Surgical Procedures
Hysteroscopy
Doctors will often perform an operative hysteroscopy if a uterine abnormality is suspected.
Use of a thin telescope called a “hysteroscope” enables the physician to insert operating tools, such as a scalpel or scissors, cautery devices or a laser fiber, into the uterus with precision and accuracy. The hysteroscope is also valuable in treating some forms of tubal occlusion, which is a blockage at the junction of the uterus and fallopian tube. Operative hysteroscopy is usually performed in the first part of the menstrual cycle so that the build-up of the endometrium does not block or obscure the physician’s view of the uterus.
Patients can usually return to their normal activities the following day with some minor limitations, and can typically try to start conceiving again two weeks after the procedure (with her next period).
Side effects of a hysteroscopy may include vaginal discharge and slight discomfort. If a patient experiences heavy bleeding, blood clots, or foul-smelling vaginal discharge, she should consult her physician immediately.
Laparoscopy
In a laparoscopy, a fiber optic telescope called a laparoscope is inserted into the Female's abdomen below the navel to look for endometriosis, scarring, adhesions, and other pelvic disease and is used in place of a more invasive abdominal procedure. At times, the procedure is performed to look for the cause of pelvic pain or infertility, and is called a "diagnostic" laparoscopy. Once a disease is identified, however, the surgeon should be capable of performing an "operative" laparoscopy, and actually treat the disease. Instruments such as laser can be useful in some cases to treat adhesions and endometriosis. The primary advantages of laparoscopy include rapid patient recovery and decreased cost attributed to the extremely small incision and the fact that the patient nearly always goes home the same day. Aside from the treatment of extremely large fibroids, most pelvic surgery can be performed laparoscopically.
Side effects of a laparoscopy may include vaginal discharge and slight discomfort. If a patient experiences heavy bleeding, blood clots, or foul-smelling discharge from the vagina or surgical site, she should consult her physician immediately.
Microsurgical Reconstruction, including Vasectomy reversal
Microsurgical reconstruction of the male reproductive tract is often a successful treatment used when an obstruction exists in the vas deferens or to reverse a vasectomy. A vasovasotomy is the operation most frequently performed for a vasectomy reversal and involves connecting the severed ends of the vas deferens. However, if following a vasectomy an obstruction has occurred in the epididymis, a vasoepididymostomy must be performed which involves connecting the vas deferens to the section of the epididymis that contains mature and motile sperm. After vasectomy reversal, sperm return to the semen in about 70 to 95% of men and pregnancy without assisted reproductive technology occurs in 30-75% of couples.
The chance for pregnancy following reconstructive surgery depends on many factors, most importantly the age and fertility status of the female partner and the number of years between the vasectomy and its reversal. The longer the period of time between vasectomy and reversal, the lower the chances for successful reversal.
Microsurgical reconstruction is a two to four hour operation and can be performed as an out patient procedure. Successful microsurgical reconstruction may allow couples to have subsequent children without resorting to invasive and expensive IVF treatments. However, a physician will consider the age and medical history of both partners to determine the optimal treatments to achieve a pregnancy.
It is important to understand that after a successful microsurgical vasectomy reversal, the average interval until pregnancy is about one year.
A patient may return to normal activities 7 days after a microsurgical reconstruction, including resumption of intercourse after 4 weeks of abstinence. Attempts to achieve a pregnancy can occur upon resumption of intercourse.
Side effects of a surgery for microsurgical reconstruction may include swelling, hematoma, or infection at the surgical site
Myomectomy
Uterine fibroids are abnormal growths in the uterus and almost always are non-cancerous. Uterine fibroids are also one of the most common causes of infertility in women. 40% of hysterectomies are performed for the treatment of uterine fibroids. New microsurgical techniques have been developed to make myomectomy a choice for some women. Myomectomy is a surgery that removes the fibroid tumor and leaves the female organs intact. Reconstruction of the uterus is often part of the procedure. Specialists who perform myomectomies can discuss whether or not this is a procedure to resolve your problem and whether or not the procedure can be done on an outpatient basis. Medications are another option for treating fibroid tumors in some women. Prescription medications are available that can shrink the size of the fibroid and lessen heavy bleeding and pain. These medications can be used for a limited period of time and require careful monitoring by a physician.
