Recent reports of an error in ICSI treatment
Recent reports of an error in ICSI treatment
Infertility surgery
Reduced fertility can also be attributed to conditions present in the body, whether congenital or the result of a disease. In some cases, surgery may offer a solution. There may be a problem in the woman’s or the man’s body that prevents an (ongoing) pregnancy. Surgery may be recommended in that case.
In some cases, a procedure or keyhole surgery is suggested as part of a fertility treatment to diagnose the problem. In other circumstances, surgery is needed to solve the fertility problem or improve chances of pregnancy, including when IVF is applied.
Brussels IVF has its own dedicated operating theatre, where these procedures are performed.
Good to know
Surgery at Brussels IVF
Elective surgery and surgical interventions can be part of a fertility pathway. In 2024, 2,216 surgical interventions were performed in the Brussels IVF operating theatre.
For whom?
Men:
A man’s fertility depends on his sperm production.
When a man is diagnosed with a low sperm count, we start by looking at potential hormonal and psychosocial causes. If no semen is found in the ejaculate, a surgical procedure may be performed to examine the testis for the presence of sperm.
In many cases, sperm transport can be restored by surgery after previous sterilisation (vasectomy) or in some specific cases after epididymitis.
Women:
The oocyte’s transport to the uterus may be impeded if the fallopian tube(s) do not function optimally or are (partially) blocked. The most common causes for this are adhesions due to abdominal inflammation or endometriosis.
Although abnormalities in the womb do not prevent fertilisation of the oocyte per se, they may have a negative impact on the embryo’s implantation and can even potentially cause miscarriage.
This includes abnormalities such as myomas or fibroids, or polyps, which can occur in the uterine cavity and along the uterine wall, as well as on the outside of the uterus. If we find that they prevent pregnancy, we can surgically remove them.
Common procedures in women
There are several gynaecological procedures that can influence a woman’s infertility.
Puncture of ovarian cysts:
Cysts are often functional and caused by the normal way in which an ovary releases an oocyte. It is only when these cysts start producing hormones themselves that they threaten to interfere with the treatment and require removal. The procedure is the same as for oocyte retrieval; the cysts are punctured using ultrasound guidance and drained, usually, under a local anaesthetic.
Hysteroscopy:
We distinguish between diagnostic hysteroscopy and therapeutic hysteroscopy.The first step is often a diagnostic hysteroscopy. This involves keyhole surgery during which we examine the womb for any inflammation or abnormality to establish a diagnosis. A very fine tube with a camera is inserted through the cervix into the uterine cavity. You can follow on screen what is going on. This is an outpatient procedure.
We constantly flush some water through the uterine cavity for improved visibility. This is completely painless in most cases. Ideally, the keyhole surgery is not performed when you are still bleeding for optimal visibility.
We often also remove some tissue (biopsy) during a diagnostic hysteroscopy for further research in the lab. While the procedure is short, it is sometimes perceived as unpleasant or painful. You may therefore take a painkiller (1 gram of paracetamol) before your diagnostic hysteroscopy.Minor abnormalities can be removed immediately. Larger abnormalities are dealt with later, during a scheduled therapeutic hysteroscopy. Your doctor discusses the results of the biopsy with you.A therapeutic hysteroscopy is a surgical procedure, which takes place under general or epidural anaesthesia. You will have to be hospitalised for this. This procedure is indicated in several cases, i.e., for a septate uterus (septum resection), or to remove a fibroid or myoma (myomectomy), or polyps (polypectomy).
After a hysteroscopy, you may lose some fluid and blood. The activity in your womb can also trigger cramps that feel like menstrual cramps.
Laparoscopy:
Here too, we distinguish between diagnostic laparoscopy and therapeutic laparoscopy. Either way, a laparoscopy is performed under general anaesthesia. We make a small incision in the navel to insert a very small viewing device (laparoscope). The duration depends on the procedure.A laparoscopy is performed to diagnose and treat endometriosis, to remove adhesions in the abdominal cavity, around the fallopian tubes or ovaries, or to open the fallopian tubes.The laparoscope is inserted into the body through an incision along the navel. Any additional instruments (clamps, forceps, scissors…) are inserted into the lower abdomen through an additional incision (0.5 cm).
Laparotomy:
A laparotomy is open abdominal surgery that is only performed under general anaesthesia. To reach the abdominal cavity, a small incision is made in the lower abdomen, near the pubic hairline. Laparotomy is recommended when a very large number of fibroids need to be removed (extended myomectomy) or for fallopian tube reconstruction.
Common procedures in men
There are several ways to find sperm in men who have no sperm in the ejaculate.
TESE or testicular sperm extraction:
This involves surgically removing a small piece of tissue from a testicle under local or general anaesthesia. The tissue is checked for the presence and quality of sperm cells in the lab. Depending on the result, more tissue is then removed from the same testicle or from the other testicle. This tissue may contain enough sperm cells for ICSI treatment. Sometimes additional sperm can still be banked.
