During this event, Dr Elias Tsakos, MD, FRCOG, Medical Director of Embryoclinic shared 3 real-life IVF success stories made possible through minimally invasive fertility surgery. Dr Tsakos provided insight into cases that have transformed the lives of his patients and demonstrated how advanced surgical techniques enhance IVF outcomes.
Moderator: Rachel Sherriff, Founder of The Fertility Suite. Having navigated her own fertility journey, Rachel brought a unique and empathetic perspective, driven by her passion for supporting others through holistic fertility care.
The uterus is the human incubator. It’s an organ, which consists of the endometrium, the lining, and also the muscular layer around it. The normal uterine anatomy and functionality are vital to accommodate the growing fetus. There are a lot of gynaecological conditions that may affect the anatomy—some congenital, some acquired, some age-related. The fact that we are treating reproductively older patients these days makes those conditions even more common. It makes it imperative that we diagnose, manage, and treat these issues before we embark on IVF.
There is a dual contribution of fertility surgery. One is restoring fertility, which includes both natural fertility and assisted fertility. The second contribution is improving and alleviating chronic clinical symptoms like endometriosis, myomas, or polyps, which may produce debilitating symptoms. On top of that, this invariably improves fertility outcomes, either natural or assisted.
Hysteroscopy consists of the term “hystero,” which means uterus in Greek, and “occupy,” which means visualization. The doctor visualizes the internal cavity of the uterus—the endometrium. Nowadays, technology allows us not only to observe but also to treat conditions inside the uterus. This includes fibroids, congenital anomalies, polyps, adhesions, and sometimes myomas that enter the uterine cavity. With hysteroscopy, we can assess, diagnose, and treat any abnormality within the endometrial cavity, which is the most vital part of the uterus for achieving pregnancy.
Laparoscopy has been around for 40 to 50 years and has evolved. The assessment of the pelvis and peritoneum remains the gold standard for diagnosing and treating endometriosis. It is performed using four or five small incisions, each less than 1 cm, and the recovery is quite quick.
Robotic surgery is the advancement of laparoscopy. It all started around the year 2000 in the US. There were trials with different systems before that, but the current system began evolving around 2000. In 2005, it received FDA approval, became widespread in the USA in 2010–2015, and moved to Europe in the last 5 to 10 years, depending on the country.
Dr Tsakos mentioned that in Greece, they have started using robotic surgery since 2006. In his department at Embryoclinic, Dr Tsakos has been working with robotic surgery for about 6 years now. The team were among the first in continental Europe to use this technology. What does it do? It improves every aspect of the technology we have been using—control, movement, vision, precision in excision, 3D visualization, and node detection. We can be more precise, thoroughly excise abnormal pathology, and spare normal tissue.
I’ve been a laparoscopic surgeon for nearly 30 years and performing robotic surgery for about 7. People ask about the difference—I compare it to a city car and an SUV. Laparoscopy is like a city car, ideal for small pathologies like fibroids or cysts. But for complex cases—multiple fibroids, severe endometriosis, or patients with many prior surgeries—robotic surgery is the SUV, equipped with advanced technology to handle the challenge.
The benefit of robotic surgery is more evident in complex cases. Complex endometriosis and multiple myoma surgeries are very challenging, not only because lesions need to be excised adequately, but also because the functionality of the organs must be preserved. In particular, with myoma surgeries, maintaining uterine function is crucial. Robotic surgery allows pushing the boundaries even further and operating on cases that were previously inoperable.
We conducted investigations to understand the causes of implantation failure. One of these was a high-end ultrasound scan—the 3D ultrasound—which we performed in our clinic. This revealed a suspicion of intrauterine adhesions.
Understanding that a standard ultrasound may not pick up uterine anomalies is key. It’s the advanced 3D/4D ultrasound scanning approach performed by highly specialized individuals—trained, certified, and experienced in identifying uterine anomalies—and, of course, with the use of very high-end equipment, this is the only way we can diagnose a uterine anomaly.
