Gynaecological endoscopy is a modern discipline of doing surgery which uses optical instruments specially designed to help diagnose the most frequent female disorders and pathologies such as some infertility problems, small vaginal hemorrhages or endometrial polyps among others. Gynaecological endoscopy employs hysteroscopy and laparoscopy for these purposes. Gynaecological endoscopy nowadays widely used for the benefit of the patient because of important technical advances, along with the sophistication and the miniaturization of the equipment used.
Hysteroscopy is an incision-free procedure that helps visualize the interior of the uterine cavity or uterus. In order to do this, a hysteroscope, (a kind of miniscule telescope of only 4 millimeters in diameter) is inserted via the mouth of the uterus cervix. Now we use micro-hysteroscope of 2.9 mm which easily goes inside uterus and reduces need of anaesthesia. During hysteroscopy we need to distend the uterus by sterile normal saline so that we can note down minute details inside. Once hysteroscope goes inside we note down size of the cavity of the uterus, inner lining of the uterus, and openings of the fallopian tubes.
Operative hysteroscopy is the procedure which requires the use of a surgical/operative hysteroscope which allows for the introduction of the instruments necessary to carry out the intervention and resolve this and other endometrial or uterine problems Removal of endometrial polyp (small swelling of the inner lining of the uterus) removal of the fibroid which is inside the cavity of the uterus, cutting of the septum/curtain inside the uterus, to enlarge the uterus from within; are few surgeries done through hysteroscopy.
Laparoscopy is a minimally invasive surgical technique which allows access to the abdominal cavity through a small incision of 1 cm at or near the belly button. If operative laparoscopy is done, few (2 or 3) smaller 5 mm cuts are there on tummy on either side of the first cut.
Laparoscopic surgeries are routinely carried out under general anaesthesia but in some cases spinal anaesthesia (below the level of the chest) can also be given.
Simple diagnostic laparoscopy is commonly done to find out abnormality in the genital tract. PCO drilling, removal of ovarian cysts, tubal ligation-family planning procedure, removal of the fibroid, removal of the uterus, endometriosis surgery, surgeries for early cancer etc are done laparoscopically.
The recovery from endoscopic gynaecological surgery is faster than in classic surgery cases as interventions are short and the patients stay in the hospital for a very short period of time. Post-operative infections are less probable than with conventional surgery. At the same time, the costs of the procedure are reduced when it is carried out in hospital like Yashadaa in comparison to larger hospitals and clinics. It is worth mentioning that these modern surgical techniques are meticulous, while anaesthetic procedures allow for a fast recovery. Side-effects are almost non-existent.
The complications of laparoscopic surgeries are rare. Complications can be due to the gas which is used for the distension of the abdomen, this gas can go in circulation and cause gas embolism. This complication can be prevented by strict adherence to the technique and guideline.
Injury to bowel, urinary bladder of bold vessels of the abdomen cans also occur. In some cases these injuries are detected while doing surgeries and corrected at the same time.
Nothing is safe in this world. In fact, one who remains safe always, cannot reach anywhere. Even crossing a road can be dangerous as there can be a small possibility of road accidents but we still walk on the road, drive on the road. Same apples to this discipline of the surgery also. Complications can occur, but rare and majority are treatable.
Day 1 of menstrual cycle is the first full day of bleeding. Lady’s levels of progesterone and estrogen will drop at the end of the previous cycle, sending a signal to the pituitary gland in brain to increase production of follicle stimulating hormone (FSH). A number of follicles (tiny sacs of fluid containing eggs) develop within the ovaries in the days leading up to menstruation. The developing follicles cause the FSH production to decrease, until there is only enough to encourage continuing development of a single follicle - the dominant follicle. The dominant follicle secretes increasing estrogen which in turn increases the thickness of the lining of the uterus (the Endometrium) in preparation for pregnancy.
