Exploring Surgical Treatments for Infertility
Dr. Douglas is dedicated to diagnosing and treating patients suffering from various causes of infertility so that they can achieve their dreams of becoming parents. In addition to the state-of-the-art infertility testing services and treatments, Dr. Douglas has extensive training in minimally invasive surgery such as laparoscopy and hysteroscopy. He has performed thousands of reproductive surgical procedures, so patients can count on receiving the best care possible and excellent results.
Reproductive laparoscopic surgery is a minimally invasive, outpatient procedure in which Dr. Douglas uses a laparoscope, a narrow instrument with a video camera, to evaluate and treat abnormalities of the uterus, fallopian tubes, and ovaries in the abdominal cavity. The laparoscope, which the doctor inserts through an incision in the belly button, can allow for identification of endometriosis, adhesions, and other disorders that affect female fertility. Because of its extremely small size, the laparoscope eliminates the need for large incisions, making it safer, less painful and has a much shorter recovery time. The procedure usually takes less than one hour, and patients are released from the hospital approximately three hours after surgery. Laparoscopic surgery can improve a woman’s fertility, or it may be needed in preparation for further infertility treatments. Dr. Douglas uses laparoscopy to treat endometriosis and repair or remove abnormal fallopian tubes. This type of surgery can also be utilized in removing ectopic pregnancies, ovarian cysts, fibroids, scar tissue, and pelvic adhesions, as well as to determine tubal patency.
In addition to laparoscopic treatment, Dr. Douglas also provides hysteroscopic surgery. Hysteroscopy, a minimally-invasive, outpatient procedure, lets Dr. Douglas inspect and operate in the uterine cavity using a fiber optic scope inserted through the cervix. This procedure allows Dr. Douglas to diagnose and treat abnormalities in the uterus that may cause miscarriages or infertility. Hysteroscopic surgery usually takes less than 30 minutes, and patients recover in two to three days. Because access occurs through the cervix, no incisions are made, making hysteroscopy a safe procedure with little discomfort. Hysteroscopic surgery is used to diagnose and treat uterine abnormalities such as uterine adhesions, scar tissue, tubal blockages, septums, endometrial polyps, and fibroids. This surgery can also help detect and treat abnormalities that may cause repeated miscarriages. Dr. Douglas will determine which type of hysteroscopy surgery (diagnostic versus operative) is best for your case.
Read more about Minimally Invasive Surgery
Treatment for Ovarian Cysts
Ovarian cysts are quite common. The great majority, if left alone and observed over a period of four to eight weeks, will resolve without treatment. The only ones that cause concern are the ones that do not go away by themselves. The more common cysts that we see that can impact infertility would be cysts of endometriosis, known as endometriomas. We also see dermoid cysts, which are not necessarily associated with infertility, but are a common finding in a younger-age class. Dr. Douglas may remove large cysts by laparoscopy if they interfere with fertility.
Treatment for Ectopic Pregnancies
Ectopic pregnancies are fairly common in an infertility practice because damaged fallopian tubes decrease the chances of getting pregnant. Occasionally, a pregnancy occurs, but the damaged fallopian tube does not function properly. In this case, the embryo doesn’t move into the uterus, and the baby implants in the fallopian tube. Because the fallopian tube does not stretch like the uterus does, this can create a perilous situation. At approximately 7 to 10 weeks, the fallopian tube becomes so swollen that it ruptures.
When the fallopian tube ruptures, it causes internal bleeding, and can cause life-threatening hemorrhage. In an infertility practice, we usually know exactly when a patient conceived, so we can detect most ectopic pregnancies before they become this dangerous.
The most common treatment is methotrexate, a non-surgical medication given, usually as a one-time injection; methotrexate kills rapidly-dividing cells such as a placenta. Over a period of three to four weeks, the patient’s pregnancy levels are monitored and should continue to drop after the injection. This process works approximately 85 percent of the time. In the other 15 percent of cases, the ectopic continues to grow and requires surgery.
For unruptured ectopic pregnancies, surgical treatment is minimally invasive and performed by laparoscopy. If the ectopic is already ruptured and the patient’s vital signs suggest the need for rapid intervention to stop internal bleeding, Dr. Douglas may perform a laparotomy instead. In our practice, we monitor the progression of early pregnancy in all patients and start early intervention when an ectopic is discovered; the need for surgery rarely arises.
