Assessments of Pelvis and Tubes
Why is this necessary?
All women suffering from sub-fertility require assessment of the uterus, fallopian tubes, ovaries and general structures within the pelvis. The first line least invasive assessment is that performed by an ultrasound scan. This can provide good information regarding the uterus, the endometrium (lining of the womb) and the ovaries. Adjoining structures are only visible if they are very abnormal and not being able to see them does not mean that they are normal.
It is important to rule out significant pathology such as pelvic inflammatory disease, pelvic adhesions or endometriosis before a treatment plan is made as problems in this area would modify how we treat you and will reduce success rates of those treatments that rely on normal pelvis and healthy tubes.
There are two methods:
This is a less invasive investigation performed in outpatients by the radiologists. It involves injection of a radio opaque dye within the uterine cavity and X-ray capture of the flow of the dye within the uterine cavity as well as the fallopian tubes.
It would allow identification of uterine abnormalities and tubal patency related problems.
It will not allow direct visualisation of the fallopian tubes, exclusion of pelvic endometriosis, peri-tubal or peri-ovarian adhesions.
Its risks include bleeding, infection, anaphylaxis to the radio opaque dye and risks associated with X-ray exposure to irradiation. Occasionally the hysterosalpingogram is so painful, (for patients who have not had children in particular) that it cannot be performed.
Laparoscopy & Hysteroscopy
These procedures allow a detailed assessment of the pelvic organs (womb / uterus, ovaries and fallopian tubes). The organs are seen using a telescope and is commonly referred to as a keyhole procedure. This is a more invasive option and requires a general anaesthetic. Patients are admitted for a day case procedure.
This involves passing a fine telescope (hysteroscope) into the womb through the cervix (neck of the womb), allowing inspection of the inside of the womb (endometrial cavity).
This is a conclusive assessment. Sometimes there may be fibroids or polyps within the cavity of the womb that can be removed at the same time as the hysteroscopy is being performed.
The main risk of a hysteroscopy is of bleeding and sometimes the small hysteroscope can perforate through the uterus and this may require the tummy cavity to be opened and very, very rarely a hysterectomy may be required.
Under the general anaesthetic a telescope is inserted through the umbilicus into the abdomen for direct examination of the fallopian tubes, ovaries, uterus and other pelvic structures. This is a more comprehensive and gold standard assessment of the pelvis. hysteroscopy can be performed simultaneously and this allows visualisation of the uterine cavity.
Conditions such as non occlusive tubal disease, peri-tubal and peri-ovarian adhesions and endometriosis, are better diagnosed by this method. Tubal patency can be confirmed in the same way as with HSG on this occasion and photographic capture of the tubes as they fill and spill the dye can be made for a permanent record. If indicated, this route of investigation also allows a therapeutic treatment to be performed at the same time (see below).
Who needs a laparoscopy?
- In infertility patients, we tend to choose this form of assessment when we need to be absolutely accurate and when we suspect from risk factors with in the history that there is the potential of problems such as those detailed below.
- Past personal or partnerâ€™s history of chlamydia infection, TOPs, pelvic surgery.
- For investigations of the cause of pelvic pain, heavy periods, painful periods, inappropriate pattern of bleeding and/or difficulty in becoming pregnant.
- When expensive treatments which also have risks such as hormone injections for induction of ovulation are being considered.
The telescope (laparoscope) is inserted usually just beneath the belly button through a small cut which is about 1cm long. A further 1, 2 or 3 incisions are made lower down in the tummy about 0.5-1cm, through which additional instruments can be inserted in order to enable careful inspection of all areas of the pelvis. When mild problems such as fine scar tissue around the tubes and ovaries, endometriosis of low grade etc. are identified it may be possible to treat them at the same time. Consent is usually therefore taken to allow for these treatments to be given. If more severe problems are identified then various treatment options are discussed with you at a later date and a further operation may be required.
The procedure takes between 20 to 40 minutes usually. Most women are admitted on the day of the operation and they go home later that day.
