Reproductive surgery

• reproductive surgery
• myoma
• endometriosis
• adenomyosis
• PCOS
• tubal reanastomosis
• congenital malformation of uterus
• dysmorphic uterus
• T-shaped uterus
• septate uterus
• vaginal agenesis
• ectopic pregnancy

Today I want to introduce you to a discipline we have been practising for a very long time, but which many Thai readers may still not know or feel familiar with. Infertility medicine normally sits under the subspecialty of reproductive medicine — which, taken literally, means restoring or achieving fertility with drugs. The other half of the field, the one that treats infertility with the scalpel, is exactly what this article is about: reproductive surgery.

In Thailand, reproductive surgery is not really taught as a discipline in its own right — the material is simply folded into the reproductive medicine curriculum, so doctors who finish reproductive medicine training here tend to come out noticeably short on the knowledge, the experience and the operative skill that reproductive surgery demands. My own practice, on the other hand, leans heavily towards reproductive surgery — and in my own head I am a reproductive surgeon who also happens to do reproductive medicine rather well, hahaha. (I went on to train in reproductive surgery at the European Academy of Gynaecological Surgery in Belgium.)

Before IVF became as effective and as successful as it is today, infertility was treated mostly by operating: removing fibroids (myomectomy), repairing blocked tubes, resecting a uterine septum (septoplasty), and so on. The guiding principle was simple — restore the anatomy of the female reproductive tract so that it can work normally again.

Then assisted reproductive technologies (ARTs) advanced and their success rates climbed. Add donor gametes, surrogacy and highly efficient embryo freezing and thawing, and the popularity of ART as infertility treatment shot up in a single leap. And yet the live birth rate from ART over the last 10-15 years has been fairly flat, despite new technology being thrown at almost every dimension of the IVF cycle. That is why attention has started to swing back towards surgery.

Alongside the IVF laboratory, another line of innovation has been quietly developing: the instruments of reproductive surgery itself. Camera systems give sharper images, scopes have become smaller, and modern instruments make cutting and controlling bleeding far easier. The scope of the field has widened too — it is no longer limited to restoring anatomy, but now includes fertility preservation, uterine transplantation and more. All of this is why reproductive surgery has become important again over the past decade.

Uterine fibroids (myoma, fibroid)

A fibroid (fibroid, myoma uteri) is a benign tumour arising from the muscle layer of the uterus; the chance of malignancy is very small. It is the most common tumour of the female reproductive tract — as many as 50-80% of women of reproductive age may have one.

Many women with fibroids have no symptoms at all. Whatever symptoms do appear depend on where the fibroid sits and how big it is. The common ones are heavy and prolonged periods, period pain, and frequent urination.

In infertile couples, fibroids can be the cause of the problem — particularly fibroids in the following positions.

• Fibroids that sit in, and distort, the uterine cavity (FIGO 0-3). These are associated with abnormal placental implantation, miscarriage, placental abruption, malpresentation, placenta praevia and fetal growth restriction. The recommended treatment is removal through a hysteroscope (hysteroscopic myomectomy).
• Fibroids that do not distort the cavity, FIGO 3-4 (abutting the cavity and lying entirely within the myometrium) but larger than 3-4 cm. Even without distorting the cavity, such a fibroid disturbs the blood supply to the endometrium and myometrium, increases uterine contractility, disturbs the production and action of the hormones the fibroid itself makes, and impairs endometrial receptivity — the endometrium's ability to accept an embryo. These can be shelled out on their own, and most can be done laparoscopically (laparoscopic myomectomy).

Endometrial polyp

An endometrial polyp is a piece of tissue growing into the uterine cavity, made of endometrium-like cells that are dividing abnormally. It arises from chronic inflammation inside the cavity — chronic endometritis, a malformed uterus, and so on. If the polyp is large relative to the space inside the cavity, it can interfere with embryo implantation.

Endometriosis

Endometriosis is common among women with infertility — some studies put it as high as 50%. The cause is thought to be retrograde menstruation: menstrual blood flows backwards into the abdominal cavity, endometrial cells settle on various organs and keep growing there. With every period those deposits shed, bleed and inflame, and the result is adhesions or a chocolate cyst.

Symptoms depend on where the lesions are and which organs the adhesions have caught, and they usually track the menstrual cycle: period pain, constipation or diarrhoea during the period, blood in the stool, blood in the urine.

Because of that inflammation and scarring, women with endometriosis can end up with a reproductive system that no longer works properly: blocked or poorly functioning tubes, disordered ovulation, impaired endometrial receptivity. A chocolate cyst in particular is linked to a rapid fall in egg numbers — the fluid inside the cyst is old blood loaded with toxins and free radicals, and the ovarian tissue that stores the primordial follicles is exposed to it directly. The follicles are lost.