Fibroids and Polyps
Common occurrences, fibroids are growths in the wall of the uterus that do not usually need treatment. Occasionally, fibroids develop in the wrong location, or grow too large and interfere with normal implantation of the embryo. Large fibroids that occupy space inside the endometrial cavity (submucosal fibroids) will divert blood flow away from the endometrial lining and cause areas where the embryo cannot implant and grow. These fibroids cause decreased fertility and increased miscarriage rates. To treat fibroids, Dr. Douglas will perform surgery, usually a laparotomy, to remove the tissue, if the great majority of the fibroid is present only within the endometrial cavity, then Dr. Douglas can remove the growth with hysteroscopy.
Uterine polyps are another common problem that we see within the uterus. These benign growths usually appear inside the uterus or the endometrial cavity. When a polyp becomes large enough, it can decrease the chance of implantation and may also increase the miscarriage rate. The size and the location of the polyp(s) will determine whether or not treatment is needed. If you have a large polyp, Dr. Douglas usually suggests hysteroscopy to remove it. If the polyp is small and low in the uterus, we may just follow the growths with sonograms.
Treatment for Tubal Blockage
Another common female fertility factor is tubal blockage. We can make this diagnosis with an HSG x-ray. During the HSG x-ray, dye is inserted into the uterine cavity; it flows through the uterine cavity and out the fallopian tube. The dye should spill into the abdomen; no spill indicates that the fallopian tubes are blocked. The fallopian tubes are usually blocked either at the beginning of the fallopian tube as it leaves the uterus, called the proximal fallopian tube, or at the end of the fallopian tube called the distal fallopian tube. The treatment for the two blockages is completely different.
Dr. Douglas treats distal tubal blockage with laparoscopy. With the laparoscope, we can evaluate the fallopian tube and try to make an incision in the end of the fallopian tube to open it. Occasionally, the fallopian tube has sustained so much damage that surgically opening the fallopian tube does not keep the tube open and it scars shut within one to two weeks. In this case, Dr. Douglas may recommend removing the fallopian tube instead of trying to correct it.
A fallopian tube blocked at the end often becomes very dilated and filled with fluid, referred to as hydrosalpinx. Research has shown that the fluid in the hydrosalpinx leaks back into the uterus and can decrease the chances of implantation. If a patient has a hydrosalpinx and does in-vitro fertilization, the pregnancy rates will decrease by one-third to one-half compared to other women her age without a hydrosalpinx. For this reason, the hydrosalpinx either has to be opened or removed, which is usually accomplished during laparoscopy, once this procedure is done the success rate of IVF returns to normal.
Two treatments are available for a patient with a proximal blockage, which occurs as the fallopian tube leaves the uterine cavity. Using the hysteroscopy, Dr. Douglas can thread a catheter into the beginning of the fallopian tube in an attempt to open the fallopian tube. The other option is to try and open the tube during a hysterosalpingogram, the radiologist can selectively catheterize the fallopian tube and try to open the proximal portion, but the procedure is only successful in some cases. If we cannot repair the tube IVF will be needed.
Read more about Conceiving after Tubal Surgery – an ASRM Guide
Often, we find couples that cannot conceive because of pelvic adhesions. Dr. Douglas makes the diagnosis during laparoscopy when he finds that the pelvic organs are stuck together, or adhered, hence the name pelvic adhesions. If the fallopian tubes are stuck to another structure in the pelvis, they cannot pick up the egg as it is released from the ovary. If the ovaries are stuck to the wall of the abdomen, again, egg pickup or ovulation is impaired. Using lasers, scissors, and other instruments during laparoscopy, Dr. Douglas can reduce or remove the pelvic adhesions, freeing the ovary and fallopian tubes to return to their normal position and increasing the chances of normal conception. Pelvic adhesions can occur because of endometriosis, previous pelvic infection, and previous surgeries in the pelvic area.
With Asherman’s syndrome, the patient has adhesions inside the uterine cavity. The most common reason for Asherman’s is previous surgery within the uterine cavity, such as a D & C. To treat Asherman’s, Dr. Douglas inserts a hysteroscope into the cervix and utilizes scissors, lasers, or a cautery to cut the adhesions. Often, to prevent the adhesions from recurring, Dr. Douglas leaves an IUD or Foley catheter in the uterus following the surgery for a specific period of time, usually five to seven days. Many times, patients receive high doses of estrogen postoperatively to help the lining of the uterus, or the endometrium, grow over the area where the scar tissue has been cut away, which helps to prevent further adhesions after the hysteroscopic surgery.
A uterine septum is a band of tissue in the very top portion of the uterus that has minimal or no blood supply. Because of this, any pregnancy that implants on this area will likely miscarry. Septums come in all sizes, from very small to filling the entire uterus. Dr. Douglas will treat the uterine septums by using hysteroscopy and removing the septum. Septums are usually diagnosed either with a hysterosalpingogram or by a saline sonogram.