In this webinar, Dr. Elias Tsakos, FRCOG, Medical Director of Embryoclinic, Thessaloniki, Greece discussed fertility surgery like laparoscopy, hysteroscopy etc. as a valuable tool in fertility care.
Everything in fertility has an indication for some assessment and evaluation via endoscopy. For unexplained infertility, many couples come saying it’s unexplained; they have done all the tests, but nothing has been discovered. Often, they haven’t undergone a laparoscopy to exclude tubal disease or mild endometriosis, nor a hysteroscopy to exclude pathology in the uterine lining.
Unexplained infertility might be explained by examining the body with a camera. The same applies to tubal factor infertility, endometriosis, fibroids, and polyps. Fertility endoscopy could be performed before IVF, after IVF, after a failed cycle, certainly after miscarriage, and even in mild male factors, as issues in the woman might prevent weak sperm from fertilizing.
Fertility endoscopy is virtually for everyone. The question is how to judge who would benefit most because it is an additional test, expense, and risk.
Currently, the fertility endoscopy tools are hysteroscopy and laparoscopy. Laparotomy is no longer used because laparoscopy has evolved significantly, including conventional laparoscopy and, for complex procedures, Da Vinci-assisted robotic surgery.
Hysteroscopy is a minimally invasive procedure where a specialized doctor examines the uterine cavity through a small tube, which can be either rigid or flexible. This can be done with no anaesthesia as an outpatient or with minimal local anaesthesia. If operative procedures are needed, it remains an outpatient, inexpensive, simple, and virtually risk-free procedure.
In my opinion, most patients would benefit from a diagnostic hysteroscopy, especially older patients, those with failed IVFs, suspected lesions in the endometrium, or with miscarriages, before many failed IVF attempts.
Even a negative hysteroscopy—one that doesn’t diagnose any serious issue—may benefit women by improving implantation rates for both natural and assisted conception. It is proven that the value is there, leading to increased spontaneous and assisted pregnancy results. This has been incorporated into many guidelines, which most IVF units and patients have access to. Hysteroscopy is a viable but often neglected tool; it is a simple, straightforward procedure that often provides the extra edge in achieving a pregnancy more quickly.
Laparotomy is now considered outdated, having been a more common option over 20 years ago when laparoscopy was less advanced. It remained relevant up to 5 or 10 years ago until robotic Da Vinci surgery took over cases where conventional laparoscopy is difficult or impossible to perform.
Laparoscopy is a minimally invasive procedure performed in the pelvis, typically as an outpatient, with very short recovery. It can be used both as a diagnostic tool and for treating endometriosis, tubal adhesions, hydrosalpinx, and fibroids. While diagnostic laparoscopies or operative laparoscopies have become less popular, they should not be overlooked, as they improve the chances of successful IVF and natural conception, especially in younger women.
Endometriosis is a condition that can only be accurately detected by laparoscopy. It affects 1 in 10 couples and one in 10 women in the general population. In fertility patients, it has been quoted to be as high as 30 to 50%. Symptoms can vary and may include cramps, pain, painful intercourse, and heavy menstruation, but sometimes there are no symptoms, and infertility is the only presenting complaint. There is a consensus that endometriosis is a chronic disease requiring lifelong management. Endometriosis can be divided into 2 main forms: visible on scan and not visible on scan. Laparoscopy is the only way to accurately diagnose and, in certain cases, treat it.
On one of the slides, Dr Tsakos presented guidelines for the clinical algorithm for managing endometriosis. IVF is always an option, but surgical intervention is also an option. Managing endometriosis in fertility patients, either before or after an IVF cycle, is valid. There is consensus in the European Society of Human Reproduction guidelines about the importance of diagnosing and managing endometriosis appropriately.
Tubal adhesions are difficult to manage and diagnose without laparoscopy, which is the gold standard for diagnosing tubal adhesions. Adhesions, or scar tissue, can block or distort the fallopian tubes. A blocked fallopian tube minimizes the chance of a natural pregnancy, by 0-50%. Whether suspected via symptoms, tubal assessment tests, or a history of previous surgery, laparoscopy not only diagnoses but can also treat these adhesions.
Hydrosalpinx is an often neglected condition. The fallopian tube is filled with a liquid that may be toxic to an implanted embryo. The tube is partly or blocked at the distal end, near the ovary. Many IVF clinics do not have a protocol to exclude hydrosalpinx before IVF. Regardless of symptoms, hydrosalpinx can be completely asymptomatic. Performing a tubal assessment is essential before IVF because hydrosalpinx reduces IVF success by 50%, increases the chance of miscarriage, and raises the risk of ectopic pregnancy. In Greece, the state does not reimburse any IVF cycle unless a standard tubal assessment to exclude hydrosalpinx has been performed.
In my 30 years of experience, I have seen many couples with multiple failed IVFs where hydrosalpinx was not considered. It is easily diagnosed and treated by laparoscopy, thereby increasing the chances of a successful IVF.
Fibroids affect many women, particularly older women. Indications for treating or observing fibroids vary. A fibroid or a myoma is a non-cancerous tumour that grows in and around the uterus. Fibroids may be within the cavity, requiring treatment by hysteroscopy before implantation, or within the wall of the uterus, where removal depends on size and location. Even a small fibroid of 2 to 3 centimetres within the myometrium can affect a successful IVF attempt. While we may choose not to remove it, if we do, laparoscopy is the method of choice. For larger fibroids, robotic surgery ensures safe removal and reconstruction of the uterus to support a healthy pregnancy.
