Fertility Promoting Surgery

Fallopian Tube Blockage

Blockage of the fallopian tube near the uterine end can be relieved by state of the art procedures available at the center. Selective salpingography is a procedure where a tube is placed at the beginning of the fallopian tube and dye is injected to pressure out any debris. If this is not successful, a catheter, very much like that used for heart surgery, is threaded into the fallopian tube to release the blockage. The above procedures can be performed either in the x-ray department or in conjunction with laparoscopy and hysteroscopy in the operating room when other information of the female pelvis is needed. When the blockage can not be relieved by cannulation, microsurgery with resection and anastomosis of the tube is required. The technique of anastomosis is the same as for sterilization reversal and it is a technique that was pioneered at the Center.


Laparoscopic Tubal Sterilization Reversal Update

In 1992, Drs. Koh and Janik presented the world's first laparoscopic microsurgical tubal anastomosis for reversal of sterilization. Since that time, this technique has expanded and a new range of microsurgical laparoscopic instruments have been designed [Koh ultra-microsurgical instruments] by the Storz Company for worldwide distribution.

The doctors continue to lecture and perform demonstrations of their technique internationally, and Dr. Koh was co-chairman of the 1st, 2nd, and 3rd World Conference on Microendoscopy in Sante Fe 1995; San Francisco 1996, Vancouver 1997, respectively. Doctors from around the world who attended the meeting are in the early stages in their development and have started to do some cases in India, Korea, Vietnam, Australia, Europe, and USA.


Update on Endometriosis Treatment by Laparoscopy

The treatment of endometriosis today is NOT hysterectomy.

 Despite the availability of new knowledge from contemporary literature in the last five years, many doctors still mistakenly believe that hysterectomies and oophorectomies are the cure for endometriosis. To underscore this problem, David Redwine, MD, in a 1995 article in Obstetrics and Gynecology, stated "Endometriosis may be unique in that it is the only disease treated by the removal of something else."

In fact, the correct treatment of endometriosis for pain today is the complete excision of the endometriosis, whether it appears on the bowel, ureter, deep in the pelvis or even on the diaphgram. The uterus and ovaries may be removed if there are other indications.

Many women who are treated by hysterectomy / oophorectomy instead of removal of the deep pelvic endometriosis continue to experience pain until these lesions are subsequently removed. The experiences of Drs. Koh and Janik have mirrored that of Dr. Redwine in Oregon, where repeat laparoscopic surgery of such women have revealed endometriosis present on bowel, around the ureter or in other deep areas of the pelvis. In an effort to publicize new understandings of endometriosis, the Endometriosis Association recently celebrated their 15th Anniversary in Milwaukee, where twenty world experts, including Drs. Koh and Janik, were invited to address the international


Ovarian Cysts

Ovarian cysts may be due to new growth (neoplasms), endometriosis, or functional cysts. A particularly unpleasant looking cyst is the dermoid which contains hair and oily material. The correct treatment in the absence of cancer is to remove the cyst while sparing the ovary. Even the very largest cysts can be operated to spare the ovary if expertly approached. At the center, no ovary is ever removed because of a benign cyst. All cystectomies are performed by laparoscopy at the Center.


Uterine Fibroids and Mymomectomy

WHAT ARE UTERINE FIBROIDS?

FIBROIDS ARE TUMORS that arise within the muscle of the uterus forming round masses. Some women have single fibroids as large as a football, others have multiple ( up to 20 or more ) which vary in size from a peanut to golf balls and larger.

Fibroids are named according to their position in relation to the uterine muscle and cavity.

WHAT PROBLEMS DO FIBROIDS CAUSE?

NO SYMPTOMS: Most fibroids up to the size of an orange(12 weeks pregnacy) cause no symptoms. Their mere presence is not a reason to treat them.

SUBMUCUS: They protrude into the uterine cavity and cause menstrual cramps, heavy periods, infertility and repeated miscarriages. The diagnosis is often missed as the uterus is not enlarged and unnecessary hysterectomies have been peformed for these. The diagnosis is made by hysterosonography or hysteroscopy.