As the level of estrogen increases, the pituitary (a gland located in brain) releases a short-lived surge of luteinizing hormone (LH). This hormone triggers ovulation, causing the dominant follicle to mature and release the egg. As the egg is released, the far end of the fallopian tube moves across the ovary and sucks up the egg. For a few days before ovulation, the cervical mucus allows sperm to pass through the cervix and uterus to the fallopian tubes. The sperm can survive there for 2 to 3 days, awaiting arrival of the egg. The egg itself is generally only able to survive 24 hours at most before it must be fertilized by a single sperm. Fertilization normally takes place in the widest part of the tube, near the ovary. A membrane called the zona pellucida surrounds the egg and hardens, forming a shell, after one sperm has penetrated it, so other sperm cannot enter. Once inside the egg the sperm releases its contents and fertilization occurs. The fertilized egg starts to divide into cells, the number of cells doubling with each division, and becomes known as an embryo.
The follicle from which the egg was released now begins to make progesterone. This hormone enables the lining of the uterus to provide nutrition, and a site for the embryo to implant during pregnancy. The embryo moves along the fallopian tube and once it reaches the uterus, it hatches out of its shell about four days after fertilization, and implants in the lining of the uterus. The embryo then starts to produce the pregnancy hormone, human chorionic gonadotrophin (hCG) – the hormone measured in pregnancy tests. The presence of this hormone drives the ovary to continue making estrogen and progesterone to support the pregnancy. If fertilization fails or does not take place, the absence of pregnancy hormone causes the ovary to stop making estrogen and progesterone so that the levels fall. Without these hormones, the lining of the uterus breaks down and the next period starts.
Infertility or inability to produce child is a complex phenomenon, usually due to abnormality or many abnormalities in above mentioned physiological process of human fertilization. As it is clearly understood by above physiology, any abnormality in any of the part/s like abnormal generation of the egg or its release( abnormal ovulation), abnormalities in fallopian tube either structural or functional, abnormal uterus or abnormal Endometrium or abnormal semen parameters can lead to infertility.
In cases where spontaneous pregnancy doesn't happen, we generally evaluate both the partners to find out the cause for the infertility. Once the cause is found out we direct our treatment to overcome the particular problem so that the couple will have one or more successful pregnancies. Infertility treatment may involve significant financial, physical, psychological and time commitments. Patience on the part of the couple towards the treatment is very important as in some cases treatment may prolong to a longer duration.
Men's options can include treatment for general sexual problems or lack of healthy sperm. Treatment may include: Altering lifestyle factors. Improving lifestyle and behavioral factors can improve chances for pregnancy, including discontinuing select medications, reducing/eliminating harmful substances, improving frequency and timing of intercourse, establishing regular exercise, and optimizing other factors that may otherwise impair fertility. Certain medications may improve a man's sperm count and likelihood for achieving a successful pregnancy. These medicines may increase testicular function, including sperm production and quality. In select conditions, surgery may be able to reverse a sperm blockage and restore fertility. In other cases, surgically repairing a varicocele may improve overall chances for pregnancy.
Sperm retrieval techniques obtain sperm when ejaculation is a problem or when no sperm are present in the ejaculated fluid. They may also be used in cases where assisted reproductive techniques are planned and sperm counts are low or otherwise abnormal.
Although a woman may need just one or two therapies to restore fertility, it's possible that several different types of treatment may be needed before she's able to conceive. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation.
Intrauterine insemination is the treatment done at the primary level. During IUI, healthy sperm are placed directly in the uterus around the time the woman's ovary releases one or more eggs to be fertilized. Depending on the reasons for infertility, the timing of IUI can be coordinated with your normal cycle or with fertility medications.
In vitro fertilization IVF involves stimulating and retrieving multiple mature eggs from a woman, fertilizing them with a man's sperm in a dish in a lab, and implanting the embryos in the uterus three to five days after fertilization.
Intracytoplasmic sperm injection (ICSI). A single healthy sperm is injected directly into a mature egg. ICSI is often used when there is poor semen quality or quantity, or if fertilization attempts during prior IVF cycles failed.
This technique assists the implantation of the embryo into the lining of the uterus by opening the outer covering of the embryo (hatching).
Most ART is done using the woman's own eggs and her partner's sperm. However, if there are severe problems with either the eggs or sperm, you may choose to use eggs, sperm or embryos from a known or anonymous donor.
Women who don't have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF using a gestational carrier. In this case, the couple's embryo is placed in the uterus of the carrier for pregnancy.