Da Vinci robot is an advanced technology with multi-arm that allows to perform a precise surgery, there is no contact between the surgeon and the patient. There are significant benefits to robotic technology, especially in complex cases with large pathologies, such as fibroids larger than 7 or 8 centimetres, multiple endometriosis cysts, frozen pelvis, or stage IV endometriosis, which involves surgery deep in the pelvis. For cases of tubal disease, particularly tubal sterilization requiring anastomosis, the Da Vinci robot offers substantial advantages.
Tubal ligation is a major chapter in fertility care. Tens of thousands of women worldwide have undergone tubal sterilization and later regretted it. Data suggests that about 20 to 30%, or roughly 1 in 5 or 4 women, regret the sterilization. Until now, IVF has been the common option. According to Dr Tsakos, Robotic Da Vinci surgery offers an alternative, as does standard laparoscopy for some cases. Patients should be aware of the option to reverse sterilization via laparoscopy or Da Vinci surgery. This is a fine piece of surgery with potentially magnificent results. Literature shows that as high as a 70% pregnancy rate after tubal anastomosis (a surgical procedure to restore a woman’s fertility after tubal ligation) can be achieved. Tubal anastomosis after previous sterilization has been scientifically proven to be a valid option for thousands of women worldwide.
When evaluating fertility surgery options, several important factors should be considered.
Related reading:
It is very difficult to say. I mean, I always quote that the best person to advise how long after surgery you’re fit to get pregnant is the surgeon who performed the surgery. The standard time is between 6 and 12 months. In my practice, invariably we suggest 6 months when we perform the surgery, and if somebody else has performed the surgery, we ask them to describe in specific the operations, how many fibroids there were, location, how big was the incision to the uterus, how were the sutures afterward, and so forth. In general, 6 to 12 months is the norm depending on the size and the number of fibroids. With regard to your symptoms after surgery, this is likely to occur because of the adhesions. In my opinion, at some stage, it may be worth having a laparoscopy to diagnose that and perhaps improve those adhesions by laparoscopic adhesiolysis.
Absolutely, I mean, of course, it affects fertility. Any surgery may potentially affect fertility, in particular open surgery. I have huge respect for all surgeons, but in my opinion, the same way most of the oncology cases are now managed by oncologists. I think fertility surgery should be managed by very experienced fertility surgeons, particularly, the ones with the appropriate equipment, in the right facility. We don’t like open surgery for many reasons, and one of the reasons is that sometimes the scarring tissues are creating problems afterward. The straight answer is that indeed any surgery may affect fertility, an open surgery by laparotomy may affect it even more than standard conventional laparoscopy. I think this has to be evaluated. I cannot answer if you need to be operated on again or not. This depends on the size, location, and symptoms of fibroids, and a careful evaluation of this by some sort of, imaging initially either scanning or CT Canning. or MRI scanning would give us a clear picture of what we need to do.
I haven’t seen any scientific evidence to support that. I don’t think it’s valid, however, a healthy diet is a healthy diet, and it has a lot of other benefits. The natural history of fibroids is very variable and depends vastly on the individual. In general, we prefer 1 or 2 large fibroids compared to much smaller, multiple fibroids invariably multiple fibroids they grow back in again, and this is simply because there’s a lot of little nuclei, little seeds of fibroid tissue all over the uterus, so if somebody has multiple fibroids, let’s say in the early 30s, and they have them removed, then we have to take advantage of the window of 2,3,4 years before more fibroids grow back in and they should get pregnant during that window.
I don’t want to sound too enthusiastic, but I am. Robotic surgery is suitable for any fibroids anywhere because it’s giving us the absolute tools of identifying and operating on. Fibroids that are located anywhere in the uterus or even outside the uterus. On top of this, one of the added advantages of robotic surgery is suturing, so we can be very confident in suturing the uterus because this has always been the key factor in performing laparoscopic surgery for fertility and suturing fibroids following the removal. Another benefit for operating via the Da Vinci system is that we have this special scanning facility by which we can scan and identify fibroids which cannot be felt or cannot be visible from the outside observation of the uterus by a laparoscopy. For any complex fibroid surgery, Da Vinci is an amazing tool. For standard surgery, myomectomy is recommended. If somebody has fibroids that have 3,4 centimeters, this can be easily managed laparoscopically. There is a place for conventional laparoscopy, as there is a place for robotic surgery.
It’s very difficult to answer this. It is a very complex history, but HyCoSy it’s not very valuable in diagnosing hydrosalpinx. With your history, there is a good chance that you may have hydrosalpinx, and there are two ways of diagnosing that. One is by a standard X-ray HSG or by laparoscopy, so I think either one of those would be indicated because you have a strong history to suggest that. With regard to the rest, someone has to look into your history in detail. What I was trying to show today is the fact that endoscopy is something that we shouldn’t forget about. Sadly, because of the progress in IVF and an increase in the IVF success rates, we have neglected that. I don’t think laparoscopy or hysteroscopy, or robotic surgery is indicated for perhaps the majority of the patient. Perhaps, the majority of the patients may not require that, however, we should consider these methods, we should consider evaluating the internal female organs, the internal pelvic organs in the process of IVF and fertility investigation and treatment, that was my message for today.
