Reproductive Surgery - 92 Harley Street website

Most of the principles of tubal microsurgery were developed at the Hammersmith Hospital in the 1970’s. It still is the busiest centre for reproductive surgery in the United Kingdom, and one of the best known centres amongst gynaecologists and patients alike in the world.

The approach - An integrated approach to reproductive surgery and IVF

We believe that reproductive surgery has a very important part to play in the logical approach to the treatment of infertility. The two consultants in Reproductive Medicine & Surgery at the Hammersmith are both experts in reproductive surgery, and indeed all aspects of fertility treatment including IVF.

Experience

The two consultants deal with all types of open microsurgery, laparoscopic and hysteroscopic surgery. The large volume of all these cases, including some of the most complex in the country, give our team a wealth of experience in this field, and correspondingly high success rates. The referral base is both national and international. We are one of the few centres in the world performing microsurgical cornual anastomosis.

Microsurgical technique

We perform all fertility surgeries with microsurgical technique - whether it is keyhole surgery (laparoscopic and hysteroscopic) or open (laparotomic) at the Hammersmith. Microsurgery not only allows the best healing of the tissue, with the least scar tissue, but also when performed correctly a significantly better pregnancy rate then that of conventional open surgery or keyhole surgery.

1. SURGERY AS AN ALTERNATIVE TO IVF

In certain conditions corrective microsurgery can give a significantly higher success rate than IVF. In other cases where the patients do not respond as well as they should to the stimulation required for IVF, they can again achieve higher success rates.

Surgery to improve success rates of IVF

In certain situations where there is disease inside the uterine cavity, such as polyps, fibroids or intrauterine adhesions (scarring), then removing the problem inside the uterine cavity can significantly improve the implantation rate (success rates) of IVF. If there is fluid in the fallopian tube (a hydrosalpinx) due to a distal tubal blockage (blockage near the ovary), then this fluid can reflux back into the uterine cavity and significantly reduce success rates with IVF. Preventing this fluid from going into the uterine cavity either by blocking or removing the tube, on the other hand significantly improves the success rate with IVF.

Gynaecological problems affecting fertility ;

Problems with the fallopian tube

Endometriosis and Infertility

Abnormalities in the uterine cavity

2. PROBLEMS WITH THE FALLOPIAN TUBE

The fallopian tube is often thought of as just a pipe transporting the egg and sperm, but in fact it is a complex organ 12 to 15cms long that secretes certain growth factors, and contracts in many different ways to facilitate the movement of the sperm to the egg, and then the fertilised egg back into the uterus. It responds to the female hormones at different times of the cycle to to contract in different ways. The inside of the tube is covered with tiny hairs (cilia) which can only be seen clearly with the electron microscope. These ‘waft’ the egg and sperm in the correct way, again in response to changes in the female hormones. Fertilisation of the egg by the sperm occurs in the ampullary portion of the tube, and then this fertilised egg, or embryo, is transported to the uterine cavity.

Tubal surgery has been around for many decades and is performed to try and correct any blockage in the fallopian tube which is preventing the egg and sperm meeting. Techniques though have improved dramatically with the advent of microsurgical procedures which involve utilising specific surgical techniques that can greatly improve the success rate of the operation, as well as to decrease any subsequent scarring. These microsurgical procedures involve techniques such as magnification (normally using the operating microscope), careful tissue handling, not allowing the tissues to dry out, limited use of cautery, and the use of very fine sutures that will minimise the risks of scarring post operatively. Indeed with some forms of tubal microsurgery the sutures used are as fine as a human hair.

Depending on the type of disease, corrective tubal surgery can be performed either by open surgery (laparotomy) or keyhole surgery (laparoscopy). The success rates of tubal surgery depend on the extent and severity of the underlying disease, as well as whether there are any other factors such as lack of ovulation or a severe sperm problem on the male side.

Patients who benefit from surgery are generally those with …..

Patients who have low success rates from tubal surgery are those with….