Surgery to restore fertility. Usually these are done through laparoscopy and hysteroscopy. Laparoscopic surgeries like removing adhesions around fallopian tubes and ovaries, removal of fibroids from the uterus, removing cysts from the ovaries, laparoscopic surgery for poly cystic ovaries, tubal surgeries to restore their patency, surgeries for endometriosis, are fertility preserving laparoscopic surgeries. Uterine problems such as endometrial polyps, fibroids inside the cavity of uterus, a uterine septum or intrauterine scar tissue can be treated with hysteroscopic surgery.
Complications of infertility treatment may include:
Multiple pregnancies. The most common complication of infertility treatment is a multiple pregnancy — twins, triplets or more. Generally, the greater the number of fetuses, the higher the risk of premature labor and delivery, as well as problems during pregnancy such as gestational diabetes. Babies born prematurely are at increased risk of health and developmental problems. Talk to your doctor about ways to prevent a multiple pregnancy before you begin treatment.
Ovarian hyper stimulation syndrome (OHSS). Fertility medications to induce ovulation can cause OHSS, in which the ovaries become swollen and painful. Symptoms may include mild abdominal pain, bloating and nausea that last about a week, or longer if you become pregnant. Rarely, a more severe form causes rapid weight gain and shortness of breath requiring emergency treatment.
Bleeding or infection. As with any invasive procedure, there is a rare risk of bleeding or infection with assisted reproductive technology.
Injury to blood vessels of the abdominal wall or those of the lower abdomen and pelvic sidewall. Injury to the urinary tract or the bowel
Generally, you may experience any of the following symptoms within the first twenty-four to forty-eight hours
Nausea and lightheadedness
Scratchy throat if a breathing tube was used during the general anesthesia
Pain around the incisions
Abdominal pain or uterine cramping
Shoulder tip pain-secondary to the carbon dioxide gas
Tender umbilicus (belly-button)
Gassy or bloated feeling
Vaginal bleeding or discharge (like a menstrual flow)
Recovery depends on the type of procedure you had performed. Most patients feel well within days of surgery. But if major surgery has been performed rest is still required. Most patients will require some form of pain medicine in the immediate postoperative period. A prescription for an anti-inflammatory, will be provided prior to discharge. Avoidance of heavy lifting , jumping and jogging is recommended until 4 weeks postoperatively. Sexual intercourse should also be postponed for 4 weeks. It is preferable not to put anything into the vagina for at least 4 weeks including tampons. The timing for returning to work depends on the procedure performed. Most patients who undergo an ovarian cystectomy or ectopic pregnancy are ready to return to work within 2 weeks. If a hysterectomy is performed, 4 to 6 weeks off work is recommended.
You should not hesitate to call the doctor if you develop any of the following symptoms:
Heavy bleeding from the incisions
Fever or chills
Problems with urination or bowel movements
Heavy vaginal bleeding
Severe or increasing abdominal pain
Redness or discharge from the skin incisions
Shortness of breath or chest pain
Yes. Occasionally two procedures are scheduled at the same time. Hysteroscopy is frequently performed at the same time as laparoscopy. Women may also elect to have another elective surgery performed in combination with their gynecologic procedure. Surgeries that have been performed concurrently have included liposuction, gallbladder removal and breast implants.
Endometriosis is a condition, when the Endometrium (the lining of the uterus) is found in other places than the uterine cavity. Endometriotic implants can be found on pelvic sidewall, fallopian tubes, ovaries, bowel, bladder, and less commonly outside of the pelvic cavity. Like the endometrial lining in the uterus, these implants undergo similar changes in response to the cyclic hormonal changes. The implants may swell and bleed every month causing pain. Endometriosis may also lead to cysts and adhesions. This condition is found in approximately 20% of women. The most common symptoms of endometriosis are pain with your period, irregular bleeding and infertility. At the present time there is no simple test for diagnosing endometriosis. The only way to diagnose endometriosis with certainty is by laparoscopy and biopsy. Rarely large endometriotic lesions can be diagnosed by ultrasound.
