Fertility Surgery: Hysteroscopy, Laparoscopy and Varicocele Repair

When surgery helps

Surgery is used when a physical problem is likely contributing to infertility and can be corrected. It can sometimes remove the need for more complex treatment, and sometimes makes treatment such as IVF more effective. Common procedures are done through small incisions or through the cervix.

For the uterus

• Hysteroscopy: a thin camera passed through the cervix lets the surgeon look inside the uterus and remove polyps, treat scar tissue (adhesions) and correct a uterine septum.
• Myomectomy: removal of fibroids that distort the uterine cavity or are large, by hysteroscopy, laparoscopy or open surgery. Not every fibroid needs treatment.

For the tubes and pelvis

• Laparoscopy: small abdominal incisions allow a surgeon to diagnose and treat endometriosis, release adhesions, open some tubal blockages and check the tubes with dye.
• Salpingectomy or tubal occlusion for a hydrosalpinx before IVF.
• Tubal reversal after tubal ligation in selected patients, as an alternative to IVF. See blocked fallopian tubes.

For sperm

• Varicocele repair: treating enlarged scrotal veins in selected men with abnormal semen results.
• Vasectomy reversal or blockage correction.
• Surgical sperm retrieval (TESE, micro-TESE or PESA) when no sperm are found in the ejaculate, usually combined with ICSI.

See male factor infertility.

Weighing the benefits and risks

Every operation has general risks, such as bleeding, infection and anesthesia reactions, plus specific ones: scarring, damage to nearby organs or, with ovarian surgery, a possible fall in ovarian reserve. Surgery can also take time away from fertile years, which matters at older ages. Ask:

• How likely is this to improve my chance of pregnancy?
• What are the alternatives, including going straight to IVF?
• Could it affect my ovarian reserve, and how long should I wait before trying?
• How many of these procedures do you perform each year?

Preparing and recovering

Follow your surgeon’s instructions about eating, medication and activity. Many people can resume daily activity within days. Tell the team promptly about fever, severe pain, heavy bleeding or other worrying symptoms. See get help now.

Hysteroscopy in more detail

A hysteroscopy uses a thin lighted camera passed through the cervix into the uterus. It can be done in an office with minimal anesthesia or in an operating room with sedation. Surgeons can remove polyps, divide a septum, cut intrauterine scar tissue (adhesions) and take biopsies. Some clinics perform a hysteroscopy before IVF to check the uterine cavity, though evidence for routine use in people without symptoms is mixed. Ask whether it is likely to benefit you.

Laparoscopy in more detail

Laparoscopy uses a camera and instruments through a few small cuts in the abdomen under general anesthesia. For fertility, surgeons may look for and treat endometriosis, remove adhesions, open or remove damaged tubes, or remove ovarian cysts. Recovery is usually quick, with shoulder pain from the gas used to inflate the abdomen being common for a day or two. Because laparoscopy is a surgery with anesthesia, it is usually reserved for situations where it is likely to change the plan.

Fibroids and fertility

Not all fibroids affect fertility. Those that bulge into the uterine cavity (submucosal) are most likely to interfere with implantation and pregnancy, and removing them may help. Fibroids within the wall of the uterus can matter if they are large or distort the cavity. Subserosal fibroids on the outside rarely affect fertility. Your specialist will consider the size and location of any fibroids, your symptoms and your plan.

Varicocele repair

A varicocele is a swelling of veins in the scrotum. It is common, and many men with a varicocele have normal fertility. Repair may be considered when there is a palpable varicocele together with abnormal semen results and a partner with normal fertility. Surgeons can use microsurgical techniques or radiologic embolization. Improvement in semen parameters may take around three months or longer, so timing must be planned.

Anesthesia and recovery planning

Ask what type of anesthesia is planned, what to do about medications before surgery, and when you can return to work and exercise. Plan help at home for the first day or two. Ask when you can resume trying to conceive, and whether you should wait a cycle after certain procedures.

Weighing surgery against going straight to IVF

For some conditions, such as a uterine septum or a large polyp, surgery is clearly useful. For others, such as mild endometriosis in a person over 35, IVF may be more direct, and surgery could delay it. This depends on age, reserve, duration of infertility, costs and personal preference. A reproductive endocrinologist can help weigh these. See IVF and how to choose a fertility clinic.

Insurance and cost

Surgery for conditions that cause symptoms, such as pain from endometriosis or heavy bleeding from fibroids, is often covered, whereas surgery performed only to improve fertility may be treated differently. Ask your insurer about both the procedure and the diagnosis codes. See fertility costs and insurance.

Where to start

Surgery is considered after testing. Read fertility testing, and find a specialist in how to choose a fertility clinic.