Proximal Disease

Disease in this portion of the tube can be a complete blockage (obstructive) or where the tube is still damaged, but there is a small opening in the tube (non obstructive). Disease in this part of the fallopian tube adjacent to the uterus is found in 10 to 25% of women with tubal related infertility. The most common cause of this disease, both obstructive and non obstructive, is a condition called salpingitis isthmica nodosa (SIN). The cause of this disease is unknown, but the majority of patients who have it have been pregnant in the past, and it could well be an inflammatory type condition related to pregnancy. It is generally not thought to be due to infection as the more sensitive distal end of the tube is unaffected. It can be seen after any pregnancy - from a miscarriage through to a normal delivery or Caesarean Section. It nearly always affects both fallopian tubes, but one side is quite often affected more than the other. In the non obstructive form, where the fallopian tube is still open, it does not mean that fertility is unaffected. Unfortunately in these situations the diseased portion of the fallopian tube has lost a lot of it’s tubal function and therefore cannot transport the sperm to the egg. If the disease is only mild, and the sperm is transported to the egg and fertilisation occurs, there is a significantly higher chance of an ectopic pregnancy because the fertilised egg cannot get back into the uterine cavity due to the narrowing of the tube in this area.

Other causes of proximal tubal disease can include adenomyosis and large polyps (cornual polyps) within the fallopian tube itself.

Proximal tubal disease is usually diagnosed either from x-ray investigation called a hysterosalpingogram (HSG) , or by a frequently performed gynaecological procedure called a laparoscopy. The HSG does not require any anaesthetic, takes 15 to 20 minutes and should be uncomfortable at most, if performed correctly. A HSG not only provides invaluable information about the fallopian tube, but also checks the uterine cavity. It is performed under x-ray control but the dose of radiation with modern equipment is extremely low, and is the same dose of radiation as someone would get from one transatlantic flight!

A laparoscopy is where a camera is inserted through the belly button (umbilicus) to look at all the pelvic and abdominal organs. It is performed under General Anaesthetic and is a day case procedure, (the patient coming in and going out of hospital the same day). Often as well as checking the tubes several others things can be looked for as well - such as endometriosis and adhesions, and possibly treated at the same time.

If proximal tubal disease has been diagnosed and the distal portion of the tube is otherwise healthy, then surgery can be performed to remove (resect) the area of blockage, and the tubes then microsurgically re-joined (anastomosis). This is normally performed under a small laparotomy incision (bikini scar) and if performed correctly using full microsurgical techniques, patients can achieve a live birth rate of up to 68%. This is significantly higher than a single cycle of IVF which is generally around 30%. If conventional surgical techniques are used as opposed to full microsurgical techniques, then success rates are much lower, and are generally around 34%.

The patient generally spends only two nights in hospital. The patency of the fallopian tubes are checked at the end of the procedure to make sure the tubes are open, before the patient is closed up. Generally both tubes are operated on to maximise the chance of a pregnancy.

The most common site of a blockage with the fallopian tube is at it’s distal end ie. next to the ovary. Delicate microscopic fingers at the end of the tube known as the fimbria normally envelope the ovary at the time of ovulation and pick up the egg to start it’s journey along the fallopian tube. The egg is then transported into their correct portion (the ampulla) by the small hair like cells known as cilia.

Disease of the distal tube can be caused by any pelvic inflammatory condition including infection, endometriosis, appendicitis and previous pelvic surgery. A blockage at this distal end can result in a fluid collection in the fallopian tube known as a hydrosalpinx. If both tubes are blocked then they are called hydrosalpinges. The amount of fluid within the tube can vary enormously and the tube can be dilated by just a few millimeters up to 7 or 8 cms. The pressure within the tube is very low and it tends to be a self limiting situation and hence the tube does not burst if the fluid carries on increasing. The fluid though can pass back into the uterine cavity and affect success rates with assisted conception. Not only can a hydrosalpnx be diagnosed with a HSG or laparoscopy, but if it is large enough it can also be seen under transvaginal ultrasound.

Surgery can be performed to re-open the distal end of the fallopian tube in order to improve the chance of natural conception. The success of the surgery depends on the extent and severity of the damage. Important factors in deciding whether surgery is appropriate are the size of the swelling, the thickening of the wall, and the condition of the lining of the tube (mucosa). The presence of adhesions (scarring) around the tube and ovary also affect success rates. Distal tubal disease can be graded from 1 (very mild) through to IV (severe). Success rates with grade I disease can be 44% which again is generally higher than a single cycle of IVF. Grade II disease the success rates go down to around 28% which would be similar to a cycle of IVF, but when there is more severe disease such as Grade III or IV, then success rates are significantly lower. Indeed with grade III disease, success rates are generally only about 12% and Grade IV disease they are less than 5%. It is in these severe disease that generally IVF gives a better success rate, although as previously noted, the fluid in the hydrosalpinx can reduce IVF success rates unless treated.