Endometriosis is treated both medically and surgically. Surgery is indicated when adhesions are compressing an important neighbouring organ such as the ureter, or when a chocolate cyst is larger than 4 cm — because it damages the ovary and because it can rupture during egg retrieval or during pregnancy.

Adenomyosis

Adenomyosis is another benign condition of the uterus, but it differs from a fibroid: here the endometrium grows down into the muscle layer, so the lesion has no clear border. To picture it, I like to compare adenomyosis to grains of sand mixed through cement — scattered everywhere. A fibroid, by contrast, arises from the uterine muscle itself and forms a mass with a distinct edge.

Women with adenomyosis may have painful periods and abnormally heavy bleeding. As in endometriosis, each period the cells shed and the lesions bleed, the uterus swells and becomes inflamed, and it contracts abnormally. An embryo then struggles to implant — and infertility follows.

A woman with adenomyosis and infertility may need the lesion excised first — if her symptoms are severe or the uterus is very enlarged — in order to improve her chance of pregnancy. But because the lesion has no clear border, excising it and then repairing the uterus strongly enough to prevent rupture in a future pregnancy is demanding work. For that reason, adenomyosis surgery in women who want to conceive is usually done as open laparotomy.

Polycystic ovary syndrome (PCOS)

PCOS is a common cause of chronic anovulation in infertility (you can read more about PCOS here). Most treatment is lifestyle: diet, exercise, and drugs to induce ovulation. But some patients with severe disease and high androgen levels simply do not respond to ovulation-induction drugs. In them, laparoscopic ovarian drilling — puncturing the ovary with diathermy through a laparoscope — often brings ovulation back. Only four points are made on each ovary, because the heat from diathermy, applied at too many sites, can shut the ovary down altogether. Why ovulation resumes after the operation is still not fully understood, but it is thought that the pressure inside the ovary drops, allowing follicles to grow and ovulate.

Tubal reversal (tubal reanastomosis)

Tubal sterilization is permanent contraception, and it can be done after delivery or at any time outside pregnancy. A segment of the tube is removed so that the tube is no longer continuous, and egg and sperm can never meet to fertilize. Alternatively, a purpose-made device such as a Falope ring can be placed to constrict the tube and close the lumen — the same result.

As I said, sterilization is permanent contraception — meaning the patient has made up her mind that she will never be pregnant again, and is closing the garage for good. But nothing in life is 100%, is it? Family circumstances, social circumstances and everything else can change, and with them the need or the wish for another child. So what then? Generally there are two options for someone who wants a baby after sterilization.

1. IVF. Eggs are collected and fertilized with sperm outside the body, the embryos are grown in the laboratory for another 3-6 days, and then transferred back into the uterine cavity. The tubes are no longer needed at all, so no reversal surgery is required.
2. Tubal reversal surgery. This is an option when the woman is not too old (generally we advise no older than 37), still has a reasonable number of eggs, and her partner's sperm is normal — if the sperm is abnormal she will need IVF anyway, so there is no point putting her through an operation. The reversal is done by opening up the two sealed ends left by the sterilization and stitching the two segments of tube back together with very fine suture. It can be done through a small abdominal incision with the anastomosis performed under a microscope (mini-laparotomy under microscope), or laparoscopically.

Congenital malformation of the uterus

Some congenital uterine anomalies are associated with infertility or recurrent miscarriage — the dysmorphic T-shaped uterus and the septate uterus, for example (more on the dysmorphic uterus here). Because the architecture of the uterus is abnormal, these conditions affect both embryo implantation and the growth of the baby. Treatment is hysteroscopic metroplasty — correcting the anomaly through a hysteroscope.

Congenital anomalies of the vagina

Congenital anomalies of the vagina, such as vaginal agenesis, may occur on their own or together with a uterine anomaly. They can block the outflow of menstrual blood or make intercourse difficult, and so they need correcting — either by dilation or by surgery.

Ectopic pregnancy

An ectopic pregnancy can implant in several places; the commonest are the fallopian tube, the cervix, and a caesarean scar. Treatment may be medical or surgical, and the surgical approach varies with where the gestational sac has implanted.

Future trends

There are some genuinely interesting studies and innovations going on right now: radiofrequency, which sends high-frequency waves in to destroy a fibroid without an operation, and mesenchymal stem cells for premature ovarian insufficiency. If anything interesting comes out, I will come straight back and update this for you.

In short

References

1. Bortoletto, Pietro et al. Reproductive surgery: revisiting its origins and role in the modern management of fertility. Fertil Steril 2023, 120, 3, 539 - 550.