Role of Laparoscopy in Infertility

Overview

Laparoscopic surgery has become a preferred operation method for bariatric surgeries and gallbladder removals – but especially for gynaecologists and the field of infertility. Minimally invasive laparoscopic surgery can be beneficial for endometriosis, treating cysts or fibroids. Let’s take a look at different ways this type of surgery can be beneficial for both treating the causes of infertility, managing pain, and preserving fertility for later in life.

1. FIBROIDS

Fibroids, also known as uterine fibroids or leiomyomas, are noncancerous growths that develop in the muscular walls of the uterus. They are composed of smooth muscle cells and fibrous connective tissue. Fibroids can vary in size, ranging from small, pea-sized nodules to large growths that can distort the shape and size of the uterus. The exact cause of fibroids is unknown, but they are influenced by hormones, particularly estrogen and progesterone. Women of reproductive age are more prone to developing fibroids, and they tend to run in families. Many women with fibroids may not experience any symptoms, but others may have heavy or prolonged menstrual periods, pelvic pain or pressure, frequent urination, difficulty emptying the bladder, or pain during sexual intercourse. Treatment options for fibroids depend on various factors, including the severity of symptoms, the size and location of the fibroids, and the woman’s reproductive goals.

Myomectomy

Myomectomy is a surgical procedure performed to remove uterine fibroids, which are noncancerous growths in the uterus. It can be done through different approaches, including abdominal myomectomy, hysteroscopic myomectomy, laparoscopic myomectomy, or robotic myomectomy. Abdominal myomectomy involves making an incision in the abdomen to access the uterus and remove the fibroids. Hysteroscopic myomectomy is performed through the vagina and cervix using specialized instruments. Laparoscopic or robotic myomectomy uses minimally invasive techniques with small incisions. Myomectomy is typically considered in the following situations:

1. Symptomatic Fibroids: If your fibroids are causing significant symptoms such as heavy menstrual bleeding, pelvic pain or pressure, or affecting your quality of life, myomectomy may be recommended to alleviate those symptoms.
2. Fertility Concerns: If you are experiencing infertility or recurrent pregnancy loss due to fibroids, myomectomy can be an option to improve your chances of conceiving and carrying a pregnancy to term.
3. Rapid Fibroid Growth: If your fibroids are growing rapidly or have reached a size that is causing complications, such as urinary or bowel problems, myomectomy may be necessary to address those issues.
4. Desire to Preserve the Uterus: Myomectomy is performed with the goal of removing fibroids while preserving the uterus. If you desire to maintain your fertility or keep your uterus intact for personal reasons, myomectomy can be considered.

How is a myomectomy operation performed?

A myomectomy is a surgical procedure performed to remove uterine fibroids while preserving the uterus. The three primary approaches for myomectomy are:

1. Abdominal Myomectomy: This is the traditional and most invasive approach. It involves making an incision in the lower abdomen, similar to a C-section incision. The surgeon accesses the uterus through this incision, removes the fibroids, and repairs the uterine This approach is typically used for larger fibroids or when multiple fibroids are present. It may require a longer recovery time compared to other methods.
2. Laparoscopic Myomectomy: This is a minimally invasive approach that utilizes small incisions in the abdomen. The surgeon inserts a laparoscope (a thin, lighted instrument with a camera) and other surgical instruments through these incisions. The fibroids are located, removed, and the uterine wall is Laparoscopic myomectomy offers faster recovery, shorter hospital stays, and less scarring compared to abdominal myomectomy.
3. Hysteroscopic Myomectomy: This approach is suitable for fibroids that are primarily located within the uterine A hysteroscope, a thin tube with a camera, is inserted through the vagina and cervix into the uterus. Surgical instruments are used to remove the fibroids. Hysteroscopic myomectomy is a minimally invasive procedure that does not involve any external incisions. It offers a quicker recovery time and no visible scarring.

Hysterectomy

A hysterectomy is a surgical procedure that involves the removal of the uterus. In some cases, it may also involve the removal of the cervix, ovaries, and fallopian tubes, depending on the reason for the surgery and the individual’s specific needs. Hysterectomy can be performed through different approaches, including:

1. Abdominal Hysterectomy: This involves making an incision in the lower abdomen to access and remove the uterus. It is typically used for large uterine fibroids, cancer, or when other approaches are not feasible.
2. Vaginal Hysterectomy: In this approach, the uterus is removed through the vagina, without any external incisions. It is suitable for certain uterine conditions or when the uterus is not excessively enlarged.
3. Laparoscopic Hysterectomy: It is a minimally invasive approach that utilizes small incisions in the abdomen. A laparoscope and surgical instruments are inserted through these incisions to remove the uterus. This approach offers faster recovery, shorter hospital stays, and less scarring compared to abdominal hysterectomy.
4. Robotic-Assisted Hysterectomy: Similar to laparoscopic hysterectomy, this approach utilizes robotic technology to assist the surgeon in performing the Robotic systems offer enhanced precision and dexterity.

