Reproductive surgery: minimally invasive interventions to restore fertility

Norman Gómez, MD
Gynecologist and surgeon at Equipo Juana Crespo, Equipo Juana Crespo

Category:
Endometriosis, Failed IVF Cycles, Miscarriages and RPL

From this video you will find out:

When patients can receive a bad reproductive prognosis?
How do doctors reach the diagnosis?
When is hysteroscopy needed and how it helps in diagnostics?
Abdominal surgery, open surgery or laparoscopy?
How long does a patient have to wait with IVF after the surgery?

Reproductive surgery: minimally invasive interventions to restore fertility

Can a minor surgery help with my next fertility treatment?

In this session, Dr Norman Gómez, a gynaecologist and surgeon at Equipo Juana Crespo, located in Valencia, has been talking about minimally invasive reproductive surgery which can be a solution to restoring fertility.

Dr Gómez presented a topic where he thoroughly explained how, from the surgical point of view, the uterus can be fixed. It’s important to understand that the uterus consists of two compartments. The first compartment is the internal one, it represents the uterine cavity. There is also the external compartment, the sterile compartment represents the ovaries and the uterine walls.

There are a lot of conditions that can be found in the external part of the uterus. The most frequent pathologies are endometriosis, and when the uterus is affected by this disease, there are many ovarian cysts, you can also find a lot of additions covering the uterus and all this is conditioned by the inflammatory environment. It is possible to treat all these problems.

The second condition is hydrosalpinx which means that a stroke develops at the end of the fallopian tubes, and when the tube is obstructed, it can accumulate liquid inside. This liquid can reduce the implantation process of the embryos by half. It can also impair natural conceptions and produce a pregnancy inside the tube and outside the uterus, called an ectopic pregnancy. In this situation, surgery is performed to remove the tubes, which can improve the possibility of pregnancy. Therefore, it is important to check the tubes before starting any kind of fertility treatment.

The third condition is uterine myomas, which are benign tumours that are located and originate from the uterine walls. It’s a tissue that grows in the uterine wall, and depending on the size of the myoma and location, it can affect reproduction or not. Myomas are very frequent pathologies, and it represents, 30% of patients with fertility problems.

In the internal compartment of the uterus, there are also a lot of other pathologic situations. The most frequent are two kinds of pathologies, one of these is congenital pathogens like a uterine septum where a uterus is divided into two small cavities, this is the most frequent congenital anomaly in patients with fertility issues. Congenital means that the patient is born with these conditions, but it is possible to treat them. There are also acquired pathologies, where the patient is not born with the pathologies but develops them during the woman’s reproductive life. The most frequent ones are polyps. There is synechia, where the uterine wall sticks together inside the fungus. Most of the time, it is related to the pain inside the uterus. Finally, three are fibroids that can also be found inside the cavity and they can affect the implantation process.

- Questions and Answers

I have fibroids, they are not inside the uterine cavity. Do I need to get them removed? Doctors have said they should not affect implantation, but now I am not sure whether to remove them. I have had embryo transfers before, but they did not implant. Any advice?

We need to evaluate the situation of this kind of uterus. There’s consensus about which type of myomas we must remove to improve the pregnancy. Generally, the submucosal myomas, which are the myomas inside the cavity we should remove them and the myomas that are located on the outside of the uterus maybe we don’t need to treat those. When it comes to myomas in the middle of the uterine wall, it depends on the location of this kind of myomas, on their size, and then we can check if they should be treated or not. We always need to evaluate the situation if the patient already had embryo transfers and failed with several embryo transfers, maybe we need to plan to extract the myoma. If the patient had no transfer possibly, we wouldn’t need to remove the myomas, but if the patient has a lot of failures, we can remove it, it would be better.

I have had a hysteroscopy 2 years ago. My fallopian tubes were not blocked. Would I need to do hysteroscopy again since my last IVF I tried was one year ago, and I’m thinking to start a cycle again, would there be that many changes in my body in one year?

