Surgical Options

The female pelvic anatomy may be disrupted by various conditions that subsequently interfere with the ability to achieve a successful pregnancy. Some forms of tubal disease will be identified utilizing an x-ray study, the hysterosalpingogram (HSG). This procedure is performed in the Radiology Department. Dye is injected through the cervix and travels into the uterus and through the fallopian tubes. In addition to outlining the uterine cavity, the internal structure of the fallopian tubes will be visualized. Tubal patency will also be confirmed, if present.

The HSG will give very good information about the fallopian tubes, however this study does not answer all of the questions about the female pelvis. To completely examine the pelvis, the laparoscopy is required. This is an outpatient operative procedure performed under general anesthesia in the operating room. During this walk-in/walkout surgery, a telescope, the laparoscope, is placed through the umbilicus and the pelvis structures visualized directly. Blue dye is then injected through the cervix and it can be then directly visualized as it flows out the ends of the fallopian tubes, if they are patent. At laparoscopy, not only are the tubes evaluated, but also the surrounding structures are assessed. The ovaries are visualized. Scar tissue or adhesions between the fallopian tubes and ovaries can be visualized. The condition of endometriosis can be identified. These findings will not be picked up with an HSG.

Among the more common problems that affect the female pelvic anatomy would be endometriosis and previous pelvic infection. Endometriosis affects 10-15% of all females. In this condition, the lining of the uterus, the endometrium, has begun to grow inside the pelvis. This leads to an inflammatory response, as the body tries to eliminate these misplaced cells. This disorder is a progressive problem that usually worsens with time. Initially, chemicals are produced that interfere with the interaction of egg and sperm. With time, scar tissue or adhesions can develop and the pelvic structures begin to stick together. This then makes it difficult for the fallopian tube to actually pick up the released egg. In its advanced form, the ovaries can develop blood-filled cysts that continue to get larger each month, causing a marked disruption in ovarian function. Some patients with endometriosis have pain. This pain can occur during intercourse or prior to the menstrual cycle, or with bowel movements. There may be worsening significant menstrual cramps. Some patients, however, do not have pain from their endometriosis. Endometriosis often leads to infertility. The key to this disorder is to diagnose it early, before it has progressed to its more advanced states, where the ultimate likelihood of pregnancy has diminished, and the potential need for a hysterectomy has increased.

The diagnosis of endometriosis is suspected by the history of pain and by findings on the pelvic examination. However, the diagnosis is definitively made by laparoscopy. The purpose of this surgery is to both identify endometriosis and also treat it surgically at that same time. The treatment involves usually the use of a laser to vaporize away the endometriosis and the associated scar tissue. Although there are various medical therapies to suppress this disorder, the mainstay of treatment for endometriosis is surgery.

Unfortunately, endometriosis is a recurrent disease. The more advanced the initial case, the more likely there will be subsequent recurrence. This is why the diagnosis needs to be made as early as possible. IVF is sometimes required in order to achieve pregnancy when endometriosis is present.

The other primary condition that leads to surgery is a previous pelvic infection, so called salpingitis. The presence of a tubal infection will often lead to the development of pus within the pelvis. This then solidifies and leads to adhesion formation. In extreme cases, one or both fallopian tubes may be scar closed. These adhesions then interfere with the tube's ability to pick up the released egg from the ovary. If scar tissue has developed within the fallopian tube itself, then the egg may get trapped in the fallopian tube and actually implant there, leading to a tubal, or ectopic, pregnancy.

At the time of laparoscopy, adhesion formation will be identified and if present, removed, using various operative laparoscopic techniques. If the ends of the fallopian tubes are closed, then an attempt can be made to reopen the tubes using laser techniques. Ideally, pregnancy will be able to occur spontaneously after this advanced laparoscopic surgery. There will be a risk of tubal pregnancy following this type of problem. Some patients will require in vitro fertilization in order to conceive, if their adhesion formation is severe enough.

Sometimes the extent of distortion in the pelvis is beyond the ability to handle the problem appropriately through a laparoscope. This then can necessitate an opened procedure for females of childbearing potential. These opened procedures are done utilizing a microsurgical technique. Very delicate tissue handling surgery is performed under an operating microscope to separate scarred tissue while minimizing trauma to the normal tissues in the pelvis. Although most people would prefer to have their surgery done as an outpatient with laparoscopy, it must be kept in mind that there are some conditions that necessitate the more advanced incisional operation of a microsurgical laparotomy.

There are conditions within the uterine cavity that can affect the chances for pregnancy. These include an endometrial polyp, a submucous fibroid and a uterine septum. Each of these conditions will interfere with proper implantation of an embryo. These problems can be identified with a hysterosalpingogram or hysteroscopy. Also, a relatively new office procedure, sonohysterography, can define these problems. With this particular study, a thin catheter is passed into the uterine cavity and sterile water is injected while a vaginal probe ultrasound is carried out. This essentially painless and easy study will nicely outline intrauterine problems. These various conditions then need to be operated upon. This surgery is done with an operative hysteroscope or a resectoscope. These procedures are done in the operating room usually under general anesthesia.

• Hysteroscopy

• Laparoscopy

• D & C for Uterine Bleeding Problems

• D & C for Miscarriage

• Hysterosalpingography

• Dilation and Curettage