Following that, the team and the couple jointly decided to perform hysteroscopy. Indeed, there was the presence of intrauterine adhesions. Adhesions—scar tissue—is abnormal tissue, tissue that is associated with either failed IVF or miscarriages, and it is not always easy to treat adhesions. On this occasion, the adhesions were not very widespread, they were localized, and they were thin. Therefore, the doctor managed to treat those adhesions via operative hysteroscopy and restore the uterine cavity.
Following that, the couple came back for IVF. The endometrium looked normal, and they had a successful outcome.
Fibroids are very common, becoming more common in women of more advanced reproductive age. According to Dr Tsakos 40–50% of women in their late 40s, or early 50s have fibroids. The majority would have fibroids not big enough to need surgery.
Ultrasound investigations revealed multiple uterine, with 2 large (4 cm) intramural leiomyomas that distorted the uterine cavity. The team decided to operate. Extensive counselling was provided for that patient, and then the team resorted to robotic surgery.
In about 4 months, the couple was matched with the donor. Although the plan was to transfer the embryo at 6 to 7 months, eventually, there was a delay beyond the team’s control at 9 months, the embryo transfer was performed, and there was a positive pregnancy test which resulted in a healthy pregnancy and a healthy delivery by Cesarean section.
In the majority of patients after fibroid surgery, a Cesarean section is recommended because we don’t feel confident having those women, with all the scar tissue in their uterus, undergo vaginal delivery. There are also associated factors with age.
I strongly believe that endometriosis and fibroids can be very, very challenging for women wishing to retain their fertility. It takes a lot of counselling, a lot of investigations, a lot of multidisciplinary meetings, and a lot of imaging to understand what is the best way forward.
In this particular case, Dr Tsakos thought it could be managed by laparoscopy, not robotic surgery. There were a lot of adhesions at this stage and some endometriosis loci that were resected and removed. The patient was discharged. It was not an easy surgery.
The couple came back 10 months later. The team performed ovarian stimulation, and with the frozen embryo transfer, the couple got a positive result. The mechanism by which endometriosis resection and excision improve fertility is not entirely clear, but certainly, there is an element of reducing inflammation in the inflammatory response that plays a role.
Conventional laparoscopy is still the gold standard in the assessment and treatment of endometriosis, perhaps for easier or earlier-stage cases. Dr Tsakos stated that in his opinion in the next 5 to 10 years, conventional laparoscopy will be fully replaced by robotic-assisted laparoscopy, if not fully robotic, then at least some sort of hybrid system that provides better access and treatment.
Pretty good chances. Bowel resection is becoming more common because, in the last 5 to 10 years, we have gained a better understanding of endometriosis, leading to improved diagnosis and treatment. The chances of success depend significantly on the quality of the uterus, particularly the endometrium, and ensuring there is no leftover endometriosis that could adversely affect implantation and pregnancy.
I presume you had very experienced surgeons treating your endometriosis, ensuring your uterus is in optimal shape. Egg donation can work wonders, so I am very optimistic about your chances. In similar cases at our practice, many patients have done extremely well. Having bowel surgery, while heavy, improves both quality of life and fertility, as it removes nodules that could cause long-term issues.
I would be hopeful and encourage you to stay optimistic. Perhaps next year, you’ll share good news about your success.
Asherman’s syndrome can be very tricky because there are different classifications and degrees of severity. I suggest finding an experienced hysteroscopist, as there are excellent specialists available. They can assess and classify your condition and work on improving the uterus. While Asherman’s cannot usually be treated 100%, even a 50–70% improvement can give you a chance for pregnancy.
Treatment often requires repeated procedures, such as operative hysteroscopies. Thankfully, advancements in the past decade have given us better equipment and technology. For example, we can cut without causing further adhesions, use advanced ultrasound for guidance, and apply anti-adhesive materials or PRP (platelet-rich plasma), which shows promising results.
With Asherman’s, patience and persistence are crucial. Each procedure might improve the uterus incrementally, and at some point, you may decide to move forward with IVF or try for natural pregnancy. While it’s not as straightforward as treating polyps or fibroids, progress is possible.