Surgery to the distal end of the fallopian tube can either be performed by a laparoscopy or by a laparotomy. The decision which to perform is often dependant on the extent and severity of the fallopian tube, and at the Hammersmith we perform both types, depending on the above factors. We will use the most appropriate technique that would give the best chance of a successful outcome.

Hydrosalpinges and IVF

Strandel in 1994 showed that if a patient has a distal blockage and formed a significant hydrosalpinx, then this can significantly lower the chance of IVF working, even though the embryos are put back into the uterine cavity. This is thought to be due primarily to the fluid from within these hydrosalpinges entering the uterine cavity and damaging the embryos (embryotoxic). It may also have a mechanical factor in ‘washing’ the embryo away from it’s implantation site.

If a tube is found to be not suitable for corrective tubal surgery, then this fluid should be prevented from entering the cavity and reducing the success rates of IVF. Initially this was done by removing the entire tube (salpingectomy) and in some situations this is still performed. More commonly these days, the proximal part of the tube is burnt (coagulated) and cut to leave the tube in place, but to prevent the fluid leaking back into the cavity. The reason that we tend to perform this second procedure (rather than a salpingectomy), is because it is a simpler and therefore safer procedure, as well as not damaging the blood supply to the ovary which can reduce the ovarian response to drugs used in IVF. This procedure has two main benefits, firstly in improving the success rates of IVF back to what they should be for that specific patient, as well as reducing the ectopic pregnancy rate from the IVF cycle. Even though the embryos are replaced in the uterine cavity, due to uterine contractions, the embryos can move into the fallopian tube. If the fallopian tube is damaged, as it is in distal tubal disease, then it is less likely that the embryo will move back into the uterine cavity. An ectopic pregnancy can therefore result. By blocking the fallopian tube(s) this significantly reduces the chance of the embryo going into the tube and sticking there, and hence reduces the chance of an ectopic pregnancy. It has been shown by very good evidence that by stopping this fluid entering the cavity success rates can be virtually doubled back to where they should have been for the individual. This sort of tubal coagulation is only done when the distal part of the tube is not correctable by the usual microsurgical technique. If the tube is correctable, then opening up the distal end (salpingostomy) would be the preferred method.

If a patient has one tube that is blocked in the distal end, but the other tube is open and healthy, then it has been shown that by either removing the diseased fallopian tube or by again blocking it in the proximal portion, that spontaneous pregnancy rates can be significantly improved. This would follow the same theory as previously noted with IVF. It could well be that a patient is forming a good embryo in the healthy tube, but that when the embryo moves into the uterine cavity itself, that the fluid from the unhealthy tube then damages the embryo and hence the spontaneous pregnancy rate is significantly lower. An excellent paper by Sagoskin has shown that if you prevent this fluid entering the cavity from this damaged tube, then spontaneous pregnancy rates for the healthy tube increase dramatically.

Reversal of sterilisation

Microsurgical reversal of sterilisation is the most successful form of tubal corrective surgery, as generally apart from the deliberate block in the tube, the patient has been proven to be otherwise fertile. At the Hammersmith Hospital in one of our series of over 200 operations, approximately 85% of our patients achieve a pregnancy within one year of the surgery. All of our reversal of sterilisation surgery is performed microsurgically though a small bikini line incision using techniques developed at the Hammersmith. We use very fine sutures and powerful operating microscopes to allow the best approximation of the fallopian tube after the blocked area has been removed. Most patients over the last 20 years have been sterilised by a clip sterilisation (either Hulka Clemens or Filshe clip) but they are sometimes sterilised by burning the tube (diathermy) or by putting small elastic bands (rings) around the tubes. In the vast majority of these cases, a reversal of sterilisation can still be performed and excellent success rates still achieved. Even if the tube had been burnt by diathermy, as long as the end of the tube (the fimbria) are still present, then success rates of over 60% can still be achieved.

