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Reproductive surgery is a subspeciality that treats anatomical abnormalities
interfering with normal reproductive function. The body, on injury, makes new
tissue, including scar tissue as part of the healing process. Unfortunately,
this natural defence can work against us. Surgery, meant to treat a problem,
can create more problems. Scar tissue (adhesions) that form can stick to the
normal tissue around it, pulling on it and disturbing the normal anatomy and
function of the structures involved. Reproductive surgeons use meticulous
surgical technique to decrease the formation of pelvic adhesions
postoperatively to obtain optimal results.
Reproductive surgeons use Microsurgery or Endoscopic Surgery to treat the
following conditions
FEMALE
The following are the surgical procedure for female infertility :-
Fallopian Tube Sterilization Reversal (Microsurgical tubal
reanastomosis)
Tubal ligation is a permanent form of contraception which will not allow you to
change your mind and attempt pregnancy unless you undergo another major
surgical procedure. The best results are obtained with microsurgery, requiring
3-4 days of hospitalisation, and a scar similar to a caesarian section
This operation is known as Microsurgical tubal reanastomosis or a Microsurgical
reversal of tubal sterilization. The surgery is considerably more complicated
than the operation performed for the sterilization and may take from one to two
hours to perform. This procedure employs the use of very fine microsutures to
carefully join the tubes back together. It is necessary to use an operating
microscope to adequately visualize the tubal anatomy and gentle tissue handling
to minimise scar formation.
The success of this type of surgery is dependent upon several
factors, most importantly, the expertise of the surgeon. The other factors
relate to where and how the sterilisation procedure has been performed. If the
sterilisation is done in the isthmic or narrow part of the tube using a clip,
band or bipolar cautery, then pregnancy rates of 80- 85% can be expected. The
length and the anatomy of the tube remaining is determined by reviewing the
operative report from the sterilization operation or from a
pre-operative diagnostic laparoscopy . If the surgery involves removing
more than ˝ of the broader part (ampulla) of the fallopian tube or the terminal
end (fimbria) of the fallopian tube then the chances of getting pregnant after
this operation would be poor, and the patient would more likely achieve
pregnancy by undergoing In Vitro
Fertilization (IVF).
- Mid Tubal Blocks
The treatment of choice in this situation would be
Microsurgical tubal reanastomosis.
- Cornual Block
The cornua is the point where the tube joins the uterus and is the narrowest
part of the Fallopian tube.
Hysteroscopic/ Laparoscopic Fallopian
tube catheterisation or fluoroscopy guided cornual cannulation is the
procedure of choice to overcome the block and ‘open’ the tube, as very often, a
cornual spasm or menstrual debris near the cornua may mislead the surgeon into
diagnosing a cornual block.
However, if there is a pathology at the cornua,
Microsurgical tubal reanastomosis. is a viable option if
In Vitro Fertilization (IVF) is not acceptable.
- Hydrosalpinx
- Adhesiolysis
- Uterine Fibroids
- Endometriosis
MALE
The following are the surgical procedure for male infertility :
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Vaso-Vasal Anastomosis (V.V.A.): A VVA is performed to reverse
a vasectomy. This is a microsurgical procedure with a very high success rate.
When the VVA is done within 5 years of the vasectomy the chances of success are
over 95%. When the duration since the vasectomy is over 10 years there is a
possibility of damage due to back pressure and the success rate drops. However,
we have successfully reversed vasectomies done over 25 years ago. PESA or
TESA
ICSI are the other options available.
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Vaso-Epididymal Anastomosis (V.E.A.): Some men have normal
sperm in their testes but have no sperm in their semen due to a block in their
epididymis (the tube that connects the testes to the vas). These men can be
helped by a VEA which would bypass the block and allow them to achieve normal
sperm counts. The surgery is performed under an operating microscope that
magnifies the structures up to 25 times. The vas is rejoined to the tiny
epididymal tube (0.3 mm in diameter) above the level of the block, thus
bypassing the obstruction and allowing sperm to come out through the natural
pathway. Because this is such a delicate procedure the tube can get blocked
again during the healing phase. Hence, the success rate of the procedure is
between 40- 70% (depending on the extent of the block) Also, it can take up to
one year after surgery for the sperm count to reach normal levels. Hence, a VEA
is ideal for young couples, while older couples are better off with epididymal
sperm aspiration (PESA) and
ICSI which offers a quicker result.
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Varicocelectomy: A varicocele is a dilatation of the veins of
the testes. It occurs when the valves in the testicular vein do not function
properly, allowing blood to flow down to the testes (instead of towards the
heart). As a result there is congestion of blood around the testes and the
local temperature rises. Some men appear to have no deleterious effect due to
the varicocele and have normal sperm counts, while in other cases the testes
may become small and normal sperm parameters may be affected, resulting in
infertility. The results after surgery to cure a varicocele are unpredictable-
some experts state that varicocele surgery confers no benefit while others
claim that surgery can benefit 70% of those who are operated. The safest
technique is microsurgical varicocelectomy in which the varicocele is operated
upon through a small incision in the lower abdomen and an operating microscope
is used to identify and divide all the malfunctioning veins. This is a minor
procedure needing just a day's hospitalization and a few days rest thereafter.
Improvement can be expected in 3 - 6 months. If there is no result in that time
then IUI or
ICSI would be required.
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