Procedures for women as part of fertility treatment

      

Gynaecological procedures

Although abnormalities in the uterus strictly speaking have no negative effect on the fertilisation of an egg, they can cause problems regarding embryo implantation and lead to miscarriage.

In Reduced fertility we discussed a number of physical abnormalities which can lead to problems to become pregnant, such as:
  • endometriosis, which can lead to adhesions in or around the ovaries, the fallopian tubes or the uterus; and
  • abnormalities of the uterus itself, such as a septum, myomas, fibroids or polyps. These growths can occur in the uterine cavity, but also on the outside of the uterus.

If the preliminary tests show a gynaecological problem – also when your fallopian tubes are tied off following sterilisation – it can be solved with an operative procedure, either
  • a therapeutic hysteroscopy is recommended
    • for septum resection (removal of a septum in the uterus)
    • for myomectomy (removal of myomas or fibroids)
    • for polypectomy (removal of polyps)
    • for the treatment of endometriosis in the uterine cavity
  • a therapeutic laparoscopy
    • for the treatment of endometriosis
    • for a myomectomy
    • for adhesiolysis, salpingolysis and ovariolysis (removal of adhesions, resp. in the abdominal cavity, around the fallopian tubes or the ovaries)
    • for a salpingostomy or salpingectomy (procedure on the fallopian tubes)
    • for sterilisation (usual procedure)
  • or a laparotomy
A hysteroscopy enables a clear picture of the inside of the uterus to be visualised:
  • this can be for diagnostic reasons, see imaging investigations of women;
  • or a specific surgical procedure, such as the removal of polyps. In this case it is known as a therapeutic hysteroscopy.

Practical

Read more here about the where-when-and-how of a therapeutic hysteroscopy.

For the practical side of the procedure, click in the bloc on the right.
The difference between the diagnostic variation and the therapeutic is the form of anaesthetic:
  • diagnostic procedures generally take place under local anaesthetic on an outpatient basis;
  • therapeutic procedures are performed under general or epidural anaesthetic.
    The procedure therefore requires a day admission, sometimes an overnight stay.

Procedure

A hysteroscopy - as well as a therapeutic hysteroscopy - is best performed during the first half of the menstrual cycle: after menstruation and before ovulation.
  • Under anaesthetic, an endoscope - a sort of fine telescope - is inserted through the vagina and cervix. 
  • The uterus is first dilated with water to obtain a good view. 
  • The hysteroscope has a separate canal, through which the surgeon can insert surgical instruments. These instruments are used to perform small surgical procedures:
    • to remove adhesions in the uterus (endometriosis treatment),
    • to cut away polyps (polypectomy),
    • to split a septum (septum resection) or remove a fibroma (myomectomy) with an electrode.

A hysteroscopy itself does not take long, the preparations, however, do.
Because the procedure takes place internally, through the cervix, there is no scar. Sometimes it is advisable to perform a laparoscopy simultaneously, which involves a series of tiny incisions on the abdomen and navel.
The most common indication for a therapeutic laparoscopy is endometriosis, or the presence of tissue from the lining of the womb around the ovaries, fallopian tubes and uterus. It can even grow too deep and too thick in the uterus itself.
Endometriosis can cause adhesions: if these adhesions affect the fallopian tubes and ovaries, it can lead to interferences in the transport of the egg, whilst adhesions in the uterus itself can prevent an embryo from implanting.

Adhesions or scar tissue in the abdominal cavity or in and around the reproductive organs can be the result of sexually transmitted diseases such as chlamydia (see STDs and infertility). An untreated STD which spreads upwards can cause Pelvic Inflammatory Disease (PID) and lead to a blockage of the fallopian tubes.

Procedure

Practical

Read more here about the where-when-and-how of a therapeutic laparoscopy.