Reversal of sterilisation can also be performed by keyhole surgery (laparoscopy) but unfortunately the success rates are significantly lower. In a similar set of patients we can achieve success rates of around 85% with a single clip sterilisation where as even the best laparoscopic surgeons in Europe, only achieve a success rate of only 65%. For an operation that has its sole purpose of trying to improve pregnancy rates, we therefore do not feel that this sort of surgery should be performed by keyhole methods, as the success rate is significantly lower (greater than 20% lower in similar cases). Unfortunately a lot of surgeons do not quote their own success rates for these forms of surgery, but rather quote the best success rates of other surgeons. We at the Hammersmith feel this is inappropriate and surgeons should quote their own success rates.

The recovery time from a microsurgically performed mini laparotomy is still quite short, and indeed the patient would only spend one extra day in hospital compared to an operation performed by laparoscopic techniques. With the significantly increased chance of the operation working, we therefore believe most patients would prefer to take the more successful option.

3. UTERINE FIBROIDS

What are Fibroids

Fibroids are the most common benign tumour in women. Up to 60% of women at the age of 40 can be affected and fibroids can vary in size, number and location. Each fibroid grows from a single cell and is stimulated by the female hormone oestrogen. Fibroids carry on growing under the influence of oestrogen until the menopause, when they slowly start to shrink back. There is a definite genetic propensity with fibroids.

Fibroids can often be completely asymptomatic, but in some patients they may produce symptoms.

Symptoms caused by fibroids include:

Heavy menstrual bleeding

Fibroids increase the amount of menstrual bleeding in two ways. Firstly by increasing the overall size of the uterus, and hence the blood flow to the uterus, but also by increasing the surface area available for bleeding. This is particularly the case if the fibroids are submucosal and distorting the cavity itself. As a general rule, the bigger the uterus and uterine cavity, the more likely there is to be increased menstrual bleeding.

Because fibroids can distort the architecture of the uterus, and particularly if they distort the uterine cavity, this can increase the rate of early pregnancy loss. If the fibroids are particularly large it can also increase the chance of pregnancy loss in the second trimester.

Fibroids and Infertility

Women with fibroids are 50% less likely to conceive naturally than women without fibroids. The size, location and number of fibroids can all increase the effect on infertility, and the type of fibroids that have the greatest effect are ones that distort the uterine cavity – submucosal fibroids.

There are several theories why fibroids decrease fertility, and these include:

Fibroid Treatments

Not all fibroids have to be treated - if they are not causing any problems, then treatment may be unnecessary. Fibroids that are symptomatic though can be treated in several different ways, depending on the symptoms, age of the patient and fertility desires.

These options include:

The surgical removal of fibroids is called myomectomy and can be performed in several different ways.

If fibroids are significant and thought to warrant removal, then removing them through an abdominal incision – laparotomy – may be the most successful way of preserving the uterus and future fertility.

The majority of fibroids can be removed by low bikini line incision, but if they are very large and extend above the belly button (umbilicus), then sometimes an incision from the belly button down to the pubic area may be necessary. The crucial thing if either of these incisions are made, is that full microsurgical techniques are used. This is a surgical discipline that comprises certain surgical techniques including ; minimal tissue handling, immaculate haemostasis, not allowing the tissues to dehydrate, the use of very fine sutures and suturing techniques that invert cut edges. If these microsurgical techniques are used it has been shown to significantly reduce the chance of post operative scarring ( adhesions).

It is imperative that the fibroids are carefully dissected free, and if possible the uterine cavity not entered. It is equally important that after the fibroids have been removed, the uterus is very carefully reconstructed, again using full microsurgical techniques and inverting all the cut surfaces to minimise one of the most common post-operative problems with fibroids - that of adhesions. Adhesions can form whenever any cut surface heals, but it can be minimised by certain techniques such as microsurgery.

At the Hammersmith Hospital 99% of open myomectomy patients stay in only 2 nights, and are back driving after 7 to 10 days. By using the full microsurgical techniques, not only does the patient recover far faster, but the chance of hysterectomy is very low (again in our hands less than 1%), and the risk of post operative adhesions again significantly reduced. This not only reduces post operative pain, but improves the chance of a spontaneous pregnancy.

ii. Laparoscopic myomectomy

Some fibroids can be removed by keyhole surgery and the fibroids shredded (morcellated) in the patients abdomen before being removed through small incisions. Although fibroids can be removed adequately this way, unfortunately it is not possible to get such a good uterine repair and approximation of the tissue. This can result in significantly more post operative adhesions than by correctly performed open microsurgery. The patient still tends to be in hospital for 1 or 2 nights and has multiple small incisions rather than one small bikini line incision.

