Reproductive surgery involves surgery in the field of reproductive medicine. Reproductive surgeons consist of gynecologists and urologists who specialize in reproductive surgery and are the experts in the conservative treatment of reproductive organs in both men and women. Reproductive surgery includes a wide range of operations designed for different purposes. Most operations are done to restore normal uterus, tubes and ovaries.
Although the use of assisted reproductive technology (ART) has become more prevalent, surgeries conducted on the fallopian tubes and ovaries have become less common. Nevertheless, there are still many occasions where reproductive surgery can make a difference. At the UCLA Fertility and Reproductive Health Center, our reproductive surgeons specialize in surgeries that aim to investigate female reproductive organs and treat reproductive problems that lead to infertility such as endometriosis, uterine fibroids, pelvic adhesions, tubal occlusions, ovarian cysts, and congenital or acquired abnormalities. Male reproductive surgeries are performed by our UCLA urologists who specialize in male infertility.
Endometriosis is a gynecologic condition characterized by endometrial tissue from the inner lining of the uterus growing outside of the uterine cavity. Typical symptoms of endometriosis are painful menstrual periods, vaginal bleeding between periods, and infertility; however, some women with infertility associated with endometriosis have no symptoms. Although the exact mechanism of how endometriosis causes infertility remains poorly understood, the strong association between endometriosis and unexplained infertility exists. Many studies have shown that treatment of moderate and severe endometriosis can improve fertility in women attempting to conceive on their own or with fertility treatments. For women with endometriosis, surgery can be done to remove, or lessen, the amount of abnormal tissue in the pelvis. This can be achieved through:
Laparoscopy: Laparoscopy can be used to diagnose and treat endometriosis in a single procedure. The surgeon makes a tiny incision below the navel and places a small telescope into the abdominal cavity, allowing the doctor to visualize any scarring or abnormal tissue with a fiber optic camera. Additional small incisions can be made to introduce additional instruments needed to perform surgery.
Mini-laparotomy: The surgeon makes an incision in the abdominal wall to reach the affected areas. Mini-laparotomy is performed through a small incision located just above the pubic bone. The surgeon explores the pelvis and corrects the problem.
Laparotomy: In a laparotomy, an incision is made in the lower abdomen which allows the surgeon direct access to all structures of the pelvis. This procedure may be needed for severe pelvic diseases and requires a few days of hospitalization and a 4–6 week period of recovery.
Approximately 30 percent of patients will have leiomyoma uteri (fibroid tumors). Fibroid tumors may be asymptomatic or may cause excessive uterine bleeding, recurrent miscarriages, pain and pressure, or severe anemia. Fibroid tumors may be removed via laparotomy or, in select cases, by outpatient hysteroscopy.
Hysteroscopy is an outpatient procedure in which the doctor uses a narrow fiber optic telescope inserted into uterus through the cervix, to look for and, if necessary, remove fibroids or adhesions inside the uterus.
Adhesions can cause major problems with fertility. Although adhesions can be removed during surgery, surgery can sometimes also cause adhesions. In fact, previous abdominal, and particularly pelvic, surgery continues to be an important risk factor for tubal infertility. It is known that adnexal adhesions form in the majority of patients undergoing myomectomy. The more damage there is during surgery, the greater the chance that adhesions will occur. UCLA reproductive surgeons emphasize the value of good surgical techniques and adhesion reduction for their patients and their practices.
The fallopian tubes are the path that the sperm and egg must take to achieve fertilization and successfully implant in the uterine cavity. Disorders of the fallopian tubes can lead to the inability to conceive, because the sperm and egg cannot meet. Prior pelvic infection, surgery, or endometriosis can cause blocked fallopian tubes. Hydrosalpinx means "water tube" and describes the balloon-like appearance of fluid trapped in the blocked tube. Laparoscopy is often used to diagnose and treat these disorders. In some cases, severely damaged fallopian tubes must be removed to improve chances of contraception with in vitro fertilization (IVF) because fluid buildup in the fallopian tubes can create a toxic environment for implantation. In other cases, pelvic scaring and endometriosis can be treated by tubal fertility surgery to improve the likelihood of conceiving naturally or with other fertility treatments.
Tubal surgery to increase fertility involves reversal of tubal sterilization or opening the tubes that were blocked by endometriosis or infection at the far (distal) end next to the ovary (hydrosalpinx), or at the near (proximal) end arising from the uterus (cornua). Microsurgical tubal reversal, anastomosis and reanastomosis are terms used to describe repair or untying of a tube or both tubes using microsurgery. These techniques can be used after a sterilization procedure such as tying, cutting, clipping or burning the tubes and after cornual damage to a tube by infection. This operation also has other names such as repairing tubes, having the tubes untied, and undoing a tubal ligation.
Ovarian cysts are a frequent finding in women of reproductive age. Many of them resolve on their own and do not require surgery. Cysts that are large or persistent, lasting more than several months may require surgery. Most ovarian cysts are non-cancerous and may be the result of endometriosis or other benign processes. Cancer is rarely found in women of reproductive age with simple ovarian cysts, but surgical removal and microscopic examination is the only way to definitively diagnose the type of cyst. Ovarian cysts can typically be removed with a laparoscope, and do not require removal of the entire ovary. Other ovarian disorders, such as polycystic ovarian syndrome, can be treated medically and rarely require surgery.
During fetal development, abnormalities of the uterus, fallopian tubes and vagina may occur. Such malformations may contribute to infertility, severe pelvic pain, or recurrent pregnancy loss. Patients with septate uterus, duplicate cervix, and a longitudinal vaginal septum may be treated with hysteroscopy and laparoscopy. Laparoscopic and hysteroscopic procedures allow for confirmation of anatomic findings along with hysteroscopic resection of the septum. Hysteroscopic resection is successful in most patients with structural abnormalities. The few patients, who fail hysteroscopic management, may undergo laparotomy for more involved surgical procedures.
The uterus or womb is the organ where the embryo implants and develops throughout a pregnancy. Uterine abnormalities can contribute to decreased fertilization, miscarriage, or pregnancy complications. Common acquired uterine abnormalities requiring surgical treatment include polyps, scarring, and fibroids. Many of these abnormalities can be treated using hysteroscopy and/or laparoscopy, but some may require more extensive surgery depending on the patient’s condition. Uterine fibroids are very common among women of reproductive age and not all fibroids need to be removed in order to achieve a successful pregnancy.
Testicular biopsy: in-office surgical procedure in which several small pieces of testicular tissue are removed and examined for sperm, which can be used in fertility procedures.
Testicular sperm aspiration (TESA): involves a needle biopsy of the testicle in which a sample of tissue is taken directly from the testis and used to extract sperm for IVF or ICSI.
Percutaneous sperm aspiration (PESA): involves a needle being inserted into the epididymis in an effort to locate and aspirate a pocket of sperm.
Vasectomy reversal: A vasectomy reversal is often performed as an outpatient procedure and is done to reverse a previous vasectomy and restore the male's ability to release sperm into his semen from the testicles.