For the practical side of the procedure, click in the bloc on the right.
A laparoscopy – also a pure diagnostic laparoscopy – is always under general anaesthetic.
  • Through an incision in the navel, an endoscope - a kind of telescope, less than a centimetre in diameter - is inserted partly into the abdominal cavity.
  • Gas is then used to inflate the cavity, between the front abdominal wall and intestines, so that a good view can be obtained of the uterus and fallopian tubes.
  • Through the endoscope canal or a small incision (0.5 cm) in the lower abdomen one or several surgical instrument(s) can be inserted: small forceps, an electrode or a pair of scissors.
  • They can be used to perform the following procedures:
    • removal of superfluous mucous membrane lining (treatment of endometriosis);
    • treatment of adhesions in the abdominal cavity (adhesiolysis), on the fallopian tubes (salpingolysis) or the ovaries (ovariolysis).
      Adhesions in the uterus can be treated with therapeutic hysteroscopy;
    • reopening blocked fallopian tubes (salpingoneostomy);
    • removal of an ectopic pregnancy (salpingostomy or salpingectomy);
    • removal of a (big) myoma (myomectomy) or a fallopian tube (salpingectomy).
  • The duration of the procedure depends on the extent of the problem and can vary from thirty minutes to a number of hours.
A laparotomy is an open abdominal operation under general anaesthesia.
To get to the abdominal cavity a small incision is made - a so-called 'bikini cut' - approximately at the line of the pubic hair. This incision goes through the skin, through the wall of your lower abdomen and through the peritoneum.

At the CRG a laparotomy is only performed
  • for an extensive myomectomy, or
  • for a reanastomosis (reversal of sterilisation).

In the first case the laparotomy is necessary because the fibroids have become too big or too numerous, or both.
A laparotomy is necessary for a reanastomosis, because the fallopian tubes are repaired via micro surgery.

Sterilisation is only performed via laparotomy if planned during a caesarean section. The abdominal wall is opened for the delivery and not specifically for the sterilisation, which in all other cases is performed laparoscopically.
In this case it concerns a procedure performed at the Gynaecology department of UZ Brussel.

Laparoscopic
Via laparotomy

The CRG's main activity concerns the treatment of patients' fertility problems. However, we will now provide some more information about a procedure somewhat at odds with this: sterilisation.Sterilisation of woman is mainly performed at the Gynaecology department, unless performed together with the removal of eggs for donation.

It is in principle a non-reversible operation, aimed at people who are sure they do not want any more children. A reversal operation is possible, but cannot guarantee the restoration of fertility.

Laparoscopic    

Sterilisation is usually performed via laparoscopy:
  • through the endoscope canal a small instrument is inserted into the abdominal cavity, and 
  • plastic clips are placed on the fallopian tubes to close them,
  • or they are cauterised with an electrode.
The procedure is performed under general anaesthetic, but usually you can still go home the same day – after a few hours of rest in your room.
You will need to take it easy for a few days following the operation.

Via laparotomy    

Sterilisation can also be done with laparotomy - an abdominal operation. This will be the case when the procedure is performed following a caesarean section.
  • Through the incision in the abdomen a small pair of scissors are inserted into the abdominal cavity.
  • A small piece of each fallopian tube is cut off,
  • and the two open ends are tied off.
The procedure is performed under general anaesthetic, and you will have to stay one or more nights in the hospital until you are fully recovered. You have to take at least a week's rest.
If you were sterilised and decide you want another child, you are not automatically referred to assisted fertilisation or adoption. After a reanastomosis, a procedure aimed at undoing the sterilisation, chances are fair that a natural pregnancy will again be possible.

The procedure involves re-connecting the tied off, clipped or cauterised fallopian tubes.
Depending on the damage to the tubes, the chances of a successful restoration of normal fertility are around 80% if you are younger than 36. However, there is a 1 in 10 chance of an ectopic pregnancy occurring.

A reanastomosis is performed via laparoscopy or via laparotomy. It is a procedure under general anaesthetic and involves a few nights in hospital after the operation.