Also in several previously reported papers more fibroids tend to be removed by laparotomy than laparoscopic treatment, and also the risk of uterine rupture during labour is reported to be greater by the keyhole method.

If subsequent fertility is not an issue then the adhesions may not be so much of a problem, although again can result in other serious consequences such as small bowel obstruction.

iii. Transcervical resection of fibroids (TCRF)

If the fibroids are predominantly within the uterine cavity, then these can be resected by special keyhole surgical technique called transcervical resection of fibroids. This is where a small TV camera with a special resecting loop is inserted through the vagina into the cervix. The uterine cavity is then distended with special fluid and the fibroids carefully resected away. This is the optimal treatment for the type of fibroids which are distorting the cavity. (If though the fibroid is greater than 5cm, and is predominantly within the wall of the womb, then it may be better to remove these trans-abdominally and to remove the small ones hysteroscopically at a later stage). TCRF is performed as a day case procedure under general anaesthetic – the patient comes in at 07.30 in the morning and leaves the same afternoon.

iv. Hysterectomy

If a patient has completed her family, and has very large fibroids, then some surgeons will recommend the entire uterus be removed. At our Reproductive Surgery Unit we tend to only recommend this treatment for patients who have already had several previous myomectomies and in the most extreme cases. This would not be a routine form of management that we would normally advocate.

Medical treatment of fibroids

Fibroids require oestrogen to grow and if you medically suppress the oestrogen production from the ovaries and put the patient into a temporary menopause, then you can cause shrinkage of the fibroids while the patient continues these drugs. The drugs are called GnRh agonists and have various names including Zoladex and Prostap. They can be given for anywhere between 1 to 6 months, but if given longer than 6 months additional drugs called add-back therapy has to be given to protect the patients bones from becoming too thin (osteoporosis).

Although this can be a reasonable treatment to get up to 50% shrinkage of the fibroids, unfortunately it is only a temporary treatment. When the drugs wear off, the fibroids can then rebound and go back to their previous size quite quickly.

This treatment is sometimes used prior to transcervical resection of fibroids to get a better view inside the uterine cavity, as well as prior to open surgery. In open surgery they are used to shrink the fibroids down to size which can help reduce blood loss as well as sometimes allowing a bikini line incision to be made, rather than the up and down incision below the umbilicus

The drugs do have side effects because they are putting the patient into a temporary menopause and the patient can suffer from hot flushes, night sweats, increase in irritability and lack of concentration.

Uterine artery embolisation (U.A.E.)

This treatment is where a small incision is made in the patients groin and special catheters fed up to the uterus and the blood vessel feeding the fibroid is blocked or embolised. This is generally performed under local anaesthesia. After this technique it has been reported significant reductions in the size of the fibroids, although of course the fibroid still remains in place - but just smaller. We feel that this can be a particularly good treatment in patients not desirous of fertility, and who may not be suitable medically for a more definitive procedure such as open myomectomy.

We do not advocate this procedure in patients desirous of future fertility. We have several reasons for this. Firstly the particles used to embolise the feeding blood vessel to the fibroid can also dissipate into other areas and can cause a reduction in blood flow to the ovaries. Indeed it has been reported that around 4% of patients after this technique can be put into an early menopause. Even patients who are not put into an early menopause may have their ovarian function reduced, and hence be more difficult to stimulate for techniques such as IVF in the future. Secondly this reduction in blood flow to the uterus can also cause other implantation problems by making the lining not as healthy as it otherwise would be. Thirdly the way the fibroids have their blood supply cut off and shrink can also cause scarring inside the uterine cavity which can cause great problems in patients trying to conceive in the future.

Although there have been pregnancies reported in some cases of patients who have had uterine artery embolisation, we believe at the Hammersmith that the overall risks of UAE far outweigh the supposed benefits in infertility patients. As previously mentioned, the fibroid is still left in situ and therefore can still cause other problems to do with uterine contractility and uterine blood flow. We therefore believe patients who would like to consider future pregnancies, or the infertile patient, that it is far better to remove the fibroid in the full microsurgical manner than using UAE and leaving a potential bigger problem behind.