The small incisions on the skin are usually closed with dissolving sutures placed under the skin and therefore do not need removal. They take 2 to 3 weeks to dissolve and when not under the skin they are sometimes removed after a week, usually by a nurse at your general practitioners surgery. The space in your tummy called the peritoneal cavity is inflated with a gas called carbon dioxide in order to be able to create a space so that organs can be seen apart and carefully inspected. This space also allows for instrumentation.
What are the common problems?
It is quite common for there to be a small amount of bruising and tenderness at the site of incision. It is common for a small amount of gas to remain and for the tummy to feel bloated and distended for a few days. Sometimes you may experience shoulder pain for a few days. In addition, a small amount of fluid is sometimes left within the tummy cavity, which is thought to help with the healing process and to prevent adhesions / scar formation. Sometimes a small amount of this fluid can leak through the incisions in the skin.
It is also advisable not to have unprotected sexual intercourse from the time of your last menstrual period until the time of the laparoscopy, in order to ensure that there is no chance that you could be pregnant when the laparoscopy is performed. Whilst you may not prefer to have the procedure when menstruating, rescheduling surgery at very short notice can mean further delay to you and wastage of the surgical teams availability. As you know we need to minimize the risk of wasting this important NHS resource and to avoid short notice cancellations as far as is possible which cause delays to everybody on the waiting list. It is therefore important for you to know that the procedure is always performed with full sterile precautions and concluded with a pelvic washout. You therefore should not cancel the procedure yourself even if you have started your period.
Please make a note of your last menstrual period so that you can tell the staff when you are admitted to the ward. Usually a pregnancy test is performed before you go to theatre but it will not diagnose a very early implantation.
What are the risks?
It is important to appreciate the risks of all operations, fortunately these are very rare and most operations are carried out without any problems, enabling you to have a diagnosis and be treated within the same day.
The risk of a general anaesthetic in an otherwise fit and healthy person is quite low at 1:10,000.
The main risks of surgery are those of bleeding or damage to the bowel and bladder with the instruments. If such a complication occurs then you will need an operation for repair. The cut made in your tummy at that time will depend upon the nature of the problem and could be across on the bikini line or an up and down cut from the belly button. The risk of requiring a larger operation like this is less than 1%. The risk is increased if you have had previous abdominal surgery, have had peritonitis or are overweight. You should discuss your specific risks relating to your own medical history with your Consultant.
What treatments can be performed at the time of laparoscopy?
This is a condition whereby small amounts of skin like the lining of the womb settles and starts to grow in the pelvic cavity around the ovaries and womb. This condition causes internal inflammation and bleeding with periods which then can lead to pain, formation of scar tissue and affect fertility. There are various grades of this problem. Discrete deposits in early stages can be burnt using diathermy (electro-cautery) at the time of laparoscopy.
Adhesions or scar tissue may result from endometriosis or infection. These can cause the ovaries, fallopian tubes, bowel, bladder and womb to be stuck together. You are not always aware of the infection when it happens until you develop pain and/or other problems such as infertility. Adhesions can be cut at the time of surgery if necessary, or appropriate, but have the risk of developing again. Certain types of fluids can be left within the tummy cavity that may help reduce the risk of them coming back after surgery.
Cysts can occur on the ovary due to a number of causes. These are usually detected by ultrasound scans prior to a laparoscopy. A cyst may be removed using laparoscopic surgery or by an open cut (laparotomy). This will be discussed with you by your Consultant. The first and foremost aim is to be safe, to remove a cyst and preserve normal tissue as well and as much as is possible. Sometime, however, cysts can occupy the whole of the ovary and there is no tissue left to preserve. In this situation, the whole ovary may need to be removed. If an ovary is removed the remaining ovary will usually function to provide a monthly menstrual cycle.
An ectopic pregnancy occurs when a pregnancy develops outside the womb, most commonly within the fallopian tube. This may require surgery to either remove the ectopic pregnancy from the fallopian tube, or remove the entire fallopian tube. The decision as to which operation is most appropriate is made when the laparoscopy is actually performed and the fallopian tube is inspected. In general the surgeon will do as little as needs to be done in order to treat the ectopic pregnancy unless prior discussion with you has taken place with respect to prevention of future ectopic pregnancies or improvement in pelvic health.
