Reproductive surgery to improve fertility outcomes
One in seven couples has difficulty conceiving in the UK. 1/3 of cases are due to female factors, 1/3 due to male factors and 1/3 due to a combination of male and female factors.
In the UK, the treatment end point for half of all couples is in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). The other half conceive spontaneously or through intrauterine insemination. A minority would adopt a child, or not have any treatment at all. Among those with female factors infertility, management options include lifestyle changes such as weight loss, stopping smoking, ovulation induction or surgical treatments to aid conception.
Several conditions affect the uterus, ovaries as well as the fallopian tubes. These would lower the chances of conceiving, increase the risk of miscarriage or risk of preterm premature delivery. Thankfully, most of these conditions are amenable to surgery. Surgical procedures results in spontaneous conceptions in many cases. Where patients require intrauterine insemination (IUI) / IVF / ICSI, surgery optimises the chances if a live birth. With most of these conditions managed as day surgery or office procedures using key hole surgery, recovery is much quicker with very low complication rates, as opposed to open surgery. Women are also able to start trying to conceive again / start their fertility treatment within a few weeks of the procedure.
Uterine conditions
Endometrial polyps
Endometrial polyps are benign growths that occupy the uterine cavity. They lower the chances of getting pregnant and increase the risk of miscarriage. Removal is performed by a key- hole procedure, known as hysteroscopy.
Uterine fibroids
Uterine fibroids could also grow into the cavity of the womb, and are known as sub mucous fibroids. These benign growths are amenable to hysteroscopic removal. There is very strong scientific evidence that polyps and sub mucous fibroids lower the chances of a live birth and surgical removal significantly improves the live birth rates.
Uterine fibroids could also grow within the wall of the womb (intramural fibroids) or grow outwards from the womb (subserous fibroids). Intramural fibroids when large would lower live birth rates. The effect of surgery is not very clear, but depends on the size and location of the intramural as well as subserous fibroids.
Uterine cavity scarring (Asherman’s syndrome)
Uterine cavity could get scarred by previous surgical procedures, womb infections, retained placenta etc. The scarred cavity has a lower chance of implantation. Hysteroscopy and repair of the scarring resolves the condition in most cases.
Uterine septum
During the development of a baby within its mother’s womb, the uterus starts off as two structures that join in the midline. The joining wall gradually disappears resulting in one womb cavity. In some females, this middle wall does not disappear, resulting in a uterine septum, a wall dividing the womb cavity into two separate chambers.
Uterine septum is more often seen among women having difficulties conceiving and those who have suffered repeated miscarriages. They are also associated with premature deliver and abnormal baby position at birth (breech or transverse presentation).
In our practice, all patients have a 3D ultrasound scan to screen for this as well other abnormal uterine structural defects that may lower the chances of a live birth. There is very good evidence that a simple day surgery key hole procedure, hysteroscopic resection of the uterine septum improves live birth rates. Where confirmed, we have the expertise and experience to resolve these abnormalities and we have very good outcomes data. The National Institute of Health and Care Excellence (NICE) in their 2015 guidelines recommends that surgery should be offered and discussed to women with infertility and recurrent pregnancy loss found to have a uterine septum.
Tubal conditions
Blocked fallopian tubes
Fallopian tubes transport eggs and sperm, nourish the two and enable their fertilisation. The initial five days of the fertilised eggs’ (embryos’) development takes place within the fallopian tube before being transported into the uterine cavity for implantation.
Fallopian tubes could be damaged and blocked by infections, endometriosis (abnormal uterine lining cells growing outside the womb), previous appendicitis complications among others.
Where the damage or blockage is not too severe, key hole surgery could be used to repair and reopen the blockage. However, in cases of irreversible blockage, the tubes will occasionally fill up with fluid. This is known as a hydrosalpinx.
Hydrosalpinx
This is a fallopian tube that is blocked and filled up with fluid. The hydrosalpinx is usually visible on ultrasound scan. There is very good evidence that hydrosalpinx significantly lowers the probability of successful conception and also increases the risk of a miscarriage. It is thought that the fluid in the tubes tracks back into the uterus and could physically flush out an embryo from the womb. The noxious material from the hydrosalpinx fluid could also affect the developing embryo. For women having IVF/ICSI, removal of the damaged tube (salpingectomy) or clipping the tube to prevent the fluid from entering the uterine cavity doubles the chances of a live birth. This is again performed through a day surgery key hole procedure (laparoscopy) with very quick recovery, with the IVF treatment starting as soon as a month later.
Endometriosis and ovarian cysts
Endometriosis is a condition in which cells from the uterine cavity lining ( endometrial cells) end up in the pelvis , outside the womb, develop a blood supply and develop into ovarian cysts, ( endometriosis cyst or endometrioma), cause scarring, matting of abdominal and pelvic organs, block fallopian tube etc. They could have no symptoms, or present with painful periods, pain during sexual intercourse, pain when opening bowels etc. They are a common cause for tubal blockage as well. Depending on the structures involved, laparoscopic surgery may be necessary to enable spontaneous conception, especially in young woman with mild to moderate endometriosis as well as to improve the chances of success for IVF.
Most ovarian cysts found in women undergoing fertility investigations or treatments are benign. The vast majority will resolve spontaneously without the need for medical intervention. However, some may require surgical removal and the vast majority can be removed by key hole surgery as a day case.
Conclusion
A detailed assessment as a one stop service ensures prompt diagnosis and management to optimise the chances of a live birth in the shortest possible time.
All our patients have a detailed ultrasound assessment of the uterus, its walls, the fallopian tubes, ovaries and surrounding pelvic structures. Where abnormalities are detected, prompt expert management with minimally invasive surgical procedures where necessary optimises the chances of a spontaneous conception, and where required, significantly improves the IVF / ICSI success rates.
For more information, please contact us at:
Mr David Ogutu
Consultant gynaecologist and fertility specialist, BMI Cavell Hospital, Enfield
Private Secretary: Ruth Blissett
Email:
Tel: 07838171641
Fax: 01992 423832
Or
Herts & Essex Fertility Centre
Bishops College Churchgate Cheshunt, London, EN8 9XP
http://hertsandessexfertility.com/
Secretary: Sharon Julians
Email: ,
Tel: 01992 78 50 60
Fax: 01992 350 111