INTRAMURAL: These fibroids are within the muscle of the uterus and can be very large. Because they enlarge the cavity of the uterus they can also cause heavy periods. The most common problem is PRESSURE symptoms on the bladder and rectum.

SUBSEROUS: These are external to the uterine muscle and are connected by a thin stalk. They are the least likely to be symptomatic and rarely need removal. TORSION (twisting) is a very rare complication.

DEGENERATION: Rarely there is liquifaction and bleeding within the center causing pain and fever. Infection may also occur. The most common occurrence is during pregnancy. Treatment is never surgery but conservative with fluids, pain medication and antibiotics.

FIBROIDS AND INFERTILITY, MISCARRIAGE

Only submucus fibroids cause repeated miscarriages. Large intramural fibroids may be the cause of longstanding infertility if all other causes have been excluded.

TREATMENT

NONSURGICAL: Fibroids shrink at the menopause to 50% of their size but never go away. GnRh agonists e.g. Lupron, Synarel, Busarelin are medications given by injection or nasal spray that create a temporary menopause allowing shrinkage. However on stopping medication the fibroid regrows to its original size. Therefore longterm treatment is not indicated as these drugs cause severe menopausal symptoms and osteoporosis. They are used for 1-3 months before surgery to reduce the blood loss of surgery.

SURGICAL: The treatment for removing the fibroids from the uterine muscle is known as MYOMECTOMY. It is a specialised operation done by reproductive surgeons who have considerable experience in preserving the uterus for future fertility. Hysterectomy should not be a complication of this surgery in experienced hands. It is important that the uterine lining be not entered to allow normal birth later, and that the muscle is adequately repaired in many layers. This operation is traditionally done through a LAPAROTOMY via a 'bikini' or 'up and down' incision. When the fibroids are less than 5 and less than 18 weeks size LAPAROSCOPIC myomectomy can be performed. There are fewer doctors who can perform this than by laparotomy as the need to accurately suture the muscle laparoscopically is a difficult skill. Inadequate Suturing has led to reports of uterine rupture in pregnancy and labor.

LAPAROSCOPIC MYOMECTOMY: The advantage of this is that patients can go home the same or next day and be back to work in 1-2 weeks. However it is important that the surgery be as complete as by laparotomy or any advantage is lost. Our center has pioneered the technique of VERTICAL DEEP LAYERED REPAIR of the muscle by laparoscopic suturing. This creates a strong repair allowing normal VAGINAL delivery even after removing larger intramural fibroids. The use of an electric morcellator to remove the fibroid tissue in long strips has made the surgery speedier so that 18 week size fibroids can be treated in 2 hours.It does not matter whether the fibroids are removed by laser, harmonic scalpel, knife or electrosurgery. The skill of the surgeron is paramount to results.

MINILAP MYOMECTOMY: This is another technique pioneered at our center where large multiple ( up to 24 weeks ) can be removed through a 2 inch bikini incision. Patients can go home the next day after surgery.

HYSTEROSCOPIC MYOMECTOMY: Submucus fibroids are removed by inserting a hysteroscope through the vagina and an electrical loop is used to removed the protruding part. This is rapid and effective surgery without the need of laparoscopy. Estrogen is used after surgery to promote uterine lining regrowth.


Pelvic Adhesions

Pelvic adhesions can arrive from silent infections (Chlamydia, overt infections, gonorrhea), or from endometriosis, appendicitis, pelvic inflammatory disease, or various pelvic operations. Pelvic infections may result in adhesions alone or adhesions with blockage of the tube (hydrosalpinx). When only adhesions are present without blockage of the tube, division of these adhesions by laparoscopic microsurgery is the most successful means of restoring fertility. Pregnancy rates of 60 to 70 percent within the year can be expected after such treatment and represents the most successful fertility surgery next to tubal anastomosis. At the Reproductive Center, this operation is performed using the KTP laser with ultramicro instrumentation so that the operation is very refined thus minimizing the risk of further adhesions forming because of the operation.