Assisted Reproductive Technology (ART)
Diagnostic or Operative Laparoscopy
Laparoscopy is a minimally invasive outpatient surgical procedure that allows us to evaluate the pelvic organs very closely. Under general anesthesia, 2-3 small incisions - typically the size of the tip of your little finger - are made in the navel and lower abdominal wall. Using a telescope, camera, and tiny surgical instruments, we can then diagnose and treat a variety of conditions that can adversely affect fertility. This procedure may be recommended for patients with a history of:
- longstanding infertility
- previous pelvic infection
- previous pelvic or abdominal surgery
- increasingly severe pain with menses or intercourse
- pelvic pain, or
- an abnormal pelvic sonogram or HSG
Depending on a patient’s personal health and the extent of the surgery, this procedure will be performed by your physician at one of the nearby state-of-the-art ambulatory surgery centers (Bailey Square, Northwest Surgery Center, or North Austin Surgical Center) or at nearby Seton Hospital or North Austin Medical Center.
Operative Hysteroscopy
Hysteroscopy is a minimally invasive outpatient surgical procedure performed under conscious (intravenous) sedation anesthesia in which a thin telescope is inserted through the vagina and cervix and into the uterus. Using small surgical instruments, your physician can correct most abnormalities of the uterine lining or cavity detected by previous diagnostic testing. Hysteroscopy is most commonly recommended to remove endometrial polyps or fibroids (non-cancerous growths of lining or muscular tissue), scar tissue, to correct developmental abnormalities of the uterine cavity, or to reopen a blocked fallopian tube. This procedure can be performed easily and quickly on an outpatient basis at one of the surgery centers mentioned above.
Treatment of Uterine Fibroids
Uterine fibroids are benign tumors that arise from the uterine smooth muscle. Fibroids are described by their location and by the extent of their invasion into the uterine wall. In general, fibroids are considered to be subserosal (extending from the thick part of the uterine wall to the outside of the uterus), intramural (within the wall of the uterus), or submucosal (extending from the wall into the endometrial cavity).
Subserosal fibroids are an infrequent cause of infertility. However, if the fibroid is submucosal, it is more likely to be problematic, even for patients who do not desire to become pregnant. These tumors can cause frequent and heavy bleeding that can lead to anemia. Large intramural fibroids can be problematic, as well, with recent data suggesting that pregnancy rates are significantly lower when intramural fibroids measuring 3 cm or more are present during fertility therapy...
Medical therapy for fibroids is primarily used as an adjunct to surgery. The most common medication is leuprolide acetate (Lupron). The medication temporarily reduces the symptoms attributable to the fibroids, and shrinks the size of the tumor(s). Lupron suppresses the release of pituitary hormones that stimulate the ovary leading to cessation of estrogen synthesis. The lack of circulating estrogen leads to a shrinkage of uterine fibroids.
If fibroids are associated with moderate or severe symptoms, surgery may be the best way to treat them. Options for surgery include:
1. Myomectomy - a surgery to remove fibroids without taking out the healthy tissue of the uterus. There are many ways a surgeon can perform this procedure. It can be performed as a major surgery (through a 5-8 cm abdominal incision) or via laparoscopy. The type, size, and location of the fibroids will determine which surgical approach is the most appropriate.
2. Hysterectomy - a surgery to remove the uterus. This surgery is the only definitive way to cure uterine fibroids. However, if this is performed a patient will be unable to become pregnant without using a surrogate to carry a baby.
3. Endometrial ablation - a surgery to destroy the endometrial tissue lining the inside of the uterus. This surgery usually controls heavy bleeding but, unfortunately, patients are unable to become pregnant following the procedure. Similar to hysterectomy, following an ablation, a patient desiring pregnancy must rely on a surrogate to carry a baby.
