Intrauterine surgery is any surgical procedure, which is performed in uterus. Evaluation of the uterine cavity is a basic step in female infertility workup. Classically, hysterosalpingography (Pic. 1; a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes) and transvaginal sonography (an ultrasound through vagina) are most commonly used for this purpose. Hysteroscopy (Pic. 2; the inspection of the uterine cavity by endoscopy with access through the cervix), however, is considered the gold standard for diagnosis of intrauterine lesions.
After evaluation of the uterus and after finding the cause of infertility, there are several condition, when intrauterine surgery is needed:
Uterine septum
A uterine septum (Pic. 3) is a form of a congenital malformation where the uterine cavity is partitioned by a septum; the outside of the uterus has a normal typical shape. The wedge-like partition may involve only the upperr part of the cavity resulting in an incomplete septum or a subseptate uterus, or less frequently the total length of the cavity (complete septum) and the cervix resulting in a double cervix. The septation may also continue down into the vagina resulting in a double vagina.
The septate uterus is the most common structural uterine anomaly associated with the highest incidence of reproductive failure. Hysteroscopy and laparoscopy remain the gold standard for diagnosing the septate uterus.
A septum can be resected with surgery. Hysteroscopic removal of a uterine septum is generally the preferred method, as the intervention is relatively minor and safe in experienced hands.
It is not considered necessary to remove a septum that has not caused problems, especially in women who are not considering pregnancy.
Uterine fibroids
Uterine fibroids, also called myomas (Pic. 4), are benign smooth muscle tumors of the uterus. The exact cause is unclear. However, fibroids run in families and appear to be partly determined by hormone levels. Diagnosis may occur by pelvic examination or medical imaging.
Treatment is typically not needed if there are no symptoms. If greater symptoms are present, surgery to remove the fibroid or uterus may help.
Myomectomy is a surgery to remove one or more fibroids. It is usually recommended when more conservative treatment options fail for women who want fertility preserving surgery or who want to retain the uterus.
A myomectomy can be performed in a number of ways, depending on the location and number of lesions and the experience and preference of the surgeon. Either a general or a spinal anesthesia is administered. There are three types of myomectomy:
Traditionally a myomectomy is performed via a laparotomy with a full abdominal incision. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed.
Recovery after surgery takes six to eight weeks.
Laparoscopy is a surgical procedure that uses a thin, lighted tube called a laparoscope inserted through an incision in the abdominal wall. Using the laparoscopic approach the uterus is visualized and its fibroids located and removed. Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy.
Laparoscopic myomectomy is not generally used on very large fibroids.
A fibroid that is located in a submucous position (that is, protruding into the endometrial cavity) may be accessible to hysteroscopic removal.
Recovery after hysteroscopic surgery is but a few days.
Excessive bleeding
Endometrial ablation (Pic. 5) is a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus. This technique is most often employed for people who suffer from excessive or prolonged bleeding during their menstrual cycle but cannot or do not wish to undergo a hysterectomy (removal of uterus). The procedure is most commonly done on an outpatient basis.
Endometrial polyps
Endometrial polyps are benign localized lesions of the endometrium, which are commonly seen in women of reproductive age.
Observational studies have suggested a detrimental effect of endometrial polyps on fertility. The natural course of endometrial polyps remains unclear. Expectant management of small and asymptomatic polyps is reasonable in many cases. However, surgical resection of endometrial polyps is recommended in infertile patients prior to treatment in order to increase natural conception or assisted reproductive pregnancy rates.
Endometrial polyps can be diagnosed by ultrasound, hysterosonography, hysterosalpingography, endometrial biopsy, and uterine curettage, but diagnostic hysteroscopy is considered the method with the greatest sensitivity and specificity.
Hysteroscopy polypectomy remains the gold standard for surgical treatment. Conventional hysteroscopic polypectomy performed in an operating room, requires cervical dilation and anesthesia, which increases the risk of complications. After the 1990´s, the development of hysteroscopes with a smaller diameter, continuous flow and accessory working channels enabled the use of surgical instruments to treat uterine conditions during diagnosis, such as outpatient polypectomy, without the need for cervical dilation and anesthesia.
Symptoms
Uterine septum
Uterine septum is very often asymptomatic. The only way how it can influences woman’s life is the problem with conception or it can cause recurrent pregnancy lost.