If fibroids are small or are located within the cavity of the uterus (submucous), they can often be removed using a small fiber optic scope called a hysteroscope. In these cases, the procedure is a relatively quick outpatient procedure, and patients can usually return to their normal activities the following day with some minor limitations, and can typically try to start conceiving again 2 weeks after the procedure (with her next period).
If fibroids are larger or are located within the wall of the uterus (intramural), then removal is usually performed abdominal through a bikini incision in a procedure called an abdominal myomectomy. In these cases, the procedure may require 2 nights of hospitalization and recovery and two to three months prior to attempted conception.
Testicular Sperm Retrieval (TESA)
The testicular sperm aspiration/extraction (TESA) involves the direct removal of sperm from the testicles. Because comparatively few sperm are discovered during a TESA procedure compared to normal male ejaculate, it is required that IVF with ICSI be utilized in conjunction with the TESA procedure. TESA procedures are preformed either percutaneously or microscopically.
Percutaneous testicular sperm retrieval
When dealing with obstructive azoospermia (a blockage and normal sperm production is present), a simple percutaneous extraction of sperm is recommended. This procedure is performed under anesthesia (local or general) whereby a biopsy needle is utilized to extract a very small amount of testicular tissue. A laboratory expert will isolate sperm from the testicular tissue, which will be used in conjunction with ICSI during the IVF procedure. The wound is closed with a few small absorbable stitches.
Microscopic testicular sperm retrieval
In clinical scenarios in which the testes are not producing adequate amounts of sperm, also called non-obstructive azoospermia, microsurgical testicular sperm extraction is performed. Non-obstructive azoospermia may be the result of testicular atrophy, Y deletions, Kleinfelter’s cases, or post-chemotherapy/radiation. In this scenario, under general anesthesia, the TESA is performed using an operating microscope to search for testicular tubules that appear more developed and contain mature sperm. A microscopic TESA may take several hours. The tissue is removed and a laboratory expert will search the tissue for sperm which, if found, will be used in conjunction with ICSI during the IVF procedure.
A patient may return to normal activities 1-2 days after a percutaneous TESA procedure, and may resume intercourse within 1 week. A patient may return to normal activities 7 days after a microscopic TESA procedure, and may resume intercourse within 2 weeks.
Side effects of a TESA procedure may include hematoma, infection, and hydrocele.
Varicocele Repair
Varicoceles describe a condition where the veins located in the scrotum surrounding the testes are dilated and enlarged. Approximately 15% of all men have varicoceles and, for most men, they do not seem to impair testicular function. However, about 40% of all men with infertility have varicoceles and it is generally believed that the presence of a varicocele impairs sperm production. Although the exact effect a varicocele has on sperm production is not known, it is suspected that an increase in testicular temperature may occur, which does not allow for sperm to mature properly. Most infertile men with varicoceles have improvement of semen quality after varicocele repair, and some infertile men with varicoceles are able to achieve a conception after varicocele repair. Varicoceles are found during a physical examination. Upon detection, the physician will also order a semen analyses to determine if the varicocele may be impacting sperm production and maturation. For varicoceles that are suspected to be interfering with fertility, surgical repair may be recommended. Surgical repair of a varicocele is done in an outpatient surgical center with general or local anesthesia. The surgeon will ligate, or tie off, the dilated veins during the procedure that lasts approximately one hour. Many urologists will perform this procedure using microscopic techniques, as the higher magnification allows for increased precision. Surgical intervention is successful in 90% of cases in that the dilation of veins is corrected and does not recur; approximately 60-80% of men have improved sperm count and motility after repair of the varicocele. About 40% of couples will subsequently initiate a pregnancy following a varicocele repair.
A patient may return to normal activities 2-3 days after a varicocele repair, including resumption of intercourse after 1 week of abstinence. Attempts to achieve a pregnancy can occur upon resumption of intercourse.
Side effects of a surgery for varicocele repair may include an infection, hydrocele, hematoma, or recurrence, though these side effects are diminished by the use of microsurgical techniques.