I don’t see any relation between the hysteroscopy and the fallopian tubes and starting a cycle again. There’s no problem, you can start with the cycle.

I have adenomyosis and what has been described as ‘burnt out’ endometriosis. I also have a small fibroid. My last clinic said it was not a problem. There were no blockages of my fallopian tubes. I have had 3 failed donor egg transfers. I also have elevated NK Cells, an underactive thyroid gland, and tested positive for the MTHFR gene. My last clinic just wanted to carry on giving me lots of different medications. Would you suggest that I would need surgery?

Adenomyosis is an inflammatory condition, it’s like endometriosis inside the uterine walls. The uterus with this condition needs to be treated before transferring the embryos or at least that’s what we do in our center. Possibly it could be a good thing to do this surgery, but I would need more details about the condition of your uterine cavity. We need to evaluate a lot of aspects of this kind of pathology. If we were to perform surgery, we would always need to treat you with GnRH to stop the menstrual period for at least two months or three months because the amniotic tissue is growing more with your hormones. If we decrease the hormone levels with GnRH, we can improve the possibility of pregnancy. Adenomyosis is very difficult to treat, but we have a lot of experience in treating this kind of uterus. Sometimes the adenomyosis affects the morphology of the uterus or creates a synechia, or results in a lot of cystic lesions inside the cavity, but with surgical treatment, we can remove it.

Is there a side effect of doing ovarian rejuvenation PRP, for exactly, scar tissue on the ovary?

Rejuvenation is the holy grail for the reproductive doctor, we are starting to do this kind of procedure, and we have done it with a few patients, but this is still for experimental purposes. This kind of procedure is useful mostly for young women with premature ovarian failure, which means that their menstrual periods are stopped before they are 40. In this kind of patient, if we use this technique, possibly we will be able to find some eggs in the ovaries, but the results are still not convincing. When we start to do this kind of procedure we improve the condition of the ovary in approximately 20% of the patients. So there is still some work that needs to be done when it comes to PRP, but it is a possibility, we can do that for sure. However, we still need to explore more and study more about this kind of treatment before offering that to the patients. I think most of the fertility centers do this kind of procedure for experimental purposes.

I heard that hysteroscopy is painful, is that true? Can hysteroscopy cause any damage/scarring?

If you don’t have the experience in doing this kind of procedure, it is possible to injure the uterus, this can cause damage to the uterus, and this is very common in our community. The other thing is that it is painful most of the hysteroscopies that we do are done in the operating theater, so we do it under anesthesia, so the patient doesn’t feel any pain after the procedure, but sometimes we do it in an office. Sometimes, some pain like a menstrual period is possible but nothing else.

Can you have a hysteroscopy if you have had loads of surgeries? I also have lots of adhesions.

When you have adhesions inside the uterine cavity, the best tool to treat the adhesions inside the uterine cavity is hysteroscopy, for sure. When we do a lot of myomectomies, for example, we extract around 20 myomas from the uterine walls, we always do hysteroscopy two months after myomectomy to check the uterine cavity. There’s no problem with doing hysteroscopy after a uterine surgical procedure.

Can the arcuate uterus be the cause of 3 years without result in search of natural pregnancy? Would resonance be necessary to look for something else?

This kind of uterus with this kind of features maybe will relate to the adenomyotic condition of the uterus. We can possibly look for this pathology, for adenomyosis, which is a condition where your uterus has morphological features, and if this is the situation, we can treat the disease with GnRH and also if you have a recurring implantation failure, we can do surgery. We can do it in this case, not only to correct the morphology of the uterus but also to create some scratch effect inside the endometrial layer. Sometimes, we do its procedure to improve the implantation process.

I’ve had 2 laparoscopies and hysteroscopies and had endometriosis. I also had subserosal fibroids removed that would grow every time I did my IVF cycles, but I still kept miscarrying. I’m now using a donor and SM, but my question is: Should I have more surgeries to remove the subserosal fibroids?