During pregnancy, monitoring is essential. It wouldn’t be a standard pregnancy; a dedicated team is necessary to manage complications, monitor uterine thickness, and avoid risks like twins or contractions. For challenging cases, daily monitoring may be needed. Despite the challenges, most patients do well. I hope you’ll be among them, with a successful outcome.
Adenomyosis can be challenging. In my opinion, a 3D/4D advanced gynaecological ultrasound scan is the best way to map it. Sometimes, with the standard scan, it’s very strange. I’m sorry, I can’t show you, but next door we have standard scanning equipment, and then in the next room, we have advanced scanning. It’s like day and night, sometimes with adenomyosis. I would strongly suggest advanced ultrasound gynaecological scanning to map your adenomyosis and ensure it is adenomyosis. Sometimes there are myomas as well, or both. Then, of course, assessment of the cavity by hysteroscopy, perhaps a biopsy of the endometrium, and then a very good discussion. After the mapping, one has to decide the best way forward. I know myomas can be a little bit of a nightmare for a surgeon, and we try to avoid surgery for adenomyosis unless we have to. It’s a difficult decision based on the extent, density, measurement, and value of normal myometrial tissue, as well as its history. You can’t keep having unsuccessful transfers, for example.
There are three types of adenomyosis in my opinion: black, grey, and white. If it’s white, as in small, localized adenomyosis, I would just ignore it. Perhaps I would use a frozen embryo transfer and apply a little longer down-regulation to deflate it for two or three months before the embryo transfer. If it’s huge, diffuse adenomyosis all over, with lots of dense areas, and multiple failures in the past, then I would consider surgery, provided there is healthy myometrial tissue. Even if one cannot remove adenomyosis entirely, I think reducing it as much as we can, would probably give us a better chance of pregnancy, but that can be a very challenging surgery. For that surgery, I would use the robot.
Then, you have the grey, where you’re not sure—something in between. Should I operate, or should I not? Generally, if I’m in that area, I prefer not to operate. I’ve had some amazing teachers who repeatedly told me that if you want to be a top surgeon, you need to choose what to operate on. So, I wouldn’t jump into surgery with adenomyosis. I would be conservative. I would again use down-regulation and perhaps use PRP for the endometrium. If I see glands of adenomyosis also evident with hysteroscopy, I would only operate after repeated failures. I know it’s a little bit passive, but I would prefer not to operate if I’m not sure. If someone is borderline for an operation, I would of course listen to the patient’s wishes. In my experience, patients tend to prefer surgery, but they don’t always know what it entails. We need to spend time explaining to them that we may not be able to remove the entire adenomyosis, we may face adhesions afterwards, and we may have to wait for more than six months for the recovery process, plus the risk of rupture. If they hear that, sometimes they realize that it’s becoming more complex. I think it’s not easy. Adenomyosis is not easy. I would start with good mapping: have a very good ultrasound scan to map your adenomyosis, get a second opinion, ask for a multidisciplinary team meeting, and consider protocols for suppressing adenomyosis before transfer.
Well, it depends. If it’s straightforward, what we call type zero fibroid, 6 to 8 weeks is more than enough. But then again, it depends on the best person to ask—the surgeon. It depends on how broad the base was. If it was a thin base, grade zero, fine, no problem—you can go within four to 6 weeks. If it’s a broader-based myoma, and if it’s perhaps not exactly grade zero if it’s grade zero to one or two, sometimes I would wait a little bit longer if I’m in doubt, and very often I am, I have to confess. I suggest a second-look hysteroscopy, an office hysteroscopy—put a scope in and have a look. If everything is good, just go ahead. But in general, I think a couple of months—2 to 3 months—is more than enough for a standard, smaller to medium-sized grade zero or grade one fibroid.
This is difficult. I mean, firstly, I would do microbiome testing. I don’t know if you’ve done that. Microbiome testing is like genetic testing; you can Google that. It’s not microbiology, it’s a little bit more advanced. We use more advanced technology in next-generation sequencing. Microbiome testing may reveal either an infection that has not been shown in the standard microbiology testing or an imbalance between healthy and unhealthy bugs. There’s a lot of evidence, I mean, to be honest, it’s not my first-line implantation failure or miscarriage investigation, but I think in your case, I would suggest it.
