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Surgical Correction of Infertility

Introduction


Many causes for infertility can be corrected by surgery. They may be congenital anomalies of the uterus, fibroids in the uterus, endometriosis, tubal blockage, etc. The Center specializes in surgical correction of these anatomic anomalies including robotic surgery.


1. Hysteroscopy


Hysteroscopy is a procedure by which a camera is introduced into the uterine cavity through the cervix to assess the cavity. A simple hysteroscopy can be done in the office under local anesthesia, while an operative hysteroscopy may be done under anesthesia in the hospital or surgery center. Conditions like congenital anomalies of the uterus (e.g. uterine septum) and fibroids pushing into the uterus can be removed by operative hysteroscopy. A uterine septum can cause infertility, recurrent pregnancy loss, or recurrent implantation failure after embryo transfer. Hence, it is prudent to remove the septum before treatment to increase success. Click the link to see a resection of uterine septum performed by Dr. Jacob, Medical and Program Director of the Center. Similarly fibroids that are pushing into the cavity of the uterus can cause infertility and recurrent miscarriages. They are also removed using hysteroscopicmorcellators.


2. Robotic Myomectomies


Fibroids of the uterus can be a cause of infertility. It is reported that one out of five women have at least one fibroid in the uterus,the majority of which have no effect on fertility. But a significant number of patients with infertility have fibroids in their uterus. Previously it was thought that only fibroids pushing into the cavity of the uterus have any role in infertility. Recently, a large scale study of patients with uterine fibroids undergoing IVF treatment showed that there was 21% reduction in live births when the patient has fibroids compared to patients without fibroids. At the Center we strongly believe that myomectomy should be done prior to IVF treatment, if the fibroid is larger than the size of the uterus and/or if the blood flow to the fibroid is more than half the total blood supply to the uterus. At the Center we specialize in doing complex myomectomies including large fibroids which weigh more than 2000 grams. These complex surgeries are done using the DaVinci Robotic System. Many patients have already conceived spontaneously after robotic myomectomies. Please click the link to see complex robotic myomectomies performed by Dr. Jacob.

Robotic myomectomy with in-situ “remote morcellation” of fibroids total weight 1300 grams. Patient was a 29 year old female with 32 weeks size uterine fibroids.



3. Robotic Surgery for Advanced Stage Endometriosis.


Endometriosis is a condition where the endometrial tissue is growing outside the normal uterine cavity and is a cause of infertility. In addition to causing tubal disease by scarring and involvement of the ovary resulting in destruction of the ovaries, endometriosis is associated with poor oocyte quality and abnormal embryo development resulting in reduced pregnancy and increase miscarriage. The usual symptoms of the disease are pain with intercourse, post-coital ache, severe pelvic pain affecting quality of life, infertility and chocolate cysts on the ovaries found on routine examination. Endometriosis also is implicated in impaired embryo implantation probably due to absent or reduced expression of biomarkers and altered estrogen receptor pathway. The disease is classified based on the severity of the condition from stage I to stage IV. Interestingly while the classic lesions of flame shaped lesions, power burn lesions and peritoneal window can be seen on laparoscopy, close to 50% of the lesions are colorless and are missed at laparoscopy. At the Center, Dr. Jacob and team have expertise in resection of advanced stage endometriosis using robotic assisted surgery and using “fire fly”. See the video of Robotic Resection of Endometriosis using “fire fly”.



4. Robotic Microsurgical Tubal Reversal Surgery


Tubal factor infertility is a common cause of infertility. Historically, IVF was the treatment option for these patients where the fallopian tubes are bypassed by retrieving the eggs directly from the ovaries, fertilizing them in the incubator with sperms and transferring the resulting embryos back into the uterus. An alternative to IVF is correcting a block in the tubes whether caused by congenital blockage of the tubes or after tubal ligation (most common), using tubal microsurgery. Traditionally, tubal reversal surgery is performed after placing a small incision in the lower abdomen called “mini-laparotomy” and repairing the blockage using an operating microscope. These procedures had a success rate of around 50% recanalization. Recently, the same procedure can be done robotically with a much higher success rate of 89%, probably due to the lack of incision thus less chance of adhesions, 3D view of the operating site and better approximation of the cut ends of the tube using the DaVinci robot.

At the Center, we have specialized in doing robotic assisted microsurgical tubal reversal. Here you can see such a procedure where a 1 cm mass blocking the tube is removed and the tube is repaired with restoration of tubal patency.

At The Center for Reproductive Medicine and Robotic Surgery(CRMRS) we provide private, professional and compassionate fertility care. Dr. Jacob and our reproductive team provide a very personalized approach, from diagnostic assessment and early intervention through high-tech procedures like In Vitro Fertilization (IVF), and Intracytoplasmic Sperm Insertion (ICSI), intrauterine insemination (IUI) and Pre-Implantation Genetic Testing – Aneuploidy (PGT-A).

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