ARC Fertility Articles

Fertility Articles

Surgical Advances in Fertility Treatment

Joseph S. Sanfilippo, MD, MBA©

Professor, Department of Obstetrics, Gynecology and Reproductive Science
University of Pittsburgh School of Medicine
Vice Chairman of Reproductive Sciences
Magee Womens Hospital
Pittsburgh, PA
http://www.upmc.com/locations/ hospitals/magee/services/ center-for-fertility-and-reproductive-
endocrinology/ Pages/default.aspx
The area of Reproductive Surgery continues to witness advances in surgical technology. Minimally
Invasive Surgery is associated with new and innovative procedures for our patients. Specifically,
when faced with an ovarian cyst we are more often than not capable of complete removal of the cyst
via a laparoscopic approach.
Specifically, when a patient is under general anesthesia, carbon dioxide is introduced into the
abdominal cavity creating a space for insertion of a telescope, i.e. a laparoscope. This allows the
operating surgeon to evaluate the reproductive organs. Additionally, very small, 5mm, ports, usually
2-3 are placed in the lower abdominal area to allow for manipulating the pelvic organs. The surgeon
then makes an incision into the outer membrane, cortex, of the ovary, thus allowing separating off
and dissecting the cyst from remaining normal ovarian tissue. More often than not normal ovarian
tissue can be preserved and less commonly is it required to remove the entire ovary. Laparoscopic
minimally invasive surgery allows for assessment of all pelvic organs and the placement of dye from
the cervix into the fallopian tubes to assess whether the fallopian are open or not.

In a women who has a problem with painful menstrual periods, termed dysmenorrhea, and perhaps
with discomfort during intercourse, dysmenorrhea, and problems getting pregnant the underlying
diagnosis may be Endometriosis. This is a disease entity that may be associated with many symptoms
or virtually none except perhaps for inability to conceive. Endometriosis is defined as the lining of
the uterus outside of the uterine cavity and can be located on the ovary, on the abdominal cavity, or
virtually anywhere including within the rectal wall. A laparoscopic or minimally invasive approach
to surgical correction of this problem has many rewards including alleviation of pain, ability to
conceive and when done in this manner as opposed to a more elaborate or
“open” laparotomy approach, the chances of scar tissue formation laparoscopically, i.e. adhesions is
less.
One other concern for patients in the reproductive years is the presence of fibroids, also termed
myomas. These are tumors of the uterus which are almost always benign and can be associated
with infertility, recurrent pregnancy loss, heavy menstrual bleeding and associated cramping pain.
The treatment may be nothing more than observation or better termed “expectant”, or surgical, i.e.
myomectomy. The surgical approach includes hysteroscopic myomectomy which allows shaving of
the segment of the fibroid that is in the endometrial cavity or a laparoscopic or Mini-laparotomy
approach. The latter involves making a small, several inch incision in the lower abdomen and
removal or excision of the fibroid. Research has noted that the presence of fibroids, in part depending
on size and location may play a role in achieving a pregnancy of carrying a pregnancy. Unfortunately
there is currently no good medical therapy for fibroids. If a woman has completed her childbearing
she may be a candidate for uterine artery embolization to shrink the fibroids but she should not plan
to get pregnant after this procedure since the obstetrical complication rate is high.
One other problem facing a woman trying to conceive is that of a polyp in the lining of the uterus, i.e.
endometrium. Specifically, while the research is somewhat divided, a local inflammatory response
may occur surrounding the polyp and thus interfering with implantation of a fertilized egg. The
approach to correction of this problem is use of hysteroscopy, looking directly into the uterine cavity,
to identify the polyp and removing it under direct visualization. The operating Gynecologist may also
do a D&C to scrape the lining of the uterus and thus remove any remaining polyps or other concerns
involving the lining of the uterus.
If a woman has had her tubes tied and wishes additional pregnancies she may be a candidate for
Microsurgical Tubal Reanastomosis or rejoining the fallopian tubes. One alternative is In Vitro
Fertilization where the fallopian tubes are bypassed and sperm and egg link outside the human body,
i.e. in vitro.

Thus The Center For Fertility & Reproductive Endocrinology offers the latest technical advances
designed to assist you with pelvic pain, infertility, abnormal menstrual flow and the array of
problems responsible for your gynecologic problem.