What are the different types of hysterectomy?

There are several different types of hysterectomy, which involve varying degrees of removal of the reproductive organs. The types of hysterectomy include:

1. Total Hysterectomy: In a total hysterectomy, the entire uterus, including the cervix, is removed. The fallopian tubes and ovaries may or may not be removed along with the uterus, depending on the specific circumstances.
2. Subtotal Hysterectomy: Also known as partial hysterectomy, a subtotal hysterectomy involves the removal of the uterus while leaving the cervix The fallopian tubes and ovaries are usually not removed in this procedure.
3. Radical Hysterectomy: Radical hysterectomy is typically performed for gynaecological It involves the removal of the entire uterus, cervix, tissue around the cervix (parametrium), upper part of the vagina, and the pelvic lymph nodes. This procedure is more extensive than a total hysterectomy.
4. Supracervical Hysterectomy: In a supracervical hysterectomy, the upper part of the uterus is removed, while the cervix is preserved. The fallopian tubes and ovaries may or may not be removed. This procedure is less common than total or subtotal hysterectomy.

2. OVARIAN CYSTS

An ovarian cyst is a fluid-filled sac that forms on or inside an ovary. It is a common condition that can occur at any age, from puberty to menopause. Ovarian cysts can vary in size and may be single or multiple. Most ovarian cysts are benign (noncancerous) and resolve on their own without causing significant symptoms or complications. However, some cysts can cause pain, discomfort, or other complications. There are different types of ovarian cysts, including:

1. Functional Cysts: The most common type, functional cysts, are related to the normal functioning of the These cysts include follicular cysts and corpus luteum cysts, which form as part of the menstrual cycle. They often resolve without intervention within a few menstrual cycles.
2. Dermoid Cysts: Dermoid cysts, also called mature cystic teratomas, are made up of various types of tissue. They can contain hair, skin cells, and sometimes even teeth or other structures. Dermoid cysts are typically benign and may require surgical removal if they cause symptoms or are at risk of complications.
3. Endometriomas: Endometriomas are cysts that form as a result of endometriosis, a condition where the tissue lining the uterus grows outside the Endometriomas are filled with old blood and can cause pain and fertility issues.
4. Cystadenomas: Cystadenomas are cysts that develop from the outer surface of the ovary and are typically filled with a watery fluid. They can be benign or malignant (cancerous). Surgical removal is usually recommended for larger cystadenomas or if they are suspected to be cancerous.
5. Polycystic Ovary Syndrome (PCOS): PCOS is a hormonal disorder characterized by the presence of multiple small cysts on the These cysts are typically harmless but can contribute to hormone imbalances, irregular periods, and fertility issues.

Symptoms of ovarian cysts can vary, and some women may not experience any symptoms at all. Common symptoms include pelvic pain or discomfort, bloating, changes in menstrual patterns, pain during sexual intercourse, frequent urination, and difficulty getting pregnant.

Surgery to remove ovarian cysts

Surgery may be recommended to remove ovarian cysts in certain cases. The decision to proceed with surgery depends on factors such as the size, type, and characteristics of the cyst, the presence of symptoms, the risk of complications, and the individual’s overall health. Here are the surgical options for removing ovarian cysts:

1. Cystectomy: A cystectomy is a surgical procedure in which only the cyst is removed, preserving the unaffected ovarian tissue. This approach is commonly used for benign cysts or cysts that have the potential for preservation of ovarian function. The cyst is carefully excised while leaving the healthy ovarian tissue intact. Cystectomy can be performed using different techniques, including open surgery (laparotomy) or minimally invasive approaches such as laparoscopy or robotic-assisted surgery.
2. Oophorectomy: In some cases, if the cyst is large, complex, or suspected to be cancerous, an oophorectomy may be recommended. An oophorectomy involves the removal of one or both ovaries along with the cyst. This procedure may be performed using open surgery or minimally invasive techniques, depending on the specific circumstances.
3. Salpingo-oophorectomy: Salpingo-oophorectomy refers to the removal of both the ovary and the fallopian It may be recommended if the cyst is associated with the fallopian tube or if there are concerns about the risk of ovarian or fallopian tube cancer.

3. ENDOMETRIOSIS

Endometriosis is a chronic and often painful condition where tissue similar to the lining of the uterus (endometrium) grows outside the uterus, typically in the pelvic region. This abnormal tissue growth can occur on the ovaries, fallopian tubes, outer surface of the uterus, ligaments that support the uterus, and other pelvic organs. In rare cases, endometriosis can spread beyond the pelvic area. During the menstrual cycle, the misplaced endometrial tissue responds to hormonal changes, thickening, and breaking down just like the tissue lining the uterus. However, because this tissue is located outside the uterus, it has no way to exit the body. This can lead to the development of adhesions, scar tissue, and inflammation in the affected areas. Endometriosis affects women of reproductive age, and its exact cause is still unknown. Possible factors contributing to the condition include hormonal imbalances, genetic predisposition, immune system dysfunction, and retrograde menstruation (backward flow of menstrual blood). The most common symptom of endometriosis is pelvic pain, which can vary in intensity and may worsen during menstruation or sexual intercourse.

