Case: 32 year old G1 P1 with a history of chronic midline pelvic pain that increases when there is a full bladder (just prior to urination), status post Cesarean Section for fetal distress in labor, and slowly progressive right greater than left sided dysmenorrhea. At operative laparoscopy, extensive thick pelvic adhesions between the bladder, uterus and abdominal wall are identified yet a clear tissue plane for dissection cannot be established with certainty. Endometriosis on the right greater than left side of the pelvis is easily ablated (removed).
Question: Should the surgeon attempt a lysis of the thick bladder adhesions despite poor visibility and orientation since this woman has significant urological symptoms?
Answer: The decision on how aggressive to be during surgery depends on many different variables.
Surgeons should reflect on their surgical skills and they should only offer to perform elective surgery within the area of their particular expertise and experience.
The patient should assess the impact of the “problems” or symptoms on her daily activities and discuss with her surgeon the level of aggressiveness and the level of surgical risk that she would be willing to accept.
A detailed preoperative discussion should ideally take place between the surgeon and the patient before elective surgery including a review of the likely surgical findings, the surgical and the non-surgical treatment alternatives, and the risks and the potential benefits of surgery.
After a complete preoperative discussion the surgeon should have a good idea of how aggressive an approach the patient would like. Also, the patient should have an idea of the alternative approaches with their associated risks and benefits.
Case: 31 year old G0 with a history of regular menstrual intervals every 28-29 x 3-4 days, a normal hormone evaluation, a normal hysterosalpingogram (normal uterine cavity with bilateral tubal patency), a normal postcoital test, and a husband with a normal semen analysis undergoes a pelvic evaluation (laparoscopy and hysteroscopy) to determine and treat a possible pelvic factor (such as subtle irregularities of the uterine cavity, endometriosis or pelvic adhesions). The findings at pelvic evaluation were completely normal so treatment for “unexplained infertility” using menotropin controlled ovarian hyperstimulation (with either intrauterine insemination or In Vitro Fertilization) was suggested.
Question: Was it necessary to perform a pelvic evaluation prior to treatment with menotropins?
Answer: If the initial nonsurgical infertility evaluation is completely normal then I generally suggest a pelvic evaluation to identify and treat any remaining known causes of subfertility.
It is currently (2002) not possible to reliably assess endometriosis or pelvic adhesions with any noninvasive (radiologic) test. If these conditions are adequately treated then there may be a significant enhancement of reproductive potential (fertility). Therefore, if the initial noninvasive infertility evaluation does not suggest a treatable cause for infertility then I suggest looking for a treatable cause with the minimally invasive surgery (pelvic evaluation).
Occasionally, a couple will request menotropin treatment for controlled ovarian hyperstimulation prior to a pelvic evaluation.
I generally discourage this treatment alternative since the menotropin cycles have their own set of risks and they have a marked reduction in success (pregnancy) if there is coexisting pelvic disease.
A pelvic evaluation is not absolutely necessary if the couple wants to proceed directly to In Vitro Fertilization (IVF) since the eggs are retrieved from the ovaries and the fertilized eggs are then replaced into the uterine cavity to “bypass” many coexisting pelvic factors. This is often an expensive alternative and does not provide an opportunity to repair the cause of the subfertility.
A thorough preoperative consultation should review the rationale behind the diagnostic and treatment alternatives so that the couple is comfortable that they are proceeding in a reasonable direction and manner regardless of outcome.
In the situation discussed in this case example, the couple should feel confident that they are proceeding to menotropin therapy after a thorough diagnostic battery of tests, all of which were normal.
Case: 33 year old G0 with a history of bilateral (left and right) blocked dilated fluid filled fallopian tubes (hydrosalpinges) on hysterosalpingogram is scheduled for pelvic evaluation and consideration of surgical repair of the tubes to enhance fertility (reproductive potential).
Question: Can all blocked fallopian tubes be repaired back to their “normal condition”?
The usual indication for a surgical repair of hydrosalpinges is to enhance reproductive potential (rather than pain management, drainage of a potentially infected collection of fluid, etc).
The degree to which fertility is restored after a surgical repair of the fallopian tubes generally depends primarily on the amount of damage that has occurred prior to the repair.
If the fallopian tubes are completely blocked and dilated then the prognosis is roughly correlated to the degree of dilatation and the appearance of the inner lining of the tubes (endosalpinx). If the fimbriae (finger like structures at the opening of the tubes that help to “catch” the eggs) of the fallopian tubes are struck together (via fimbrial agglutinations) then the fimbriae can usually be separated from one another and there is often at least partial restoration of function.
It is difficult to advise a couple preoperatively on the prognosis of surgery based solely on the findings from a hysterosalpingogram. The degree of dilatation of the fallopian tubes and the radiological appearance of the endosalpinx (presence or absence of rugae or folds) provide some information that is useful.
The surgeon and the (fertility seeking) couple should discuss the extent of the surgery that they desire. Specific guidelines may be reviewed concerning when a removal of the fallopian tubes versus a repair of the tubes would be suggested and performed. This discussion would ideally take place prior to the surgery so that all involved parties are comfortable with the possible surgical alternatives.