We now have good information that suggests that when tubes are chronically inflamed the success rates of IVF are compromised. Therefore in women with tubal disease and swollen tubes (hydrosalpinges) we often recommend salpingectomy before IVF which can be performed laparoscopically except when there are extensive adhesions with bowel involvement. Then the risks of bowel injury are increased and we may prefer to do the operation by the open route which involves a larger cut. The benefits of salpingectomy are greatest when the tubes are swollen and are also full of fluid but there is also a benefit albeit to a lesser degree in women with chronic salpingitis (inflammation of the tubes) but without ultrasonically visible swelling. This is sterilising procedure and future pregnancies will only be possible with IVF. The risk of ectopics is substantially reduced but not eliminated. All patients have to be fully at terms with their infertility before this surgery is booked.
If the tubes have been damaged by past infection or endometriosis, then surgery can be performed to open up the fallopian tubes and try and improve the situation. The results however are extremely poor as open fallopian tubes are not necessarily tubes that will function normally. If any surgery has been performed to the fallopian tubes, there is an increased risk of an ectopic pregnancy with future pregnancies. This means that if you conceive after surgery, it is important to get an early ultrasound scan to confirm the site of the pregnancy.
A laparoscopy may be performed in order to achieve sterilisation of the fallopian tubes. This is usually achieved by placing a Filshie clip across each of the fallopian tubes. This is a metal clip with a locking device that is sealed across the fallopian tube. Once a sterilisation has been performed it should be considered to be permanent. Whilst there are operations that may reverse sterilisation, these have about a 50-60% chance of working and are not funded by the National Health Service. If a pregnancy does occur after a sterilisation, there is also an increased risk of an ectopic pregnancy (see above). Sometimes the clips come off the fallopian tube and the risk of sterilisation failure is approximately 1 in 300 operations. Therefore, if you miss a period and think you may be pregnant, even if you have been sterilised, it is important to have a pregnancy test and if you are pregnant get an ultrasound scan in order to determine the site of the pregnancy. Some women experience a change in the nature of their menstrual periods after a sterilisation operation. This is thought usually to be due to stopping a hormonal form of contraception, which provides an artificial control of the menstrual cycle and thus the nature of the periods after a sterilisation operation are likely to be similar to how your periods would have been had you not been taking any contraception.
This procedure is sometimes performed for induction of ovulation in those women where oral medication such as clomifene citrate and metformin has not been successful. Its mechanism of action is poorly understood. Theoretically drainage of peripherally located old follicles drains the excess precursor hormones from the ovary which may have had a suppressive effect on the development of new follicles. In the medical literature the likelihood of ovulation after such a procedure is approximately 60-70% especially when combined with the use of oral medication. Approximately 60-70% women may then conceive spontaneously. Its useful to perform such a procedure only if tubal function is normal, male sub-fertility has been excluded and there is no other disease with in the pelvis. Bleeding and adhesion formation can occur afterwards and precautions to avoid these are taken routinely after the procedure. One rare complication of this procedure is a reduction in ovarian reserve of eggs and in extremely rare situations even premature ovarian failure has been reported in the medical literature where presumably the process was performed overzealously.
Reversal of sterilization
The procedure of reversal of sterilisation is performed by a cut in your tummy usually made across the tummy on the bikini line. Prior to doing the reversal procedure a laparoscopy is performed to assess the pelvis and see if reversal is likely to have a good result. Doing so avoids making a larger cut in your tummy when success rate is likely to be poor. This can be done either just before the main operation in the same episode or separately in advance of the reversal. Benefit of doing so a single procedure is lower cost, single anaesthetic and one period of hospitalization and recovery. Doing it as two episodes gives you advance information but costs more, you will be admitted twice and will have higher costs. Your consultant will discuss this further.
Unfortunately this too can happen but is very rare. This means that it was not possible to insert the telescope in the abdomen for technical reasons. The risk of this happening is highest when the abdomen is very lax and obese. You will be observed to ensure that attempts to insert the instruments have not caused an injury or a complication. When recovered you will be allowed home and future management will be then discussed.
What happens after the operation?
Your surgeon will come and speak to you before you go home and a follow-up appointment will be made in order for you to be able to discuss the operation back in the clinic. Your general practitioner will also be sent a full summary of your operation.