Other procedures include:
1. Uterine Fibroid Embolization (UFE) - Uterine fibroid embolization (UFE) is a treatment that cuts off the blood supply to the uterus and the fibroids. This treatment causes the tumors to shrink. This is a relatively new procedure, and although preliminary results look promising, more long-term data is needed to determine if it safe to become pregnant following this procedure. Embolization can significantly alter the blood supply to the uterus and theoretically interfere with the growth of a fetus. At this time, the procedure is not recommended for patients who desire to become pregnant following the procedure.
2. ExAblate® 2000 is a medical device that uses magnetic resonance image guided focused ultrasound to target and destroy uterine fibroids. The device is intended to treat women who have completed child bearing and do not intend to become pregnant
If it is medically indicated to treat the fibroids and if the patient desires to preserve reproductive function, the best procedure is myomectomy. The short term recurrence rate of fibroid tumors following myomectomy is 15%. The long term recurrence rate over 10 years is 25-30%. If it is appropriate, it is best for patients to attempt pregnancy soon after they recover from the myomectomy.
Congenital Uterine and Vaginal Anomalies
The absence of the development of the uterus and the upper vagina is referred to as Müllerian Agenesis. These individuals present to gynecologists as patients that have experienced breast development and pubic hair growth, but have never had a menses (ie. amenorrhea). . This is a relatively common cause (approximately 1 in 4000 female births) of primary amenorrhea. Because the ovaries are derived from different structures, ovarian function is normal. The rest of the patient’s growth and development is also normal.
Further evaluation should include radiological studies. Approximately one third of patients have co-existing abnormalities of the urinary tract. Laparoscopic evaluation of the pelvis is not necessary. Although the vagina is usually not very deep, progressive dilatation can be used to lengthen the vaginal canal, making intercourse possible while also avoiding surgery. Reconstructive surgery is reserved for those patients who have been unsuccessful with the dilatation process. Either option (dilatation or surgical correction) usually prevents problems with body image and sexual enjoyment, so that although infertile, affected patients may still enjoy an otherwise full and normal life as a woman.
Genetic offspring can still be achieved in patients with Mullerian agenesis by collecting oocytes from the patient, fertilization of those oocytes by the male partner, and placement of the embryo(s) into a gestational carrier. A review of live births resulting from retrieval of oocytes from women with Müllerian Agenesis found no increased risk of passing this condition on to offspring, supporting the concept that pregnancy produced in conjunction with a gestational carrier is a reasonable option for patients with this disorder.
Microsurgical Sterilization Reversal (Tubal Reanastomosis)
Approximately 2 women per 1000 who undergo tubal sterilization will eventually undergo microsurgery for tubal reanastomosis. This procedure is associated with excellent results if only a small segment of the tube has been damaged. Pregnancy rates correlate with the length of the remaining tube. At least 4–5 cm of length is necessary for a good chance of success following reanastomosis. Pregnancy rates following reanastomosis are also related to the type of sterilization procedure that was employed. For example, pregnancy rates are lowest if the tubes were tied using electric current (electrocoagulation). At surgery for sterilization reversal of tubes that have undergone electrocoagulation, it may appear that only a small portion of the tube has been damaged by the sterilization process. However, additional damage may extend beyond the obviously occluded segment since the electrocoagulation may have damaged the function of the tube beyond that area. Sterilization procedures that involve the use of clips, rings, or the surgical removal of a small portion of the tube have the highest chance of success for reversal.
In vitro fertilization (IVF) is an alternative to microsurgical sterilization reversal with an excellent chance for success. IVF pregnancy success rates are comparable to those achieved following microsurgical sterilization reversal; IVF is much more successful if the patient has had electrocoagulation as the method for her sterilization procedure. Thus, if the patient has undergone electrocoagulation for sterilization, it is preferable to recommend IVF. Also, microsurgical sterilization reversal can be associated with a 15-20% chance of having an ectopic (tubal) pregnancy, whereas the risk of an ectopic following IVF is1%. However, IVF has a significantly greater risk of multiple gestation, as we usually transfer more than one embryo during a typical IVF procedure.
