Anatomic problems within a woman's uterus can contribute to a person's inability to conceive, or carry a pregnancy to the point of fetal viability. Anatomic problems with the uterus can be either congenital or acquired. Operative Hysteroscopy is a day surgery procedure. At Hinsdale Center for Reproduction, it’s extremely rare for a patient to need to spend the night in the hospital (far less than 1%). Hysteroscopy performed under general anesthesia, but usually doesn't require use of a breathing tube (intubation). There is no incision, and most patients return to normal activity the following day. The hysteroscope is basically a long, flexible telescope connected to a light source. The tip is only half the width of a pencil and passes easily through the dilated cervix. Dr. Hickey attaches a camera to the hysteroscope and watches the progress on a television screen. Paired with a morcellator attachment (the cutting tool), the hysteroscope gives Dr. Hickey not only the ability to see, but to remove and suction out tissue fragments. Dr. Hickey uses the instrument to reshape the uterus, and clear adhesions and blockages. Dr. Hickey is one of only a handful of U.S. surgeons offering this procedure. This video shows two Uterine Fibroids being removed using the Hysterocope, reducing the amount of time the same resection would have taken using an older instrument, the “Resectoscope,”and decreasing the risk of fluid overload.
Congenital Uterine Anomaly
A uterine septum is an example of a congenital uterine anomaly that can cause recurrent pregnancy loss (RPL). At one point during embryonic development, the uterus is solid, and shaped much like a pear. As development continues, the structure naturally hollows out, creating the upper third of the vagina, the cervix, and a triangular endometrial cavity. If this process is not complete, an avascular, fibrous tissue in the shape of a "widow's peak" is present right in the spot where pregnancies normally implant. Because they this tissue is avascular, there is not enough blood flow for the fertilized egg to grow, and it dies.
Miscarriage rates with a uterine septum are as high as 90%. Once the septum is resected, the patient's obstetric course is typically normal.
These three videos show stages of a septum removal.
Myomas are more commonly called uterine fibroids. Only myomas/fibroids which are in the endometrial cavity, that distort the uterine cavity, or are larger than 6 cm. in maximum diameter, actually affect fertility. However, myomas may interfere with sperm migration, ovum transport or embryo implantation in the uterine mucosa.
In this surgery, a myoma is being broken up and suctioned away.
Here is an example of the type of polyp that Dr. Hickey finds on the lining of the uterus or the endometrium. Dr. Hickey has found that after the removal of polyps, many women arre able to get pregnant spontaneously, and need no further infertility treatment.
Each month, the uterine lining grows in response to increasing levels of estrogen coming from the maturing follicle. The tissue grows around the arterioles supplying the nutrients for growth. Once ovulation occurs, a second ovarian hormone, progesterone, sensitizes arteries and veins to its presence. If you become pregnant, progesterone levels increase, which stabilizes the lining so you don't shed it. If you do not get pregnant, the progesterone level peaks when implantation should have occurred, then falls. When the progesterone level falls below a certain threshold, all the arteries and veins go into spasm. This brings down the existing lining (your menstrual period), which sets things up to repeat the process the next month.
If one of the arterioles does not sensitize to progesterone, and doesn't spasm when levels fall, it stays put and keeps a little island of tissue around it. Over time, the tissue around the arterioles becomes thicker, forming a polyp. Polyps frequently are discovered when the central artery causes spotting between periods.
Pre-Curettage, Polypoid Endometrium
In this video, Dr. Hickey uses a CO2 (carbon dioxide) laser to vaporize lesions caused by endometriosis. The laser allows Dr. Hickey to target endometrial lesions without damaging normal tissue.
While the incidence of endometriosis in the general population is estimated to be approximately 15%, in an infertility practice it is more like 50% to 60%. Many women's endometriosis is the cause of, or contributes to their infertility.
Endometriosis is a condition in which the endometrial tissue that lines the inside of the uterus grows outside the uterus and attaches to other organs in the pelvic cavity, such as the ovaries and fallopian tubes. Symptoms include pelvic pain, abdominal pain, and irregular or heavy menstrual bleeding.
Because the endometrial tissue outside the uterus responds to menstrual cycle hormones, it can cause an inflammation that forms scar tissue (adhesions). This scar tissue may block the fallopian tubes or interfere with ovulation. Removal of endometrial tissue offers the best chances of restored fertility.
A woman with endometriosis will find that her best chances of getting pregnant are in the first six months following the procedure. In fact, when the pelvis is “clean” is usually an opportune time to begin hormonal therapy.
C02 Laser Ablation of Endometriosis
Interceed® Used to Prevent Adhesions
In this video, Dr. Hickey is placing a mesh, called Interceed®, a surgical adhesion barrier, over areas of the ovaries, fallopian tubes and supporting ligaments of the uterus that have been “cleaned” of endometriosis.
The mesh is a wood product, just as Kleenex® is a wood product. The mesh is produced from decarboxilated methylcellulose, designed in a special pattern which prevents fibrin bridging between healing surfaces which potentially become adhesions. This natural product is dissolved by the fluid that is naturally present in the pelvis.
Dr. Hickey participated as one of the surgeons in the clinical trials Ethicon® conducted through the Division of Reproductive Endocrinology and Infertility during his Fellowship at the University of Southern California, and has published on the subject of adhesion prevention.
Interceed® Placement after Ablation
Lysis of Tubal Adhesion
The standard treatment for fallopian adhesions is hysteroscopy surgery with lysis.
The procedure is begun by inserting the hysteroscope into the cervix, through the uterus and into the fallopian tubes. The adhesions are morcellated and suctioned away. Each surgical case is unique and requires a careful understanding of the structure of the fallopian tubes, paired with patience and skilled dissection.
Prevention of adhesion reformation is crucial.
CO2 Lasery Surgery