Endometriosis can be treated with medications, surgical excision, or combination of the two methods. You should discuss the treatment options with your gynecologist.
Yes. A laparoscopic biopsy is required to diagnose endometriosis. Endometriotic implants can also be treated laparoscopically with excision or burning. This treatment usually produces more immediate results in terms of pain relief and fertility compared to medical therapy.
A cyst is a fluid filled cavity. Cysts can often be found in the ovaries. Ovarian cysts are usually diagnosed by pelvic exam or ultrasound. If the cyst is entirely filled with fluid it is called a "simple cyst". Ovarian follicles as they undergo maturation may appear on ultrasound as simple cysts or occasionally as complex cysts. These cysts usually resolve within one to two months. Simple cysts are almost always benign. Removal is indicated if they are bigger than 5-6 cm in diameter or if they cause symptoms. If the cyst contains echogenic structures (shadows by ultrasound) it is categorized as a "complex cyst". Complex cysts can represent endometriosis, infection, benign tumors, and rarely malignancies. It is generally recommended that complex cysts be evaluated laparoscopically and possibly removed. The majority of ovarian cysts can be removed laparoscopically.
Fibroids are benign growths of the uterus. They occur in 20 to 25 percent of women. Fibroids are most common in women aged 30 to 40 but may occur at any age. Women may have one fibroid or many fibroids. The size of the fibroid also varies from the size of a small pee to more than 20-25 cms. Some women may be entirely asymptomatic and others may complain of changes in menstruation, pain, pressure, miscarriages and infertility.
Yes. Some women may have their fibroids (benign growths on the uterus) excised laparoscopically. This procedure is limited to fibroids that are on the outside of the uterus (Pedunculated) or just under the uterine wall (subserosal). Fibroids that are buried deep in the uterus cannot be removed with this approach. The fibroids are then morcellated (cut into small pieces) and removed through the small incisions. Occasionally, with resection of a fibroid, the uterine cavity may be entered and suturing is required. This usually can be performed using special laparoscopic instruments but infrequently a small ("mini") pfinnenstiel ("bikini") incision is made to repair the uterus. Rarely a hysterectomy must be performed because of heavy bleeding or inability to reconstruct the uterus. Sometimes a drug (GnRH agonist) may be used to shrink the fibroid and control bleeding prior to surgery.
No. If the fibroids (benign growths on the uterus) are only in the inside of the uterus they cannot be approached laparoscopically. Rather, we may recommend a hysteroscopic approach.
In most cases the uterus can be safely removed laparoscopically. This is not an option when the uterus is very large (greater than 24 week pregnancy in size). Recovery after laparoscopic hysterectomy is usually quicker than after abdominal hysterectomy.
No, some women elect to have a subtotal hysterectomy. This simply means that the fundus of the uterus is removed and the cervix is maintained. The uterus is removed with the help of a morcelator . This instrument allows the surgeon to remove large uteri through small incisions. Not all women are candidates for a subtotal hysterectomy. A previous history of abnormal pap smears would be a contraindication to this approach. To help you choose the most suitable and safe procedure the doctor will consider all these factors prior to proceeding with a subtotal hysterectomy. All women who undergo a subtotal hysterectomy must still have pap smears performed yearly.
This procedure is often faster, associated with fewer surgical complications and more rapid return to normal activities. There is also some evidence to suggest that there is less disruption of the pelvic floor and, therefore, less pelvic Prolapse requiring additional surgery in the future. The cervix may also play a role in female orgasm. Many women request a subtotal hysterectomy in order to retain their cervix for sexual function. It is important to realize, however, that just as many women who have had a total hysterectomy have very normal sexual function.
Depending upon your symptoms, there are several different alternatives to hysterectomy. Majority of hysterectomies are performed either doe to abnormal bleeding or fibroids. If you have irregular bleeding and your uterus is not too big, endometrial ablation (destruction of the endometrial lining) can be viable option to hysterectomy (look up section under hysteroscopy). If you have fibroids, a myomectomy (removal of fibroids) may be viable treatment for you. If you have large uterine fibroid, uterine artery embolization may be an alternative to hysterectomy. You should discuss all those issues with your Gynecologist before you decide to have the hysterectomy.