvious. In the absence of pathology there is no established treatment.

Laparoscopic Uterosacral Nerve Ablation

This procedure involves burning (either by laser or by a bipolar device) the ligaments that attach the uterus to the sacrum (part of the pelvic bone). A bipolar cautery device is used to grasp the uterosacral ligaments as they join the uterus. Some medical studies show that it works well for treating "central" pain, that is, pain with deep intercourse and pain in the center of the pelvis. Other studies show that it only works for a relatively short period of time. Thus, more research is needed.

The Lee-Frankenhauser sensory nerve plexuses and parasympathetic ganglia in the uterosacral ligaments carry pain from the uterus, cervix and other pelvic structures. Interruption of these nerve trunks by laparoscopic uterosacral nerve ablation (LUNA) may alleviate pain.

The balance of benefits and risks of this intervention should be carefully assessed. Thus, laparoscopic uterosacral nerve ablation and presacral neurectomy have been introduced into practice and are options for women with severe pelvic pain refractory to other treatment modalities.

Laparoscopic Presacral Neurectomy

Presacral neurectomy has been advocated for those women with dysmenorrhea, including those who have failed laparoscopic uterosacral nerve ablation. A randomized clinical trial comparing laparoscopic presacral neurectomy with laparoscopic uterosacral nerve ablation reported a significant difference in pain relief scores favoring laparoscopic presacral neurectomy at 12 months (82% vs. 51%). Laparoscopic presacral neurectomy is performed under general anesthesia using a video laparoscope through a small incision, usually in the bellybutton. Several (usually three) small incisions are made above the pubic hairline for insertion of other instruments needed to perform the procedure. Nerve tissue that goes to and from the uterus is interrupted in an area over the sacral promontory. This location is chosen because it is the best area to access the nerves to the uterus.

Other surgical procedures, if appropriate, may be performed at the same time as the presacral neurectomy. Presacral neurectomy (PSN) is a pelvic denervation procedure that involves interruption of the superior hypogastric plexus, also called the presacral nerve. PSN has been used for the treatment of chronic pelvic pain, endometriosis, dysmenorrhea, and dyspareunia. It has been advocated for the relief of central pelvic pain in women after medical therapy has failed. PSN is performed via laparoscopy with lasers or other surgical instruments. PSN has been performed most commonly in conjunction with other surgical procedures (e.g., conservative surgery for endometriosis).

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