Case: 24 year old G0 with the onset of her LMP 13 days ago, regular menstrual intervals every 27-28 x 3-4 days, sudden onset of severe right sided pelvic pain while resting on a bench in the park, stable hemodynamically (heart rate and blood pressure normal and stable, urine output adequate, serial blood counts with stable hemoglobin and hematocrit), afebrile (without fever), and without a recent history of trauma. The pain slowly progressed over the following 1-2 days and a pelvic ultrasound revealed a normal uterine contour, a normal appearing left ovary with small simple cysts consistent with functional (follicular) cysts, a normal appearing right ovary with a 28 x 34 mm diameter complex ovarian cyst consistent with a corpus luteum cyst, and a small amount (about 8 mL) of free fluid in the cul de sac behind the uterus.
A gynecologist was consulted through the local hospital’s emergency room and he suggested a laparoscopy to identify and treat the cause of the pain. The woman accepted the recommendation and was told postoperatively in the recovery room that her right ovary was removed since there was a bleeding 2 cm diameter ovarian cyst. The pathology report for the cyst returned as a corpus luteum cyst.
Question: Should the surgeon have specifically discussed with the patient the possibility of the need to remove an ovary?
Answer: An informed consent for surgery generally involves a detailed discussion of the risks, benefits and alternatives of the surgery.
In a preoperative consultation the surgeon can review the likely surgical findings and inform the patient of possible unforeseen findings.
When laparoscopy is the intended route of surgery a basic review of the conditions under which a laparotomy (larger abdominal incision) might be necessary or desirable is suggested.
If a hemorrhagic ovarian cyst is likely to be encountered then the surgeon’s ability to remove the cyst wall (and control the bleeding) versus the removal of an entire ovary should be discussed with the patient.
Acceptance of a surgical treatment plan is more likely when a thorough discussion of the risks, benefits and alternatives for surgery are reviewed preoperatively. If the possibility of an oophorectomy (removal of an ovary) or hysterectomy (removal of a uterus) were not discussed prior to surgery, then many women would be very upset with their surgeon if they discovered postoperatively that such extensive surgery was in fact required.
Case: 27 year old G0 with a known history of a fibroid uterus and an abnormal hysterosalpingogram (bilateral tubal patency but a 2cm diameter rounded filling defect in the uterine cavity) is undergoing a pelvic evaluation (laparoscopy and hysteroscopy) as part of her infertility workup. There is a 6 x 7 cm subserosal leiomyoma (fibroid) projecting posteriorly into the cul de sac of Douglas (behind the uterus) that acutely displaces the uterine cavity anteriorly (toward the abdominal wall). The cervical dilators are rigid (metallic) and relatively straight (slightly curved) so that they cannot readily negotiate the acute flexion of this (displaced) uterine cervix and cavity.
Question: How can the large rounded filling defect seen on hysterosalpingography be further assessed and treated if the cervix cannot be dilated? In these sorts of situations, should difficulty with operative hysteroscopy be anticipated and discussed with the patient preoperatively?
Answer: The rounded filling defect identified using hysterosalpingography (HSG) is large (from a fertility point of view) and most likely represents either a fibroid (overgrowth of the smooth muscle that makes up the wall of the uterus) or an endometrial polyp (organized overgrowth of the endometrial lining of the uterine cavity). Occasionally, a blood clot will present as a round filling defect on HSG and this will resolve spontaneously.
The surgical removal of a 2 cm submucosal leiomyoma (fibroid) or 2 cm endometrial polyp is generally most easily and most safely accomplished with operative hysteroscopy. The operative hysteroscopes (able to remove large filling defects) and resectoscopes are generally straight and rigid (non flexible). Therefore, these scopes may not be able to enter the uterine cavity when the cavity is acutely displaced within the pelvis or the cervix cannot be dilated sufficiently.
The large subserosal myoma may be able to be removed relatively easily with either a laparoscope (when the fibroid has very little investment into the wall of the uterus) or via laparotomy (the larger abdominal incision). If the large posterior fibroid is removed, then the uterine cavity often will return to a normal position within the pelvis. This change in the position of the uterus may allow the cervix to be dilated and the operative hysteroscope to be placed through this dilated cervix into the uterine cavity.
If the posterior fibroid is significantly growing within the wall of the uterus then a laparotomy is generally required to remove the myoma (myomectomy). In this situation, the cavity of the uterus may be entered during the myomectomy (surgical removal of the fibroid) and the filling defect within the cavity can then usually be removed through this open uterine wall.
A preoperative MRI exam of the uterus can often delineate the position of the fibroid within the uterine wall and pelvis quite clearly. If an MRI were performed prior to the surgery, then this would then allow the surgeon to discuss the various treatment options with the patient before surgery. Generally, it is optimal to discuss surgical options in as much detail as possible prior to surgery so that there is little room for misunderstanding or confusion.