Mini-invasive surgery (CMI) in assisted reproduction

The gynecological endoscopy (laparoscopy / Hysteroscopy) contribute in solving certain anatomic alterations, not in a very aggressive way, by favoring a better recovery.

Despite the progress made in the domain of assisted reproductive treatments, the problem of fertility or sterility still need to be solved by surgery.

Occlusion of tubes

The merging of the egg and the sperm is possible only if the tubes are not blocked off. An occlusion may be attributable to adhesions (scar tissue) owing to an endometriosis, an inflammatory pelvic disease or an abdominal surgery, a prior ligature of tubes, congenital problems or myoma (not very frequent).

The diagnosis is established by a hysterosalpingogram, a sonohysterography or a laparoscopy. The main fertility treatment for a bilateral tubal occlusion is the In Vitro Fertilization. The tubal micro-surgery used to once again make the tubes permeable may be done depending on the location of the occlusion and the state of the tubes.

Using this surgery reduces the success rate of the In Vitro Fertilization treatment. If only one tube is blocked, we can also perform an Artificial Insemination.

Hydrosalpinx

It consists of the accumulation of liquid in a tube, due to an occlusion located at its distal extreme. The diagnosis is established by an ultrasound, a 3D ultrasound, a 4D ultrasound, a Hysterosalpingogram, a sonohysterography or a laparoscopy. We recommend an excision (an ablation of the tube) if the hydrosalpinx appears in the ultrasound or after multiple implantation failures during the In Vitro Fertilization.

Myoma (fibroma)

Myoma consists of benign tumors on the wall of the uterus, formed by muscular fibers. The impact in the reproduction domain depends on the location and the number of myoma. The main symptom is the increase in quantity of menstrual blood. The diagnosis is established by a transvaginal ultrasound, an hysteroscopy or a laparoscopy. A myomectomy (myoma extraction) may be performed by laparoscopic or by hysteroscopy (submucosal myoma). The surgery should be prescribed depending on the individual case of each patient.

Adhesion (cicatrices)

They are tissue bridges uniting the organs in an abnormal way. These bridges are created after an infection, a surgery or an endometriosis. The diagnosis and the treatment consist of laparoscopy.

Uterus/vaginal defects by birth (malformations)

The symptoms are very general (pain, stoppage of menstruation, etc.). We diagnose these defects by a gynecological evaluation, a transvaginal ultrasound, a 3D or 4D ultrasound, a hysterosalpingogram, a sonohysterography, a nuclear magnetic resonance (RMN) or a laparoscopy/hysteroscopy. Even if they are asymptomatic, these defects are associated to repeated abortions, premature deliveries, and abnormal foetal presentations during the delivery and sub-fertility. The most frequent malformations are: a uterus bicornis (35%), a didelphys uterus (25%) and an arched uterus (20%).

Only 20% of women showing these malformations suffer from reduced fertility. The resectoscope by hysteroscopy improves the prognostic of the uterus bicornis. The reproduction treatment is prescribed depending on the individual case of each patient.

Endometriosis

The internal cavity of the uterus is covered with a tissue called endometrium. This tissue is removed on a cyclical basis, provoking menstruation. Endometriosis is a benign problem, characterized by the presence of an endometrial tissue outside the uterus cavity.

The most frequent symptom linked to this pathology is dysmenorrhea (pain during menstruation). Whether this is the cause for the release of toxic products or due to the creation of adhesions between the pelvic organs, the endometriosis may harm the fertility of the woman. Even if we can suspect the existence of an endometrium (an endometriosis cyst in the ovary) from the symptoms themselves or from an ultrasound result, the laparoscopy will help assure the diagnostic.

The possible treatments are:

  • Cystectomy by laparoscopy of endometrium of more than 4 centimeters. Release of adhesions between the pelvic organs and the study of permeability of tubes. As far as possible, we should avoid multiple surgeries which could lead to a reduction in fertility.
  • If there is still no pregnancy after the surgical treatment, the prescription of fertility treatments such as Artificial Insemination or In Vitro Fertilization is the same as for the remaining couples suffering from infertility. These reproduction treatments however show lower success rates than in other patients.
Last Update: 12/09/2014
References:
– Yoshiki N, Okawa T, Kubota T. Single-incision laparoscopic myomectomy with intracorporeal suturing. Fertil Steril 2011; 95:2426.
– Tulandi T, Marzal A. Redefining reproductive surgery. J Minim Invasive Gynecol 2012; 19:296.