Fertility Enhancement Surgery and Restoring Function
CRRS: Minimally invasive approach to Reproductive Surgery
Vaginal septum corrective surgery
Vaginal septum is a rare abnormality that is present from birth. This condition can cause menstrual problems or pain during sex or tampon use. Surgery to remove the septum can allow women to menstruate and use tampons normally. This surgery can also relieve associated menstrual pain, and provide for a normal, healthy sex life.
Cervical stenosis corrective surgery
Infections can cause cervical stenosis or adhesions, or by procedures such as sonohysterogram, hysterosalpingogram, endometrial biopsy, intra-uterine insemniation (IUI). By correcting the stenosis, cervical mucus production is restored and the cervical canal is no longer blocking the passage of sperm.
Cervical ectropion cautery
Cervical ectropion occurs when the glandular cells that line the inside of the cervical canal spread to the outer surface of your cervix. The outside of your cervix normally has epithelial cells. This condition can cause bleeding after sex and it can also cause constant cervical mucus production - which can make ovulation tracking difficult. We can correct this by applying heat to cauterize the affected area.
Diagnostic hysteroscopy is when a camera is inserted into the uterine cavity to evaluate the cavity and the lining of the uterus. This is done routinely as part of your fertility evaluation.
Endometrial sampling is done routinely as part of your fertility evaluation to evaluate for abnormal pathology, infections or chronic inflammation.
Restoring the uterine cavity to its normal state can help with implantation and improve pregnancy rates. These procedures include:
- Correction of uterine septum
- Removal of uterine polyps
- Elimination of fibroids distorting the uterine cavity
- Removal of scars inside the uterus (Asherman syndrome)
Endometrial growth enhancement
In selected patients with poor response of the endometrium, autologous (i.e. deriving from your own blood) platelet rich plasma has been shown to promote endometrial growth and improve pregnancy outcome. Click here for more information on platelet rich plasma.
During a combined hysteroscopic and laparoscopic procedure, the fallopian tubes are individually evaluated for blockage by putting a tiny catheter at the opening of each tube and inserting the diluted dye directly to each tube (selective chromotubation). Spillage is concurrently observed with the laparoscope.
Proximal fallopian tube cannulation
If there is a proximal blockage or high resistance encountered during the selective chromotubation, cannulation of the fallopian tube will be attempted. A guide wire is inserted through the tiny catheter in an attempt to reestablish patency. Tubal cannulation is effective in treating patients with mucus plug, cellular debris and tubal spasm.
Laparoscopic surgery / Microsurgery
Please see the section on endometriosis excision for more details.
Adhesion or scar tissue has been shown to be a cause of infertility. In fact, it may be a major cause of infertility. If the reproductive organs are scarred down, then it will be difficult for the sperm to encounter the egg for fertilization. Adhesions can form as a result of prior intra abdominal infections, inflammatory conditions of the pelvis such as endometriosis, etc. Having had surgery is also a risk factor of developing adhesions.
Three main factors contributing to adhesion formation following surgery:
- The patient's own body predisposition to healing and scar tissue formation.
- The completeness of disease removal during surgery.
- Operative technique that respects the pelvic environment which minimizes bleeding and devitalized tissue.
There are also numerous cutting edge, evidence based modalities that has been shown to help with healing and reduce adhesion formation. We routinely use autologous platelet rich plasma during surgery (click here for more details) and in select patients we use dehydrated amniotic membrane allograft (click here for more details).
Surgery of the uterus
Fibroids are non-cancerous growth that appear in the uterus. For women who have fibroid symptoms or have large fibroids that is distorting the uterine cavity causing infertility or recurrent miscarriages, myomectomy (removal of fibroids) is the best treatment option. Depending on the location, number and size of your fibroids, myomectomy can be done in a number different ways. It is important to note that while myomectomy is very effective, fibroids can regrow.
Surgery of the fallopian tube
Microsurgical resection with tubo-cornual reanastomosis
This procedure is needed when the blockage is at the segment of the fallopian tube right next to the uterus. When a proximal tubal blockage cannot corrected with hysteroscopic tubal cannulation there is usually fibrosis or thickening in this area as a result of a disease process (e.g. endometriosis). If the disease is at the segment of the fallopian tube close to the uterus, a resection of the abnormal portion of the tube is required. After that, the end of the cut tube is reattached to the uterus and patency is confirmed. These procedures are done using microsurgical techniques where a microscope is used during surgery and delicate handling of tissue is critical.
Microsurgical resection with tuboplasty
This procedure is needed when the blockage is along the segment of the fallopian tube some distance away from the uterus. When a tubal blockage cannot be corrected with hysteroscopic tubal cannulation, there is usually fibrosis or thickening in this area as a result of a disease process (e.g. endometriosis). A resection of the abnormal segment of the tube is required. After this is performed, the ends of the cut tube are reattached and patency is confirmed. These procedures are done using microsurgical techniques where a microscope is used during surgery and delicate handling of tissue is critical.
Microsurgical sterilization reversal (tubal ligation reversal)
There is a number of ways how female sterilization / tubal ligation are performed. Depending on the method of sterilization, microsurgical techniques are used to resect the site of sterilization and reconnect the separated part of the tubes.
Microsurgical Essure reversal
The Essure system is a type of permanent birth control for women. The procedure involve placing small metal and fiber coils in the fallopian tubes, which creates scar tissue that prevents sperm from reaching an egg. There have been many reported adverse events following ensure placement ranging from chronic pain to perforation and organ damage.
The FDA has issued a black box warning for Essure and the production of this device will be discontinued at the end of 2018. During Essure reversals, it is important to remove the coils intact without fragmentation.
Fimbrioplasty is done when the ends of the fallopian tube is blocked or clubbed causing infertility. Fimbrioplasty is one of several reconstructive procedures done to preserve and release the multiple delicate fimbriae. The purpose of the operation is to open the obstructed Fallopian tube and salvage enough function of the fimbriae to allow successful extraction and transport the oocyte from the ovary.
Correction of hydrosalpinx
Hydrosalpinx is the blockage of a woman’s fallopian tube caused by a fluid buildup and dilation of the tube at its end. Most often it occurs at the fimbrial end of the tube next to the ovary, but it can also occur at the other end of the tube that attaches to the uterus. It commonly affects both tubes.
Previous infection is a common cause of hydrosalpinx and therefore a course of pretreatment with antibiotics is usually required prior to surgery. Depending on where the blockage is, a number of surgical procedures exists to correct the hydrosalpinx.
Surgery of the ovary
Most ovarian cystic masses occurring in women of reproductive age are non cancerous. However, depending on the type of benign cysts it can contribute to infertility by causing inflammation, reducing ovarian reserve or creating pressure within the ovarian cortex, hence not allowing follicles to form. To minimize damage to vital ovarian tissues, meticulous dissection is needed while separating the cyst wall from the ovarian tissue.
Ovarian wedge resection
This procedure is done in women with an established diagnosis of polycystic ovarian syndrome (PCOS) which is refractory to medical treatment. By reducing the ovarian ovulation volume during a wedge resection, ovulation dysfunction may be surgically corrected. Patients may ovulate normally and fertility is restored. It is important to note that good surgical technique is needed to minimize bleeding and adhesion formation.
Ovarian rejuvenation is relatively new concept in the treatment for infertility. It is done in selected patients with poor ovarian reserve or premature ovarian failure. Autologous platelet rich plasma is used for this procedure (click here for more details) and the process stimulates the ovaries allowing for the creation and release of new eggs.