Surgical options usually arise when the cause of infertility is an underlying gynaecological condition, for example, endometriosis, fibroids or ovarian cysts. These conditions can impact ovulation, fertilisation of the egg, delivery of the egg to the uterus, and implantation of the fertilised egg. To understand why there is an impact, we have to first understand how fertilization happens.

Therefore, any physical disruptions in any of the parts of the reproductive system mentioned above could have an impact on fertility, and might need to be managed surgically.

Starting with the ovaries, certain ovarian cysts and fibroids can disrupt ovulation and egg delivery, and undergoing surgery to remove these abnormalities can help to improve these two aspects.

At the fallopian tubes, there may be inflammation that could be caused by infection or endometriosis. The inflammation can affect egg collection by the fimbriae at the end of the fallopian tube, as well as the motility of the entire tube transporting the egg, affecting egg delivery. As a result, fertility may be disrupted. Surgery then becomes a key factor in removing the infection or treating the endometriosis to reduce the inflammation.

Endometriosis is known to be a huge cause of fertility problems, affecting 40 to 50% of the sub-fertile population. When left untreated in the early stages, surgery may become the only option to improve the condition. Sometimes, the presence of fibroids blocking the fallopian tubes can also interfere with egg collection. Removal of these fibroids will be essential to improve the environment for conceiving.

At the uterus, there may also be congenital abnormalities like a uterine septum, which is a thin wall dividing the uterus into half. This condition can lead to implantation failure or early miscarriage. Another problem that could also occur in the uterus is intra-uterine adhesions. This can be caused by inflammation or infection after a Dilation and Curettage (D&C) procedure, resulting in the uterine walls sticking together and affecting implantation and pregnancy.

While uterine fibroids are generally harmless, they can sometimes affect implantation of the egg. Depending on their position and size, submucosal and deep intramural fibroids have been thought to have an impact on fertility.

A. Laparoscopic Surgery (Keyhole Surgery)
As the ovaries, fallopian tubes, and uterus are located in the pelvis at the bottom part of the abdomen, laparoscopy is usually performed to examine these reproductive organs to detect any abnormalities that might be affecting the woman’s ability to conceive.

Laparoscopy is a minimally-invasive surgical procedure where a thin fibre-optic camera (called a laparoscope) is inserted via a small incision in the abdomen to allow the surgeon a closer look at the organs, in this case the reproductive organs, to diagnose conditions that cannot be concluded solely with a ultrasound scan.

The diagnostic procedure is performed under general anaesthesia and carbon dioxide gas will be introduced to lift the abdominal wall and separate the organs within the abdomen. The laparoscope transmits a live feed with magnified images to a TV monitor to provide the surgeon a clear view of the organs.

Once the physical constraints and abnormalities are observed during diagnostic laparoscopy, the procedure is converted to a laparoscopic surgery. A few small incisions of 0.5 to 1cm are made at the abdomen where thin surgical instruments are subsequently inserted through for the surgeon to operate. Most of these gynaecological conditions like cysts, fibroids and endometriosis that require surgery are done laparoscopically, except for the removal of submucous fibroids where hysteroscopic surgery may be more ideal due to the location of the fibroids.

Laparoscopic Surgery Vs Open Surgery (Laparotomy)
Laparoscopic surgery is becoming an increasingly popular option over open surgery for several reasons. As the incisions are small, post-surgery pain is significantly reduced. This results in a shorter hospital stay and cost savings. Sometimes, patients may even be able to go home on the same day as the surgery. For the same reason, the recovery process is a lot faster and scars are smaller and less obvious. From a surgical aspect, due to the principles of magnification and microsurgical techniques, there is better tissue handling and control, allowing for a more delicate procedure which is better for the patient.

B. Hysteroscopic Surgery
Hysteroscopic surgery is another technique of minimally-invasive surgery that is performed through the vaginal. A hysteroscope, which is similar to a laparoscope, is inserted through the vagina and cervix and into the uterus.

A live feed with magnified images is reflected on a TV screen for the surgeon to have a closer look at the uterus to diagnosis any abnormalities. When the abnormalities are identified, thin surgical instruments are inserted through the hysteroscope to carry out the surgery.

Hysteroscopic surgery is also performed under general anaesthesia and this procedure is preferred over laparoscopic surgery when detecting and treating abnormalities in the interior parts of the uterus. The rule of thumb for deciding between laparoscopy and hysteroscopy is largely dependent on the ease of access to the operative site so as to achieve minimal tissue damage.

For example, submucous fibroids that protrude into the womb cavity and impede implantation are often removed through a hysteroscopic procedure because the site of entry by the surgical instrument is nearer than if it was done via the abdomen, in which case the surgeon would have to cut through the uterus in order to gain access and remove the fibroids. Hysteroscopic surgery can also be performed to remove cases of uterine septum and intra-uterine adhesions.

The recovery time for hysteroscopic surgery is fast and most patients are able to go home on the same day of the surgery. As there are no abdominal wounds, post-surgery pain is very minimal and there are no obvious scars. Also, wound infections are unlikely to develop.

C. Open Surgery (Laparotomy)
Open surgery or laparotomy is the traditional method of surgery where a large incision of about 8 to 10cm is made at the abdomen to reach the reproductive organs to be operated on. Due to the large incision, post-surgery pain is experienced on varying levels and the patient may have to stay in the hospital for about a week. Recovery process is slower and the post-operative scar is usually large and obvious. Also, in open surgery, a lot more body tissue is exposed to the external environment, increasing the risk of adhesions and infections.

Open surgery may only have to be performed when the patient has multiple big fibroids. Multiple being at least 4 to 5 fibroids, and big referring to each fibroid being about 4 to 5cm.

However, the philosophy is to avoid open surgery whenever possible because it has been shown to result in more post-operative adhesions, which then further impedes fertility.