by Dr. Adam Fechner
People understand the role of sperm and eggs in reproduction dating back to their middle-school health class. Indeed, a baby cannot be created without a sperm successfully fertilizing an egg. But many patients (and even some doctors) fail to appreciate the role that the anatomy plays in the process of conception. Fertilization does not occur in a vacuum, which is why a thorough evaluation of the fallopian tubes and the uterus are part of any basic infertility evaluation.
When a woman ovulates, the egg enters the fallopian tube from one end (the distal end, or the side farthest from the uterus). With intercourse, sperm enters the vagina then swims up through the cervix, through the uterus and into the tube from the opposite end (the proximal end, which is attached to the uterus). Fertilization occurs in the fallopian tube, then the embryo must travel to the uterus where it implants and grows. All of these steps must occur in order to achieve a normal pregnancy. A woman’s anatomy is therefore critical to the process, since you can have the best egg and sperm in the world but if the tubes are blocked, they can never come together. Similarly, fertilization can occur properly in the tube, but if there is some pathology distorting the uterus where the baby wants to implant (e.g. a fibroid, septum or scar tissue), implantation may not be able to occur. This is where reproductive surgery comes into play.
Reproductive surgery aims to repair any underlying anatomical abnormalities that may be hindering conception, thereby optimizing a couple’s chance to conceive. With respect to the uterus, any pathology inside the cavity can keep a couple from getting pregnant, or can predispose to recurrent miscarriages. One example is a uterine septum, which is an extra wedge of tissue at the top of the uterus, in the area where the embryo is most likely to implant. This tissue has a poor blood supply, so an embryo may not be able to implant, or it may implant but ultimately miscarry because it cannot grow appropriately. This condition is congenital, meaning it there from birth, and is completely asymptomatic until a woman tries to conceive. The uterus can also be distorted by a fibroid, which is a benign smooth muscle tumor that can grow into the cavity, or by a polyp, which is an overgrowth of the endometrial lining. Scar tissue inside the uterus, known as adhesions, can form after previous surgeries (e.g. a dilation and curettage, or D&C) and can also impair implantation or lead to miscarriages. These conditions, and others, can typically be fixed through a procedure known as a hysteroscopy.
Hysteroscopy involves dilating the cervix and inserting a camera into the uterus to visualize the pathology. Scissors and other instruments can then be passed through this camera to remove a polyp or fibroid, cut adhesions, or divide a uterine septum. The patient is asleep for this procedure but they are done as same-day-surgeries, with most procedures taking an hour or less and the patient going home shortly thereafter. All instruments pass through the vagina so there is no need for any incisions, and recovery time is minimal, with most patients returning to work within a day or two. If there is any underlying pathology inside the uterus, we would obviously want to fix it prior to a patient going through any treatment cycle such as IVF. However, in many cases, repair of an underlying septum, fibroid or adhesions is all a patient needs to conceive naturally without ever needing additional fertility treatment.
If a patient has some anatomic issue outside of the uterus, such as ovarian cysts, pelvic adhesions, or a blocked and dilated fallopian tube, laparoscopy is typically the treatment of choice. This procedure involves making anywhere from 1-3 small incisions in the abdomen (each typically 1cm or less) and inserting a camera though a plastic sleeve and into the pelvis. The surgeon can see the anatomy on a screen and can operate with instruments passed through the additional port sites. This type of surgery can be performed to remove an ovarian cyst or cut scar tissue in a patient with pelvic pain, or to remove a blocked and dilated fallopian tube (hydrosalpinx) prior to an IVF cycle. As with hysteroscopy, this is typically a same-day-surgery, with most patients returning to work within a week. The vast majority of reproductive surgery is thus performed on an outpatient basis, the main exception being surgery to remove very large or numerous fibroids which typically is done through a larger abdominal incision (C-section incision, or “bikini cut”). And in some cases even these larger fibroids can be removed via laparoscopy using the surgical robot.
Reproductive surgery represents a very powerful tool for the diagnosis and treatment of infertility. And while many surgeries are performed to optimize a patient’s anatomy prior to undergoing fertility treatment, many patients do not require any additional treatment following their surgeries. If a patient is young and the rest of her fertility work-up is normal, it is perfectly reasonable for a couple to try to conceive naturally for several months following reproductive surgery rather than being rushed immediately into treatment.