Uterine fibroids
Fibroids, particularly when small, may be entirely asymptomatic. Symptoms depend on the location and size of the fibroid. Important symptoms include abnormal uterine bleeding, heavy or painful periods, abdominal discomfort or bloating, painful defecation, back ache, urinary frequency or retention, and in some cases, infertility.
There may also be pain during intercourse, depending on the location of the fibroid.
During pregnancy, they may also be the cause of miscarriage, bleeding, premature labor, or interference with the position of the fetus.
In cases of intercurrent uterine fibroids in infertility, a fibroid is typically located in a submucosal position and it is thought that this location may interfere with the function of the lining and the ability of the embryo to implant. Also, larger fibroids may distort or block the fallopian tubes.
Excessive bleeding
Excessive bleeding can occure during menstruation or between the periods. Sometimes due to blood loss, women can feel tired, sleepy, exhausted and look pale.
Endometrial polyps
Some of women with uterine polyps do not have any symptoms at all. Others can suffer from irregular menstrual bleeding, bleeding between periods, heavy excessive menstrual periods, after menopause sometime women start to bleed again due to endometrial polyps.
Associated diseases
Complications
Mild complications of the surgery include the possibility of significant blood loss leading to a blood transfusion, the risk of adhesion or scar formation around the uterus or within its cavity.
Although uncommon, the procedure can have serious complications including:
It may not be possible to remove all fibroid lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42-55% of patients undergoing a myomectomy.
It is well known that myomectomy surgery is associated with a higher risk of uterine rupture in later pregnancy. Thus, women who have had myomectomy (with the exception of small submucosal myoma removal via hysteroscopy, or largely pedunculated myoma removal) should get Cesarean delivery to avoid the risk of uterine rupture that is commonly fatal to the fetus.
Risk factors
Uterine septum
There are no known risk factors of uterine septum.
Uterine fibroids
Risk factors of uterine fibroids include obesity. The risk of myomas increased 21% with each 10 kg increase in body weight and with increasing body mass index.
Several studies reported a rapid increase of fibroid incidence after the age of 30. This could be the result of time-related hormonal changes or an enhanced symptomatology from already existing fibroids. Furthermore, the high incidence of fibroids in the perimenopausal period could be responsible for increasing gynecologic surgery rates in women who have completed the childbearing period.
An early menarche, before the age of 10, has been found to be a risk factor for uterine myomas, while a menarche over the age of 16 seems to decrease the same risk.
Excessive bleeding
Several conditions can cause excessive menstrual bleeding such as hormonal imbalance, dysfunction of ovaries, uterine fibroids, polyps, adenomyosis, intrauterine device, cancer, inherited bleeding disorder, also medications or medical conditions such as liver or kidney disease.
Endometrial polyps
Endometrial polyps occure more often in perimenopausal or postmenopausal women. Also woman with high blood pressure and obese are at higher risk.
Prevention
Intrauterine surgery cannot be prevented.
Uterine factors can be found in only 2 to 3% of infertile women, but intrauterine lesions are much more common in this setting (40–50%). These lesions can compromise spontaneous fertility as well as reduce pregnancy rates in assisted reproduction. Published observational studies suggest increased pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum, or intrauterine adhesions, which can be found in 10% to 15% of women seeking treatment for subfertility.
Several studies have shown that submucous fibroids are associated with infertility, probably as a result of decreased implantation. Some studies have also shown that submucous fibroids are associated with recurrent spontaneous abortions. However, in many cases the infertility preceded the fibroids and the fibroids have grown because of incessant ovulation. There may also be abnormalities of tubal motility or tubal obstruction based on the location of the fibroid.
Hysteroscopic removal of a uterine septum
Some study have shown, that women who undergo a hysteroscopic resection of a uterine septum demonstrate a decrease in miscarriage from 80% to 17% and an increase int the live birth rates from 18% to 91%.
Myomectomy
Myomectomy can improve the chance of having a baby. Sometimes it is neccessary to choose a Caesarian section for delivery after the surgery.
Endometrial ablation
After an endometrial ablation it is still possible to get pregnant, because the ovaries are functional. But the chance of embryonal implantation is decreased. It is because the endomentrium where the embryo nest is destroyed.
It is not recomend to try to concieve right after the procedure, but in the future, it is still possible to get pregnant.
Hysteroscopy polypectomy
Some studies have shown that hysteroscopic polypectomy of endometrial polyps improve pregnancy rates in previous infertile women with no other reason to explain their infertility.
