Because endometriosis is a common disease entity among infertile patients with a prevalence of up to 50%, one could argue that without laparoscopy clinical work-ups can not completely rule out all of the causes of infertility. The decision to perform laparoscopy on patients with infertility is very complex owing to a number of factors, such as maternal age, semen parameters, tubal patency, pelvic symptoms, insurance coverage, surgical risks, and availability of surgical expertise.
Endometriosis is one of the most common gynecologic disorders and is significantly more prevalent in the setting of infertility. The prevalence of endometriosis in infertile women ranges from 25% to 50% compared to 5% in fertile women. Successful laparoscopic management of all stages of endometriosis was reported as early as 1986. This has revolutionized the management of endometriosis. The benefits of surgical therapy for infertility associated with endometriosis have been well documented.
For the past three decades, gynecologists have been utilizing the hysteroscope in the office to diagnose a variety of conditions that can be responsible for symptoms such as abnormal uterine bleeding, recurrent miscarriage, infertility, and post menopausal bleeding. The most common lesions found during diagnostic office hysteroscopy include cervical and uterine polyps, submucous myomata, uterine septae, intrauterine adhesions, endometrial hyperplasia and endometrial cancer.
It is advantageous to perform surgery in the least invasive way possible while still getting optimal results. Although I usually prefer to do surgery through a laparoscope rather than through a larger incision, I have felt limited by the lack of wrist-like movements of the instruments. I felt that deeper myomas (that couldn’t be removed by a hysteroscope) were better removed through a regular incision.
It is usually quite simple to find the cause of abnormal menstrual bleeding, although occasionally the cause may not be found. Since abnormal uterine bleeding can be caused by disorders of the uterus, hormone imbalance (usually not ovulating), and pregnancy, it is helpful to look at each area separately. When I see someone for abnormal bleeding, I ask the following questions.
Fibroids are non-cancerous (benign) growths of the muscle wall of the uterus. They are probably responsible for more unnecessary gynecologic surgery than any other condition. Every year a staggering 600,000 American women have a hysterectomy. And about 30 percent of those hysterectomies, 180,000 in all, are performed because of fibroids. For many years gynecologists have surgically removed these growths, often because of fear of the problems they might cause in the future. And those problems are often overstated.
Laparoscopic myomectomy (LM) is a minimally invasive surgical procedure for the removal of uterine myomas. It was first described in the late 1970s by Semm. Subsequently, equipment has been developed to enhance the procedure. LM requires advanced laparoscopic skill and expertise in suturing and tissue removal. Laparoscopic assisted myomectomy (LAM), a procedure that combines operative laparoscopy and minilaparotomy, was described by Nezhat et al in 1994.
The usefulness of hysterosalpingography (HSG) as routine investigation in the fertility work-up prior to laparoscopy and dye had been assessed in a randomized controlled trial. Recruiting subjects to the study was more difficult than anticipated. The objective of this study was to explore possible reasons for non-participation in the trial.
Intracytoplasmic sperm injection (ICSI) is a component of infertility treatment often employed when conventional in vitro fertilization is unlikely to be successful. Despite good clinical results with ICSI, the procedure is typically associated with degeneration of a significant percentage (approximately 10%) of the treated oocytes. The cause of this degeneration remains unclear. Speculation that damage caused by oocyte compression during the injection procedure may be responsible has led to the development of a novel technique known as laser-assisted ICSI.
A Randomised Controlled Trial to Assess the Efficacy of Laparoscopic Uterosacral Nerve Ablation (LUNA) in the Treatment of Chronic Pelvic Pain: The trial protocol [ISRCTN41196151]The LUNA Trial Collaboration
It is usually quite simple to find the cause of abnormal menstrual bleeding, although occasionally the cause may not be found. Since abnormal uterine bleeding can be caused by disorders of the uterus, hormone imbalance (usually not ovulating), and pregnancy, it is helpful to look at each area separately.
"Fibroids" or "uterine myomas (short for leiomyoma)", affect 30% of women. The terms "fibroid" and "myoma" are used interchangeably. Most fibroids do not cause symptoms, and do not require treatment.
Myomectomy is the only surgical treatment of myomas that preserves fertility. The safety of pregnancy after uterine artery embolization has not been established, and pregnancy is impossible after hysterectomy. The average reduction in volume of fibroids after a UAE is 50%, where fibroids that have removed are completely gone.
Endometrial ablation is the removal or destruction of the endometrium (lining of the uterus). Endometrial ablation is an alternative to hysterectomy for women with heavy uterine bleeding who are wish to avoid hysterectomy. Most women who have had a successful endometrial ablation will have little or no menstrual bleeding.
