Advances in Microsurgery for Female Infertility

Most little girls grow up believing that someday they will be able to have children. In actuality, one out of six couples are unable to conceive a child. When some women grow up and find that they are unable to conceive, the news can be devastating. Infertility is a family issue that can stem from many causes. With medical treatment and surgery, many of these causes can be reversed or eliminated.

A woman dealing with infertility may feel a myriad of emotions, ranging from despair to anger. She may feel betrayed by a body that will not perform its biological duty. She may feel guilty for having waited until career goals were fulfilled before trying to get pregnant. These, unfortunately, are normal reactions.

Dramatic advances in the field of infertility have recently occurred, and more are expected. Many of these advances have been due to the increasing use of microsurgery in gynecology. The gynecologic microsurgeon can now correct problems which previously were considered incurable.

What is Microsurgery?

Microsurgery is different that macrosurgery or conventional open surgery in that it is surgery performed with the aid of magnification. Very fine suture materials that minimize skin irritation and delicate tissue handling techniques are hallmarks of this type of surgery.

Initially, operating glasses or loops which allowed moderate magnification were used by the microsurgeon, however, for most modern microsurgery, the use of the operating microscope (which allows magnification from 2 to 30 fold) has produced better surgical results.

Another form of gynecological microsurgery is performed using a laparoscope which also magnifies pelvic structures. Similar in theory to a telescope, the laparoscope is inserted into the pelvic cavity through a small incision in the navel. Lighting and visualization are greatly enhanced allowing for the use of laser to reduce bleeding. Specialized solutions are also used to prevent tissue drying and for inhibiting adhesions (scarring).

New techniques on the horizon include the use of absorbable shields to protect against adhesion formation. These techniques result in far less damage to adjacent tissues, which in turn results in faster healing, less scarring, less postoperative pain and more rapid return of the woman to her normal activities.

Pelviscopy and its Use

Pelviscopy refers to a special type of operative laparoscopy, in which more extensive procedures are performed. This is done with the aid of magnification provided through the laparoscope lenses, and frequently with the use of video monitoring which allows the surgical assistant to work as one with the surgeon. Currently pelviscopy is used in the treatment of ectopic pregnancy, uterine fibroids, ovarian cysts and tumors, pelvic endometriosis and pelvic adhesions.

Pelviscopy, when used properly, offers numerous advantages. First, an open abdominal incision can be avoided, allowing the procedure to be done on an outpatient basis. There is minimal discomfort and the absence of a visible surgical scar. Most importantly, in many cases the laparoscopic approach produces better results than conventional macro or microsurgery, probably as a result of decreased tissue trauma and less adhesion formation.

Pelvic and Tubal Adhesions

The recent increase in infertility rates can, in part, be attributed to a marked increase in sexually transmitted infections and the corresponding pelvic adhesions and tubal obstructions. Adhesions involving the tubes or ovaries cause infertility by encapsulating the end of the fallopian tube, the ovary, or both, thereby preventing the egg from reaching the tube. Even minimal adhesions may substantially reduce fertility. Pelviscopic surgery is ideal for treating these types of adhesions, because the scarring is less than with open surgery.

Pelvic Endometriosis

Pelvic endometriosis occurs when the lining of the uterus, rather than being shed through the cervix during menstruation, backs up into various pelvic structures. This creates scarring and subtle hormonal changes within the woman. Endometriosis can have significant effects in preventing pregnancy even if the occurrence is very slight.

Laparoscopic surgery is used to treat all stages of pelvic endometriosis, from mild to severe with excellent results. Surgical lasers are frequently used to increase accuracy and decrease adjacent tissue trauma, leading to better postoperative healing and better results.

Reversal of Sterilization

A recent survey indicated that over 12 million people in the United States have been sterilized, and over 60 percent of sterilization procedures are performed on women. Approximately 15,000 to 20,000 of these women (1.5 percent) will want to reverse this procedure due to a renewed desire for children.

Using microsurgical technique, tubal repair can be accomplished with excellent results. An 80 percent term pregnancy rate can be expected if at least 4 centimeters of the fallopian tube remains following the tubal reversal procedure.

In Vitro Fertilization (IVF) and Gamete Intrafallopian Tube Transfer (Gift)

Although laparoscopy has revolutionized many aspects of modern gynecologic practice, some of its applications have been replaced by even newer techniques such as in vitro fertilization. IVF involves removing an egg from the ovary and combining it with active sperm and returning and fertilized egg to the uterus where the fetus can develop. Initially, all egg recovery procedures were performed by laparoscopy. Now, 90 percent of IVF egg recoveries are performed using an ultrasound-guided needle.

For some variations in IVF such as the GIFT procedure (gamete intrafallopian tube transfer) the laparoscope is used not only to recover the eggs from the ovary, but also to transfer the sperm and the eggs back into the ends of the fallopian tube. Likewise, in one of the newer areas of in vitro fertilization, tubal embryo transfer (TET) also known as zygotic intrafallopian tube transfer (ZIFT), the laparoscope is used to place embryos into the ends of the tubes, with excellent pregnancy rates.

While not all women will desire a child or their own, for those who do, it can become of primary importance in their life. For some women, this may be an impossible task without the assistance of modern technology such as gynecologic microsurgery.

While effective in many patients, microsurgery is not for every woman or every problem, but is another of the treatment modalities currently available in today's field of reproductive surgery and gynecology. It is another means of assisting couples in achieving their dream of children and a family.