High Energy Focused Ultrasound

This is a research technique which ‘cooks’ the fibroid from the inside out and therefore prevents it growing. Indeed because it destroys the blood vessels within the fibroid, the fibroid then shrinks in size. It is a research technique and not generally recommended for patients desirous of fertility. Similarly to the UAE technique described above, it can also have other complications and should only be performed in centres with full surgical backup and as part of a controlled research project.

Interstitial therapy

Again this involves cooking the fibroid from the inside out, either by placing a needle electrode inside it, or a laser fibre at laparoscopic surgery. This can be a reasonable option in patients who have multiple small fibroids where the general size is less than 2cms. It is not a good technique for large fibroids. Great care has to be taken with its use as you are using heat sources within the abdomen, and great care has to be taken to prevent these heat modalities from damaging bowel.

Myomectomy and fertility

A meta-analysis is a way of pooling the data for multiple studies. One meta-analysis from 46 different studies suggest that myomectomy can improve fertility towards the normal range. However it is important to assess the benefit of the surgery carefully in each individual case. This experience is particularly important when performing surgery for fibroids.

Myomectomy, more than any other gynaecological operation, can result in extensive scar tissue in the pelvis (adhesions). Myomectomy can also sometimes distort the integrity of the uterine cavity and actually have a negative affect on fertility, unless performed correctly. The two consultant reproductive surgeons at the Hammersmith perform myomectomies on a weekly basis. Because of our long experience, we believe that microsurgical removal of these fibroids has a particular role in fertility surgery. Both reproductive surgeons in our team are also fertility specialists which means we can take a holistic approach to the problem of uterine fibroids when fertility is the most important factor.

Two significant papers have shown that fibroids that are above a certain size (3 cms) can still have a significant affect on either success rates, even if they do not distort the uterine cavity. Eldar-Geva from Monash University showed in 1998 a significant reduction in implantation rates with these sort of fibroids. This was confirmed by Roger Hart in 2001. We therefore very carefully assess any patient with fibroids before proceeding with IVF treatment.

4. ENDOMETRIOSIS

What is Endometriosis ?

The lining of the uterine cavity is known as endometrium. When this tissue is found in other areas outside the correct place it is known as endometriosis. This can occur in most places in the body but is far more commonly found in the pelvis itself. The most frequently affected areas of endometriosis are behind the uterus in the Pouch of Douglas, and also around the ovaries. These areas of tissue then respond to the same hormones that the lining responds to, and can produce certain chemicals as well as bleeding during the period. This bleeding can irritate surrounding tissues causing pain as well as in some situations causing scarring and cysts.

Endometriosis is quite an enigmatic condition and does not necessarily produce symptoms in all patients. Indeed in patients with no symptoms at all, apart from infertility, they still can be found to have quite severe endometriosis. Also to further complicate things, if symptoms are present then they are not always proportional to the severity of the disease. Sometimes you can have only a few spots of endometriosis which can cause severe crippling pain, and other times the patient can have an entire pelvis full, with no pain at all.

The pain can start prior to the period as well as going into the period itself. Sometimes patients get low back pain or pain referred down the legs, as well as quite commonly pain during sex (dyspareunia). If there is endometriosis within the ovary itself this can cause cysts known as endometriomas. These endometriomas can also cause pain and significantly affect fertility.

Some patients with severe disease can have areas of endometriosis and scarring between the bowel and back of the womb, (recto-vaginal endometriosis). This can cause pain when the patient opens her bowel during the period (dyschexia), some patients also get it in the bladder and can pass blood stained urine during her period.

There is a significant genetic link with patients with endometriosis, and if one of the family has got it, then there is a significantly increased chance of other female members also having it.

Endometriosis and infertility

Endometriosis can also cause infertility, and this can be both from a mechanical effect due to scarring as well as a chemical effect from the diseased tissue itself. The physical effect of the scarring can stick down ovaries and tubes and make it very difficult for the fallopian tube to envelop the ovary to pick up the eggs. It is also known that the endometriotic tissue can release chemicals which damage the sperm, and even if there is no scarring or distortion of the organs this can still significantly lower the chance of that couple achieving a spontaneous pregnancy.