FNA or fine needle aspiration:
This procedure is done under local anaesthetic. It is a minor procedure. FNA may be a valid alternative if your sperm production is normal but you have no sperm in your ejaculate due to a blockage along the way. However, the procedure produces too few sperm cells to freeze any for further attempts.
PESA or precutaneous epididymal sperm aspiration:
This is a simple technique under local anaesthesia that does not require an incision. The doctor punctures the epididymis through the skin to aspire the sperm cells from it.
The appropriate technique, FNA or PESA, will be suggested, depending on your situation or diagnosis.
Electrostimulation:
This technique is used in men who are unable to ejaculate on their own. Electrostimulation is routinely done under sedation with the exception of patients with paraplegia with complete spinal cord injury. During the procedure, a special probe is inserted into the man’s rectum. The nerves are stimulated for several minutes to induce ejaculation. Before this treatment, we need to perform blood work and a urine culture. Please note that this treatment is never reimbursed by your mutual health insurance fund.
Reversal surgery after sterilisation or reanastomosis:
In this reversal surgery, the two ends of the ligated seminal duct are reconnected with microsurgery. In 7 to 8 out of 10 men, sperm transport is restored. Because sperm quality is not always the same as it used to be, chances of pregnancy are 50 to 60 per cent if your partner is under 35 years old.
Do you have (suspected) endometriosis?
Find out what the Endometriosis Centre at UZ Brussel can do for you.
Five common questions about infertility surgery answered:
Is surgery necessary if my pregnancy does not evolve as hoped?
When we establish with a blood test that a woman is pregnant after fertility treatment, we monitor how the pregnancy evolves, like with natural conception. Unfortunately, about 1 in 6 women experience pregnancy loss. In most cases, when the pregnancy is non-viable, the body takes care of this on its own. In about 5% of women, an intervention is still needed. In the majority of cases, this is done by administering medication, but sometimes through surgery. This procedure is done under local anaesthesia, during which the uterus is emptied through keyhole surgery (hysteroscopy). If the pregnancy is already more advanced, the procedure is performed under general anaesthesia and curettage (aspiration) is sometimes inevitable. When an ectopic pregnancy is diagnosed, it means that the developing foetus did not implant in the uterus, but in the fallopian tube or another place in the abdominal cavity. Unfortunately, the pregnancy cannot then evolve correctly. However, it is important that the growth of the foetus is timely interrupted as this is dangerous for the pregnant woman (e.g. bleeding inside the abdomen may occur). Sometimes this is treated via administration of medication, but it may also be necessary to surgically remove the foetus (and sometimes the affected fallopian tube). This is always performed through keyhole surgery (laparoscopy) under general anaesthesia. A pregnancy loss can be a devastating experience. Although there is a biological explanation, such an experience is at odds with the desire to have children. You can request support and counselling from a fertility psychologist at our centre.
Are cysts malignant?
No, ovarian cysts mean the ovaries are working as they should, except when these cysts produce hormones as these may interfere with treatment. They are then usually punctured to remove them. A cyst may thus cause a delay in the planning schedule of your treatment. But a cyst on the ultrasound is not a cause for concern.
Dr. Michelle Soares
Can quality sperm be obtained through TESE/PESA/FNA?
Even if sperm cells are found during a surgical procedure, this does not necessarily mean that they are all of high quality. Some sperm cells may be abnormally shaped or have reduced motility. This can affect the chances of successful conception and an ongoing pregnancy.
Dr. Veerle Vloeberghs
Is a hysteroscopy painful?
Generally, a diagnostic hysteroscopy is considered less invasive or less painful than a laparoscopy. In most cases, the keyhole surgery is mildly unpleasant and almost painless. During diagnostic hysteroscopy, we also remove some tissue (biopsy) for examination. While this does not take long, it may feel uncomfortable. You may therefore take a painkiller (1 gram of paracetamol) before your diagnostic hysteroscopy. Please talk to your doctor about any concerns you have regarding pain or discomfort. If you are relaxed, the procedure will go more smoothly. We provide you with all the necessary information so you know what to expect and which measures can be taken to improve your comfort during the procedure. An operative or therapeutic hysteroscopy, during which an abnormality is corrected, is always performed under full anaesthesia to maximise your comfort during this longer procedure.
I had a vasectomy but I still want to have children. What are the possibilities?
Vasectomy is a definitive procedure. Although reversal surgery exists, unfortunately your fertility may not always be (fully) restored. In half the cases, men develop antibodies against their own sperm cells. These antibodies reduce sperm motility or make sperm stick together, which can reduce your fertility. Nonetheless, the prognosis for recovery is very favourable.