I don’t think you’ll need to remove the subserosal fibroids, but we always need to see the size of this kind of fibroids. Generally, these fibroids grow from the external layer of the uterus, so they do not affect the endometrial cavity. If the fibroids are too big and they press the uterine cavity, then maybe we need to treat this fibroid. I don’t see the indication for the subserosal fibroids to be removed.

I am a patient with a desire for pregnancy who suffers from uterine myomatosis, with the presence of a FIGO type 0 submucosal myoma greater than 2 cm. In their clinical surgical practice, when they perform hysteroscopic myoma resection, do they leave the myoma in the uterine cavity for spontaneous reabsorption? What conduct and treatment would you carry out?

When we have a submucosal myoma, we can treat them with a lot of different techniques and remove them. The most important thing is to disinsert the myoma and extract it from the uterine wall. If you extract the myoma from the uterine wall and leave the myoma inside the uterus, but if it is released from the uterine wall, you can keep it inside the uterus, but the word is not reabsorption. If you disinsert the myoma and leave it inside the cavity, the uterus can spill out spontaneously by contractions, this is normal. There is a paper about a multicenter study of myomectomy, and it says to always leave the myoma inside the cavity, and the myoma will be spilled out with the uterine contractions after one month, this happens frequently.

Would a transfer from a donated embryo be successful after a surgical hysteroscopy/laparoscopy? The reason is the removal of the endometriomas and fixing a malformation of the uterus from adenomyosis? Also, how long do I need to be at the clinic until the surgery is done and I can go home?

The short answer is yes. If we do the surgical procedure in your case, for sure, we will improve the condition of the uterus so you will have a higher percentage of success rate.

I have read that after the interventions, the pregnancies are considered risky, is it true?

Yes, sometimes it depends on the treatment that you do to the uterus, for example, if you do the only hysteroscopy, there is no need to consider that it will be a risky pregnancy, but if we do an abdominal surgery to remove a lot of myomas, the users will have a lot of scars in the uterine wall, so yes, we would consider this a risky pregnancy. If you don’t wait until full recovery, so those 5-6 months after the surgery, sometimes, the pregnancy can cause a break in the uterine wall at some point, and this is risky. We always advise patients who had a myomectomy or multiple myomectomies to do a cesarean section when the baby is being born. It is best to avoid long or prolonged labor.

Are myomas and fibroids the same thing?

It’s the same thing, we use both to differentiate, but it is the same.

With laparoscopy do the additional 3 incisions only typically happen if there is anything to fix? I don’t have any known condition and have unexplained infertility. I did have ectopic pregnancy 1 year ago, which resolved naturally. My doctor didn’t suggest any further investigation although, I was offered laparoscopy to investigate right-sided pain following ectopic. However, wondering if hysteroscopy would be better and less invasive. Since then, I’ve had one round of IVF with failed implantation. I am 42.

Normally, when we have an ectopic pregnancy, and it resolved spontaneously, as you’ve mentioned, possibly the tube in this part of the uterus doesn’t work very well, and sometimes, we can detect a liquid inside, it’s called hydrosalpinx, and so we need to check that. Hysteroscopy can detect other problems inside the cavity. You also need to know that as you are 42 years old, possibly the quality of the embryo is not the best, so this is another aspect that we need to take into consideration in this situation, not only the uterus.

Do you always consider removing a tube with hydrosalpinx that is permeable? Or, may the situation arise that it has hydrosalpinx but no internal fluid and it doesn’t need to be removed? Is it clear whether or not there is fluid in the uterus on hysterosalpingography images?

By definition, the hydrosalpinx means that the tube is not working. Sometimes, when we do the endometrial preparation to do the embryo transfer, we can see the liquid inside the uterus, but we don’t know where this kind of liquid is coming from. You only need to check the tube, and if the tube is thicker with the liquid inside, definitely you must remove it before putting the embryo inside because the probability of pregnancy is lower with this condition.

