Gynecologic and reproductive surgery
Hysteroscopy
Description
A hysteroscopy is a diagnosis and therapeutic procedure that helps identify and solve any problems within the uterine cavity. It is normally used to detect lesions like polyps, fibroids and septum that can affect the inside of the uterus.
Procedure
This method can be performed in a consultation room applying local anesthetics on the cervix, or it also can be performed in an operating room under general anesthesia. This procedure it’s quite common in reproductive medicine, specially with patients with fertility problems.
Indications
The indications for a hysteroscopy can be divided in two categories:
1. Evaluation and treatment of any abnormal uterine bleeding.
2. Evaluation and treatment for infertility cases. Which may include:
• Recurrent pregnancy loss (two or more miscarriages)
• Extraction of a translocated intrauterine device.
• Submucosal uterine fibroids.
• Endometrial polyps.
• Proximal tubal occlusion.
• Traumatic uterine adhesions.
• Uterine malformations
• Any history of one or more unsuccessful fertility treatments.
• Unsuccessful implantation
Laparoscopy
Description
The Laparoscopy is a surgical procedure that allows the doctor to directly visualize the pelvic and abdominal cavity through small incisions made in the abdominal wall. It is used to treat various conditions that used to be treated only by open surgery, such as Fallopian Tube recanalization, ectopic pregnancy, fibroid removal and ovarian cysts.
Benefits
• Low complication rate
• Quick recovery
• Better visualization of pelvic structures.
Indications
There are various indications for laparoscopy, specially in the context of fertility problems and they include:
• Uterine fibroids.
• Congenital malformations.
• Suspicions of uterine perforation.
• Tubal obstruction.
• Endometriosis.
• Ectopic pregnancy.
• Hydrosalpinx.
• Tubo-Ovarian abscess.
• Adhesions.
• Pelvic inflammatory disease.
• Benign and malignant tumors.
• Treatment-resistant polycystic ovary syndrome.
Fallopian Tube Recanalization
This procedure’s objective is to reestablish the fallopian tubes function by eliminating any internal or external obstructions, that often are caused by chronic inflammation due to infections, previous pelvic surgery or family planning methods such as tubal ligation.
Procedure
The relief of internal obstructions is done through a hysteroscopy, where a thin catheter is introduced to the fallopian tube and then pressurized liquid is applied. If the liquid comes out from the other side, that means the tube is now permeable.
Success Factors
• The patient’s age: Women 35 years old or younger have a higher success rate.
éxito.
• Tubal ligation technique: It is shown that some techniques, such as the Pomeroy,
show higher success probabilities.
• Remnant tube segment: A segment longer than 4 centimeters is
associated with better results.
• Usage of mechanic methods: The usage of mechanic methods instead of
nergy to seal the tubes improves the recanalization probability.
• Presence of fimbria: The fimbria is essential for proper ovum recollection;
its absence makes the process more difficult.
• Absence of peritubal adhesions: Adhesions can interfere with the fallopian tubes’
function and affect the procedure’s success.
• Fallopian tube’s diameter: The alignment and diameter of the tube’s segments that are being
attached have great influence on the procedure’s viability.
• Time since the surgery: Patients who underwent this surgery 5 years ago or
less have a higher success rate.
Myomectomy
A myomectomy is the surgery to remove uterine fibroids, almost always non-cancerous tumors that grow from the organ’s muscle. Between 25% and 40% of women in reproductive age develop fibroids, that usually are asymptomatic. When they do show symptoms, these usually are abundant bleeding, chronic pelvic pain and infertility. Fibroids can also obstruct the tubes, deform the uterine cavity and affect the quality of the endometrium. This can rise the possibility of a miscarriage or a premature birth. Even though there are other medical treatments that can relieve the symptoms, the myomectomy is the most efficient method for those that wish to keep both an intact uterus and healthy fertility. Generally, the patient can attempt to get pregnant 6 months after the surgery, though there is a risk of the fibroids reappearing.
Procedure
The myomectomy can be performed via open surgery (a laparotomy) or through a laparoscopy. For submucosal uterine fibroids, it is preferred to perform a surgical hysteroscopy, where a hysteroscope and other instruments are used for the extraction.
Benefits of a myomectomy
If there are not any other infertility factors present, the pregnancy rate after the surgery is close to 60%. An effective localization of the fibroids is crucial, especially the submucosal fibroids, because they can reduce the in vitro fertility treatment success rate. Once removed, these rates can increase 20%.
Endometriosis
Endometriosis is one of the most common gynecologic disorders, that affects women all over the world, and it can either be asymptomatic or show severe symptoms related to fertility. Approximately 30% of women present endometriosis in some degree, and from those women, 30% may experience significant medical problems.
This disorder occurs when the endometrial tissue, that normally covers the uterine cavity, grows out of it. This ectopic tissue can implant or develop in other parts of the abdominal cavity and even, in some rare cases, it can develop in places such as the belly button or even the lungs. It can manifest in different ways:
• Superficial implants: Small patches of tissue.
• Penetrating nodules: Thicker tissue formations.
• Ovarian endometrioma: Ovary cysts.
Endometriosis responds to ovarian hormones in a similar way that a normal endometrium would do. Under the influence of estrogens and progesterone, this tissue swells and produces substances like prostaglandins. When the hormonal levels decrease, the tissue can bleed, however, unlike the endometrium, the blood and the endometriosis tissue do not have a way out, which can irritate the surrounding tissue. Infertility can be an endometriosis symptom, even though other factors like ovulation alterations or semen quality problems can also affect it. Some women with endometriosis manage to conceive, whilst other women face difficulties doing it, this may be because of this condition alone, or in combination with other problems.
This condition can hinder conception in different ways:
• Ovulation alterations: The ovum can be affected.
• Swelling and adhesions: The ectopic endometrial tissue can cause adhesions between the organs, obstructing the fallopian tubes.
• Ovaries separation: If the ovaries are separated from the fallopian tubes, the ovum can face difficulties in reaching them after ovulation.
Treatment
The main endometriosis treatment options are medication and surgery. The main objectives of the treatment is to increase the patient’s quality of life by relieving the pain and increasing the pregnancy possibilities. In comparison with the surgical treatment, there is a possibility that pregnancy can be achieved between 6 to 12 months after receiving a combined treatment of surgery and medication. The lesions produced by endometriosis can be treated via laparoscopy.