Fertility surgery, a valuable (and often neglected) tool in fertility care

Elias Tsakos MD, FRCOG
Medical Director , Embryoclinic

Failed IVF Cycles, IVF Abroad

Surgery as a neglected option
From this video you will find out:
  • Fertility endoscopy – when is it recommended?
  • What are the indications for hysteroscopy and laparoscopy?
  • What are the benefits of laparoscopy?
  • What are the IVF and surgery options with endometriosis?
  • What is hydrosalpinx and how can it be treated?




When fertility surgery is necessary?

In this webinar, Dr. Elias Tsakos, FRCOG, Medical Director of Embryoclinic, Thessaloniki, Greece has been talking about fertility surgery like laparoscopy, hysteroscopy etc. as a valuable tool in fertility care.

- Questions and Answers

I had 3 large fibroids removed in 2 operations (ultimately, they were much bigger, than what the gynecologist initially thought on ultrasounds), but still, all transfers didn’t work even with a proven donor who donated multiple times and has her own children. My husband’s sperm is of very good quality apparently, according to the DNA Fragmentation test. So my question is: How long after having fibroids removed should I have had transfers as I had very sharp stabbing pains for about 2 years after the surgeries – especially when flying for some reason, have no idea if altitude played a role?

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.

When can fibroid surgery scars affect fertility? I had surgery because of uterus myomatosus a few years ago. Some new fibroids have grown again. Should I remove them again? Can multiples surgeries affect fertility? When? It was done via open myomectomy.

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.

Does diet affect fibroids? I was told to avoid any animal products such as milk, cheeses, meat (fish is fine, apparently).

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.

Can robotic-assisted laparoscopic surgery be used for fibroids behind the uterus?

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.

I had a natural pregnancy last year at 41, which was ectopic with a twin pregnancy in my right tube. I wanted to avoid removal of the tube, and so with monitoring, I miscarried without the need for intervention or surgery. Since then, I have had right-sided pelvic pain on and off across the month, so worried about scar tissue or endometriosis. I have never been diagnosed with either. Would you suggest laparoscopy? My doctor has advised the laparoscopic carries risk of damage to other organs in the vicinity, which worries me. I had HyCoSy earlier this year to check for blocked tubes, the liquid spilled out on both sides, and I didn’t require additional force, however, the doctor could not see the liquid traveling through the right tube. Does this suggest any issues with my right tube? Since then, I have had one round of IVF with failed implantation.

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.
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Elias Tsakos MD, FRCOG

Elias Tsakos MD, FRCOG

Dr Elias Tsakos, FRCOG, is a Medical Director of Embryoclinic - Assisted Reproduction Clinic in Thessaloniki, Greece. He has received extensive and certified training in the United Kingdom and is a Fellow of the Royal College of Obstetrics & Gynaecology. Dr Tsakos is also a Board Member Representative of the Royal College for Greece and Cyprus and a Board Member of the Hellenic Society of Assisted Reproduction. He is a Member of the British, European and American Fertility Societies (BFS, ESHRE, ASRM). Dr Tsakos has been living and working in Thessaloniki, Greece, since 1999.
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Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.
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