At Bubtree we never start from an assumption that fertility surgery is the answer to solving your fertility issue. There may be good reasons why you should consider having surgery either to assess if certain factors are contributing to a delay in becoming pregnant and/or to undergo treatment. However, if alternative approaches are available we will discuss those with you. Our goal is to empower you with answers and information as soon as possible, so together we can decide the best approach to your fertility evaluation and treatment.
Fertility surgery can be performed either to find out (diagnose) if there is a problem with your reproductive organs such as a blockage of your fallopian tubes, scar tissue (adhesions) or endometriosis, or as a surgical treatment. Surgery to diagnose problems is performed through specialized telescopes (endoscopes) called a hysteroscope and a laparoscope as will be described in detail below.
The advantage of these diagnostic techniques over other "dye tests" (a hysterosalpingogram or a sono-hysterogram) is that a laparoscope can see if you have endometriosis and/or scar tissue (adhesions) and can also be used to treat certain conditions at the same time. Please refer to the Bubtree web page about alternative methods of checking whether there is a blockage of your fallopian tubes. Disadvantages of laparoscopy and hysteroscopy over alternative methods of checking your fallopian tubes are that they usually require an anaesthetic and, although uncommon, there are risks associated with surgery that are outlined in detail in our fact sheet which can be found at the bottom of this page.
Fertility surgery aims to preserve and, where possible, improve the function of your reproductive organs by treating certain conditions if present such as endometriosis, scar tissue and blocked fallopian tubes. Until the last 10-15 years this was usually done through open surgery and a combination of techniques called microsurgery. During microsurgery a highly trained Fertility Specialist uses an operating microscope, specialized miniature instruments and sutures, and very careful surgical techniques all of which allow the Fertility Specialist to operate in minute detail, minimize handling of tissues and bleeding and so reduce the risk of scar tissue (adhesion) formation. The learning curve and training required to be a competent micro-surgeon can be a number of years and involves performing many procedures under supervision. Although most fertility surgery is now done by laparoscopy, microsurgery is still performed in some situations such as for reversal of sterilization.
Fertility surgery undertaken by laparoscopy has a number of advantages over traditional (open) surgery as will be outlined below. However, the principle of careful tissue handling in order to minimize the risk of scar tissue formation and damage to the reproductive organs remains essential. Therefore, to be competent at performing fertility surgery your specialist must have undergone extensive training in a dedicated training centre.
A hysteroscopy is a procedure used to look inside the uterus. A thin instrument called a hysteroscope is passed through the vagina and cervix and into the uterus to help your Fertility Specialist find the cause of your problem, or to operate.
Your Fertility Specialist might suggest a hysteroscopy if you have:
- difficulty getting pregnant (infertility)
- frequent miscarriages (lost pregnancies)
- had other tests that have suggested an abnormality inside of your uterus
- heavy and/or long menstrual periods
- bleeding between your periods
- irregular cycles
- severe cramping
Following a diagnosis, your Fertility Specialist would often be able to use a hysteroscope to correct problem(s) that are found with the help of special equipment.
How is hysteroscopy performed?
Below is a diagram of a hysteroscope that has already been placed inside a uterus (womb). This is done in the following way. Before the hysteroscopy, the canal in your cervix may be gently widened with another instrument to allow the hysteroscope to enter your uterus. Once inside, a liquid or gas is inserted through the hysteroscope to expand the uterus, making it easier for your Fertility Specialist to see.
Your Fertility Specialist would then carefully look at the inside of the uterus, searching for possible source(s) of the problem as in the video below.
A sample of the lining of the uterus (endometrium) may also be taken at the same time and sent to pathology for examination under a microscope. Your Fertility Specialist may also discuss with you that he/she may have to perform the following procedures during your hysteroscopy;
- divide adhesions
- remove a polyp (an overgrowth of the lining of the uterus)
- resect fibroid(s) (a fibrous overgrowth in the muscle tissue of the uterus/womb)
- cannulate the fallopian tube(s)
- divide a septum (extra tissue in the womb causing an abnormal shape that may increase the risk of miscarriages)
- dilate the opening to your uterus (cervical canal) if it is severely narrowed (stenosed)
The fluid is then drained out.
A laparoscopy is an operation used to look inside your abdomen and look carefully at your pelvic (reproductive) organs. A thin instrument called a laparoscope is inserted through a tiny cut under your belly button to help your Fertility Specialist look, examine and operate (if needed) in your abdomen without making large cuts.
Your Fertility Specialist may suggest that you have this operation if you have one or more of the following condition(s):
- Trouble getting pregnant
- Pain in your pelvis or abdomen
- Adhesions (scar tissue that attaches to organs)
- Blocked fallopian tube(s)
- Fluid filled fallopian tube(s) (hydrosalpinx)
- An ovarian cyst or an endometrioma (a fluid filled "balloon" in the ovary)
- A tubal pregnancy (when a pregnancy grows outside the uterus)
Other options exist such as open surgery. You could decide to have an alternative assessment of your fallopian tubes such as a hysterosalpingogram, or if you have significant pain not to go ahead with the operation and live with the problem, but sometimes there is no alternative to a laparoscopy.
How might a laparoscopy help me?
By looking at your internal organs and tissues, this operation would help your Fertility Specialist diagnose and often proceed to treat your problem at the same time. You and your Fertility Specialist can then decide whether further treatment such as medication, in-vitro fertilization (IVF) or surgery is needed.
The following procedure would be performed:
At first, you would be given a medication called a general anaesthetic to block the pain. This would make you unconscious during the operation, requiring that a tube or breathing mask be used to help you breathe. Your Fertility Specialist would then make a small cut just under your belly button to pass the laparoscope into your abdomen. Usually, one or two other small cuts are made to complete the operation. A gas is used to expand your abdomen, making it easier for your Fertility Specialist to see your organs as in the diagram below.
Your Fertility Specialist then guides the laparoscope to examine certain organs like the womb (uterus), ovaries, fallopian tubes and sometimes the appendix. Other internal organs may also be examined. The video below shows what a Fertility Specialist sees as he/she performs a diagnostic laparoscopy.
If there are any abnormal findings, your Fertility Specialist may remove a small sample for further examination (a biopsy). Sometimes, bands of fibrous tissue grow around the fallopian tube(s), ovaries, uterus and/or bowel, and there may be endometriosis present. If so, your Fertility Specialist may need to cut the adhesions and cauterize the endometriosis. Your Fertility Specialist may also perform the following procedures (operation(s)/treatment(s)) on your pelvic organs;
- Infuse blue coloured fluid through the fallopian tube(s) to confirm whether or not they are open
- Open the outer end(s) of blocked fallopian tube(s) (salpingostomy)
- Remove ovarian cyst(s)
- Drain an endometrioma (ovarian cyst caused by endometriosis) and remove the capsule of the endometrioma
- Remove an endometriotic nodule
- Remove fluid filled and blocked fallopian tube(s) (hydrosalpinx)
- Remove a tubal (ectopic) pregnancy by either shelling it out of a fallopian tube or by removing part or all of a fallopian tube
A copy of our Fact Sheet can be found below.