Number two, I would get the best person—the most senior person in the unit—to do the embryo transfer. I think this is a secret between all of us, not so well-hidden: embryo transfer is operator-dependent. I believe that most units—and I’ve visited more than 100 units in Europe—do this automatically when it becomes a little difficult to achieve a pregnancy. They get the most experienced person. I would ensure the best, most experienced person to do the embryo transfer for you, and equally, the most experienced embryologist to handle your embryo.
Then, I would touch upon immunology. Immunology is a black box; it’s a very black box. My opinion is that we cannot disregard it 100%. I know that most fertility specialists disregard it because the evidence says that all of that is not necessary, but some amazing immunologists raise the flag. I think the truth is somewhere in the middle. I believe that a small subgroup of patients—how small, I don’t know, maybe 2%, 5%, 10%—may benefit from immunology assessment and management. You may be in that subgroup. I believe that immunology plays a part, but I just feel that we haven’t identified, perhaps we don’t have the means to identify, which group of patients may benefit. So, just approach that black box of immunology with a little bit of caution. Maybe there is a little element there, perhaps, because everything else is done.
I think it is unlikely the previous caesarean section could be a contributory factor. Having said that, I would exclude hydrosalpinges, for example. I think the only way I can think of that a Caesarean section could affect implantation is by creating a niche, a gap, in the healing process of the Caesarean section. You can Google that. We’ve published on that subject. If that was the case, it would be evident on the scan. You would see it on the 3D scan—a little black spot just underneath the scar. That may affect implantation. The second mechanism I can think of is the creation of hydrosalpinges. There’s a small risk—less than 1%—of pelvic infection after a C-section. If that has affected your tubes, and you have hydrosalpinges, which is the accumulation of fluid in the tubes, that may adversely affect implantation. If you want to explore that, I would suggest a 3D/4D ultrasound scan, and if you want to exclude it 100%, perhaps an HSG.
Difficult question to answer. If we are discussing back-to-back stimulation, I am not sure if by that they mean double stimulation every cycle or stimulation every cycle. To be honest, in the overall outcome, I don’t think it makes a difference. At 45 years of age, the main limiting factor is the DNA integrity of the embryo. So, in my opinion, it doesn’t matter if you do it back-to-back or not. If I were to suggest something, it would be PGT-A testing on the embryos to avoid unnecessary embryo transfers or transfers of abnormal embryos, which could lead to miscarriage and the associated psychological and physical impacts.
That depends on the condition of the tubes. What I would do is have a clear discussion with the surgeon about what they think the condition of the tubes is. If they feel the tubes are normal or nearly normal, I would try for a few months. However, there’s always a possibility that even if the tubes appear normal after complex surgery, they may become scarred later. So, if I were to rely on natural conception, I wouldn’t waste time without testing the tubes first.
Whatever your doctor is familiar with is probably the best option, as most solutions do the same job. I am not aware of any comparative studies that show one is better than the other. Some people don’t even use gels and do fine, while others use a coil, PRP straight after the procedure, or inexpensive methods like a small balloon catheter. Hysteroscopic surgery, especially for Asherman’s syndrome, can be tricky, sometimes trickier than stage four endometriosis. Unless you use a scan, you might not even realize when you’re through the uterus. So, I would ask your surgeon to use whatever they feel most comfortable with.
I think it’s unlikely. However, I would exclude hydrosalpinges as a possible issue. Most Cesarean sections are performed well, but there’s always individual variation in how women heal. The only mechanism I can think of where a C-section could affect implantation is the creation of a niche or gap in the healing process of the C-section scar. If that were the case, it would be evident on a 3D scan. The second possibility is the creation of hydrosalpinges, which could affect implantation. If you want to explore this, I suggest a 3D or 4D ultrasound scan, or possibly an HSG to rule it out.