4. ADENOMYOSIS

Adenomyosis is when tissue similar to the lining of your uterus (endometrium) starts to grow into the muscle wall of your uterus (myometrium). It causes your uterus to thicken and enlarge — sometimes, up to double or triple its usual size. Adenomyosis can cause painful periods, heavy or prolonged menstrual bleeding with clotting and abdominal/pelvic pain.

Causes of adenomyosis

The exact cause of adenomyosis is unknown. There are several theories about what causes this condition. They include:

• invasive growth of endometrial cells into the uterine muscle — this may be due to an incision made in the uterus during surgery (like a cesarean delivery) or during normal uterine functioning
• uterine inflammation that occurs after childbirth — this may break the usual boundaries of the cells that line the uterus
• extra tissues in the uterine wall, which are present before birth and grow during adulthood
• stem cells in the myometrium, or uterine muscle wall

Risk factors for adenomyosis

There are certain factors that put people at greater risk for the condition. These include:

• age, with most people diagnosed in their 30s or 40s, a smaller proportion diagnosed as early as their teens, and some diagnosed after the age of 50 years old
• having given birth before
• undergoing treatment with the breast cancer drug tamoxifen
• Other risk factors that have been suggested, but are controversial or have fewer data to support them, include:
• having had uterine surgery, like a cesarean delivery or surgery to remove uterine fibroids
• a history of depression or antidepressant use
• smoking

Potential complications of adenomyosis

Adenomyosis symptoms can negatively affect your lifestyle. Some people have excessive bleeding and pelvic pain that may prevent them from enjoying normal activities like sexual intercourse. People with adenomyosis are at an increased risk of anemia, which is caused by blood loss and can result in an iron deficiency. The blood loss associated with adenomyosis can reduce iron levels in the body. Without enough iron, the body can’t make enough red blood cells to carry oxygen to the body’s tissues. This can cause fatigue, dizziness, and moodiness. Adenomyosis has also been linked with anxiety, depression, and irritability. Long-term outlook for people with adenomyosis Adenomyosis isn’t typically life threatening, but it can be associated with severe bleeding. Many treatments are available to help alleviate your symptoms. A hysterectomy is the only treatment that can eliminate them altogether. But the condition often goes away on its own after menopause.

5. PROLAPSED UTERUS

The uterus (womb) is a muscular structure that’s held in place by pelvic muscles and ligaments. If these muscles or ligaments stretch or become weak, they’re no longer able to support the uterus, causing prolapse. Uterine prolapse occurs when the uterus sags or slips from its normal position and into the vagina (birth canal). Uterine prolapse may be incomplete or complete. An incomplete prolapse occurs when the uterus is only partly sagging into the vagina. A complete prolapse occurs when the uterus falls so far down that some tissue protrudes outside of the vagina.

Who gets uterine prolapse?

Uterine prolapse is most likely to happen in people who:

• Have had one or more vaginal deliveries.
• Have reached menopause.
• Have a family history of uterine prolapse.
• Have had prior pelvic surgeries.

What conditions are associated with uterine prolapse?

Other organs in your pelvic region can fall out of position when the muscles around it become too weak. Some of the other types of pelvic organ prolapse are:

1. Cystocele: When your bladder drops into or out of your vagina.
2. Rectocele: When your rectum bulges into or out of your vagina.
3. Enterocele: When part of your small intestine bulges into your vagina.

Surgical options

Hysterectomy and prolapse repair: Uterine prolapse may be treated by removing your uterus in a surgical procedure called a hysterectomy. This may be done through a cut (incision) made in your vagina (vaginal hysterectomy) or through your abdomen (abdominal hysterectomy). Hysterectomy is major surgery, and removing your uterus means pregnancy is no longer possible. Prolapse repair without hysterectomy: This procedure involves putting your uterus back into its normal position. Uterine suspension may be done by reattaching the pelvic ligaments to the lower part of your uterus to hold it in place. The surgery can be done through your vagina or through your abdomen depending on the technique your provider uses.

What happens if a prolapsed uterus is left untreated?

It depends on the severity of the prolapse. In mild cases where your quality of life isn’t affected, your healthcare provider may not recommend treatment. Uterine prolapse can affect other organs in the pelvic area of your body (like your bladder and rectum). Healthcare providers typically recommend treatment when uterine prolapse becomes troublesome.