The most important question to ask is whether or not the fibroids need to be treated at all. The vast majority of fibroids grow as a woman gets older, and tend to shrink after menopause. Obviously, fibroids that are causing significant symptoms need treatment. While it is often easier to treat smaller fibroids than larger ones, many of the small fibroids never will need to be treated. So just because we can treat fibroids while they are small, it doesn't follow that we should treat them. The location of the fibroids plays a strong influence on how to approach them. A gynecologist experienced in the treatment of fibroids can help you determine if they need to be treated.
Fibroids are non-cancerous (benign) growths of the muscle wall of the uterus. They are probably responsible for more unnecessary gynecologic surgery than any other condition. It is a staggering number, but about 600,000 American women have a hysterectomy every year. And about 30% of those hysterectomies, 180,000 in all, are performed because of fibroids. For many years these growths have been surgically removed, often because of fear of the problems they might cause in the future. And, those problems are often overstated. While approximately 30% of all women will have fibroids during their lifetimes, the vast majority of these women will never have symptoms and will never require treatment. And, for the rare patient that does have problems, there are a number of sound and effective options available. Hysterectomy should be the solution of last resort.
The terminology used to describe pap smear results has changed over the past few years, leading to confusion about what the results of your pap smear actually mean. Originally, pap smears were divided into 5 "classes" based on what the cells looked like to the pathologist. Class I was normal, while class II cells appeared a little irregular to the pathologist, usually representing bacterial infection. Class III and IV pap smears suggested that dysplastic cells were present, and further testing needed to be done. Class V usually meant cancer.
Over the past decade, a technique has been developed that can reduce or stop your periods without a hysterectomy. This surgery can be done in women who have flooding either with or without fibroid tumors. Dr. Dott was one of the surgeons who introduced this minimally invasive procedure in Atlanta. He has performed this procedure many times and is certified by the Accreditation Council for Gynecological Endoscopy in Advanced Hysteroscopic Surgery. He has taught this procedure in training institutions both in the United States and Russia.
Chronic pelvic pain (CPP) is often accompanied by poorly defined symptoms and a sense of failure by both doctor and patient.
Laparoscopy, looking inside the abdomen through a tube placed through a small incision, is a procedure commonly used by gynecologists to diagnose and treat a number of medical conditions. Since the early 1900's when rudimentary laparoscopes were used to visualize, but not treat, abdominal diseases, advancements in this technique have led to the ability to perform complex surgical procedures through a few small incisions, rather than the larger incisions used in the past.
A patient of mine who regularly reads the forum recently asked me about board certification for Ob/Gyn doctors. She explained that there is a lot of confusion about this issue, and that many women's magazines and other media tell women to always seek out the services of an Ob/Gyn who is board certified. So, this looked like a good opportunity to review the board certification process.
Uterine fibroids ( "fibroid tumors";" leiomyoma"; "myomas") are benign, (non-cancerous) growths present in about 30% of women over the age of 30. They are usually detected on pelvic examination, which may reveal the uterus to be enlarged and/or irregular in configuration. The vast majority of cases are absolutely silent and cause no symptoms. The size of a single fibroid may be smaller than a pea, or larger than a melon. In a given patient, there may be a single fibroid, or multiple fibroids of varying size. In the latter situation, the summation of the fibroids of varying sizes will lead to an aggregate size increase.
Pelvic adhesions cause many problems for millions of women. From obstructed tubes associated with infertility, to pelvic tenderness, and painful intercourse, to chronic pelvic pain. Curiously, adhesions can be very extensive, yet relatively silent. They may remain silent indefinitely, or long after the causative event, become symptomatic. The causes of adhesions are multiple but basically the tissue irritation that produces the adhesive process arises from an inflammatory event, or from trauma (i.e. post surgical).
"Abnormal Uterine Bleeding" or "AUB" is a relatively common condition. Normal menstrual flow produces less than 3 ounces of blood, in a maximum of 7 days. AUB patterns are characterized by flows that are heavier, and/or more prolonged or more frequent than a 21-28 day interval. AUB can cause anemia, embarrassment, or marked inconvenience. It has been said by many so afflicted women-" I have to plan my life around my period".
Fibroids and Hysterectomies used to go together like Rogers and Hammerstein. Not anymore. If your physician recommends removing your uterus as the most effective treatment for severe fibroids without first considering less invasive therapies, start singing another tune and get a second opinion!