Treatment of endometriosis

Endometriosis can be treated by either medical or surgical treatment. In medical treatment the endometriotic tissue is suppressed, and although this can have a beneficial effect on pain, it does not improve fertility. By far the best treatment for most forms of endometriosis is surgically. This is where you burn away the tissue and divide the scarring, which can both improve both the pain as well as significantly improving fertility. The technique used to burn away the endometriosis can be varied, either with a special electric current, through to several types of laser. At Hammersmith we use a particular type of laser called a Diode laser which has been shown to be very effective and safe in these procedures.

It has been shown that even in situations where there is only moderate disease that by burning the endometriosis away you can then double the natural conception rate.

The success rates of surgery for endometriosis is multi-factorial and depends on the extent and severity of the disease, as well as any scarring that has been caused, as well as any other factors contributing to the sub-fertility such as age or sperm problems. Ovarian endometriosis can also affect success rates with IVF, and indeed if there is a significantly large endometriotic cyst present, then quite often it can be far better to try and remove this prior to the IVF cycle.

Hysteroscopic surgery is where a small camera is inserted through the vagina and through the cervix with no cuts in the abdomen. This can be performed for a range of intrauterine problems. These include:

The uterine cavity is remarkably small and is exquisitely sensitive to any problem within it. Whatever that problem is, it can significantly reduce the chance of successful implantation. We would therefore always check the uterine cavity either by hysterosalpingogram (HSG) or hysteroscopy. It is often neglected and this can lead to repeated cycles of IVF failing because of an undiagnosed intrauterine problem.

These are soft fleshy growths that originate from the lining itself. They can be quite small or very large and sometimes occupy the entire cavity. The effect on fertility is proportional to the size of the polyp, and even small ones can reduce the implantation significantly. The vast majority of these polyps are benign, but very occasionally’ if left untreated’ polyps can become pre-malignant or even malignant. All polyps removed are sent off to histopathology to ensure there is no other worrying underlying problem.

Transcervical resection of fibroids

As previously discussed in the section under fibroids, any fibroid that distorts the uterine cavity can cause a variety of symptoms ranging from pain, heavy periods or infertility. These can be resected safely and the underlying symptoms greatly improved.

There are many different types of congenital uterine abnormalities. Congenital abnormalities are ones that the patient is born with and can affect the uterus, fallopian tubes and ovaries. One of the most common types that affects fertility is where there is a bridge of fibrotic tissue extending down the middle of the uterine cavity called a septum. This can be very small and which may have very little if any effect on fertility. Other times it can be large and can not only cause a problem with the patient becoming pregnant, but also can increase early pregnancy loss or miscarriage.

Not all uterine septum are significant and not all have to be removed. If though the patient has a history of infertility or a history of miscarriage, then this can be one of the contributing causes towards the situation. As part of the logical approach we take at the Hammersmith Hospital, we would always investigate the cavity and if the uterine septum is thought to be significant, then the patient would be bought in for a laparoscopy (to check the outside of the womb), hysteroscopy and division of this uterine septum. This is performed with micro scissors as this tends to give the best surgical result with the most successful fertility rates afterwards. Although you can use lasers and electrosurgery inside the uterine cavity, it tends to cause a burn (thermal eschar) which can cause problems with implantation in the future. Sometimes after a large septum has been removed, two contraceptive coils will be placed in the uterine cavity to prevent the areas sticking back down and the cavity can be checked afterwards with a further HSG. If the septum is particularly large it can take two or very occasionally three operations before we are satisfied with the end result.

Intrauterine adhesions

The uterine cavity is a sensitive environment and adhesions can be caused by any trauma within the cavity. Most commonly they are caused after a miscarriage. Any pregnancy though, including a normal delivery at term, can cause intrauterine scarring. It is therefore an area that should be checked if the patient has become infertile after a preceding pregnancy.

The cavity is generally checked with an x-ray called a hysterosalpingogram and this will show up any uterine scarring if performed correctly. If significant scarring is found a hysteroscopy is performed to confirm this, and at the same time the adhesions are divided using a tiny pair of scissors (called micro scissors) introduced through a special channel in the hysteroscope. As many areas of scarring are safely divided as possible and two contraceptive coils are inserted to prevent re-formation of this scarring. These are removed 4 – 6 weeks later. This scarring can be thin and filmy or dense and vascular. Cases of severe dense vascular adhesions can sometimes require two or three operations to recreate the cavity to a suitable and acceptable standard. Often antibiotics and a special hormonal regime is used to try to reduce the chance of the scarring re-forming.

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