Is HyCoSy better than an HSG (Hysterosalpingogram), or is HSG better? Does one give better results than the other?

It depends on the experience of the doctor that does the test. For me, it’s better to do the hysterosalpingography because you can check the tube thoroughly. With the HyCoSy, it depends on your ability to check it with the ultrasound scan to see all the trajectories of the tube. If the tube is normal, it’s easy to interpret this kind of study, but if the tube has been surrounded by endometriosis or surrounded by the adhesions, sometimes even if the tube is permeable, you can miss a diagnosis with HyCoSy because it’s difficult to interpret it in pathologic situation.

I lost my menstruation early due to stress, it’s been over a year since. I never got pregnant, however, I am healthy, and I am not overweight. I did an ultrasound scan and was told that I have a low AMH level of 2.1 pmol, FSH 112.5. I want to use my own eggs, I’ve read about PRP recently. Can this help? I am 40 years old.

Yes, the PRP is now used in a lot of specialties. There are a lot of studies that are done to try to improve the ovarian reserve using this kind of option. The theory tells us that the PRP has a lot of growth factors that we can use to improve the growth of the follicles inside the ovary. Right now, we are using this kind of therapy sometimes, but it is only for experimental purposes. The AMH is quite low, which is connected with your age. My best advice in this situation would be maybe to do a cycle to see how your ovary behaves, administering the hormones, and if the ovaries did not respond possibly, your best option is to do an egg donation program. It’s not impossible to get pregnant at 40 years old with these hormone levels, it’s not impossible to have an embryo, but it is a difficult way.

I had a failed IVF transfer last week. I have stage 4 endometriosis and I did a laparoscopic surgery in June. I did intralipid infusions 6 days before transfer. My lining was 9 millimeters 10 days before the transfer day. Is there a reason my transfer failed? I’m 31 years old.

If you have endometriosis stage 4, for sure, you have an adenomyotic condition of the uterus. It’s always linked with this kind of stage of the disease. If you have any kind of problems inside the uterus, maybe hysteroscopy would be a good option, or perhaps we could treat the uterus with the GnRH before the embryo transfer. At your age, the quality of the embryos might be good, but as you have endometriosis, the quality of the eggs can be affected because the eggs grow in the inflammatory environment inside the abdomen, so when we extract the eggs, they can be of worse quality. Possibly, we need to check the condition of the uterus more. Even if they removed a lot of diseases, we need to check the uterine itself, the uterine cavity, and the uterine walls because sometimes we need to treat the uterus before putting embryos inside.

Do you recommend having an endometrial scratch before the transfer, or would you say this is not necessary?

There is a lot of controversies about the endometrial scratch, there are some groups that do not believe in this kind of treatment, but there is another group that gets very good results with doing the endometrial scratch. The endometrial scratch is advised for repeated implantation failure, so if this is the situation, perhaps you can benefit from that before another embryo transfer. If you already had 3 or more embryo transfers and you got a negative result, possibly you can benefit from that. If you never did the embryo transfer, it’s not the first option to do.

Do you continue to lose eggs during the 9 months of pregnancy?

The short answer is yes, you will lose eggs during these 9 months, it’s like when you’re taking contraceptive pills, you are preventing ovulation, but you are still losing eggs during that time.

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Authors

Norman Gómez, MD

Dr Norman Gómez is a Gynaecologist and surgeon at Equipo Juana Crespo in Valencia. He is an expert in the practice of minimally invasive surgery to correct pathologies affecting the functionality of the reproductive organs, in order to restore fertility. He holds a Master's Degree in Human Reproduction, he studied Medicine and Surgery at the University of Zulia in Venezuela. Dr Gómez completed a residency in Gynaecology and Obstetrics in the Clinical Hospital of Valencia.

Event Moderator

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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