1)Uterus & hysteroscopy
Although congenital abnormalities in the uterus do not normally cause infertility they sometimes cause problems during a potentially subsequent pregnancy. Therefore, the potential risks arising from them should be analysed in detail before starting any fertility treatment. Accordingly, if the uterus has fibroids which are in contact with the endometrial cavity and affect its shape, they should be removed hysteroscopically (if they are less than 2.5 cm in size).
Hysteroscopy is a simple procedure where a thin instrument with a hidden camera is inserted through the cervical canal into the uterine cavity and removes any endometrial malformation that needs to be removed, usually by diathermy.
Another indication for hysteroscopy is a history of uterine injuries, such as endometrial scratching, miscarriages, or interrupted pregnancies. These situations are usually associated with the formation of adhesions within the endometrial cavity which may prevent the embryonic implantation endometrium onto the endometrial surface. At the same time, according to recent announcements of the European Society for Human Reproduction (ESHRE), it seems that both in terms of IVF and natural conception, the conception rates are increased even after a simple hysteroscopy without any surgical manipulation involved.
Laparoscopy is another surgical treatment of the uterus that is applied in cases with presence of one or more fibroids that are bigger than 5 cm in size. The indication for laparoscopy is challenging because basically the decision of the treating physician is based on the location of the fibroid, the symptoms it causes to the woman and the presumed condition of the uterus after the surgery. However, the fibroid removal operation should be performed by laparoscopy rather than laparotomy, by all means, as it is proved that laparoscopy causes fewer adhesions and allows easier natural conception later on. Contrary to what is widely believed, neither the size nor the number of fibroids is an indication for open surgery except some very extreme cases. Personally, I’ve performed a laparoscopic removal of a fibroid,18 cm in size!
2) Fallopian tubes and ovaries
Microsurgical repair of fallopian tubes
Microsurgical repair of the fallopian tubes has quickly given way to assisted reproductive methods due to the increased likelihood of recurrence that can follow a surgery and the increased success of IVF methods. However, in cases where somebody lacks the means to go through IVF, surgical tubal ligation is an excellent solution.
Ηydrosalpinx
A hydrosalpinx is a condition that occurs when a fallopian tube is blocked on the ovarian side and this can be visualised in a salpingogram, since the fallopian tube is being internally distended by fluid and forms a sausage-like shape.
The necessity of surgical removal or ligation of a hydrosalpinx, is beyond any doubt, whether spontaneous conception is attempted or most importantly if IVF is performed. The removal of the hydrosalpinx is necessary because the inflammatory fluids contained within a hydrosalpinx leak in small quantities towards the uterus and the endometrial cavity, and they could prevent the embryonic implantation, no matter how good the embryonic quality may be.
