The Role of Modern Reproductive Surgery for the Evaluation, Therapy, and Preservation of Fertility

Keith Isaacson, M.D.

To paraphrase the words of Mark Twain, the reports of the death of reproductive surgery in the current environment of assisted reproductive technology have been greatly exaggerated. In this edition, we review evidence-based support for the benefits of reproductive surgery in all phases of the infertility process: evaluation, therapy, and preservation.

The growth of minimally invasive surgery in general gynecology began with the reproductive surgeon. The principles of operating under magnification with minimal tissue trauma, elimination of tissue drying, and absolute hemostasis were the cornerstones of reproductive surgical techniques used to reduce postoperative adhesions and optimize pregnancy rates. Long before there were assisted reproductive technologies, these principles were championed by reproductive surgical masters such as Celso-Ramon Garcia, Luigi Mastroianni, and John Rock. Modern reproductive surgery using minimal access is founded on these same proven surgical principles. Instead of loupes we use two-dimensional and three-dimensional 5- to 10-mm laparoscopes that yield 4 × to 10 × magnification. Instead of using heparinized saline to keep tissue moist during surgery, we operate through 5-mm surgical ports that prevent the peritoneum from ever being exposed to air drying, sponges, and talc from surgeons' gloves. Minimal tissue trauma is now achieved from modern energy modalities such as micro bipolar devices, lasers, and ultrasonic energy instead of handheld microsurgical instruments and monopolar radiofrequency energy.

Over the past 20 years, it has become increasingly clear that the clinical outcomes using a minimally invasive approach are at least equal to if not better than the standard laparotomy approach for reproductive surgery. A common theme in head-to-head series is a reduction in blood loss, postoperative adhesions, and a quicker return to normal activities in patients having minimally invasive surgical approaches compared with the time-tested laparotomy techniques.

We are now beyond the need for proving the benefits of minimally invasive reproductive surgery. We have entered a phase of growth and opportunity likened to the early days of in vitro fertilization (IVF). Minimally invasive reproductive surgery is in the midst of an exciting growth curve in which the end is not in sight. Numerous examples of this revolution are described in this edition of Seminars. Bettocchi et al describes how far we have come from offering just diagnostic hysteroscopy in the office. Without the need for any anesthesia, local or otherwise, we can now remove polyps, lyse adhesions, remove small polyps, and treat septa without ever going to the operating room. Goldberg describes an office-based technique for evaluating the peritoneal cavity in the office with the added possibility of peritoneal adhesiolysis and ovarian drilling. Morris and Ryley describe exciting techniques on fertility preservation that will soon be used in young women undergoing gonadotoxic chemotherapy. No doubt the indications and techniques for oocyte preservation will greatly expand in the near future. Gargiulo and Nezhat review the Model-T of robotic therapy. The first-generation surgical robot has enabled hundreds if not thousands of reproductive surgeons to become very good or expert laparoscopic surgeons. The benefit of robotic surgery is no longer a question. Future generations of the robot will be smaller, less expensive, and with greater capabilities. We are in the process of reducing the number of surgical scars from 5 to 3 to 1, and robots will clearly play a role in this process.

Assisted reproductive technology is not going to replace reproductive surgery, and reproductive surgery will not replace IVF. On the contrary, these techniques complement each other to ultimately provide optimal outcomes for patients. Success rates with in vitro fertilization are enhanced by optimizing the uterine cavity after removing polyps, submucous fibroids, adhesions, and congenital anomalies. Success rates are also improved by treating or removing hydrosalpinges, endometriosis, and intramural fibroids that distort the uterine cavity. It is understood that assisted reproductive technologies are not available to many patients due to geographic difficulties and/or financial constraints. However, many of these patients with tubal disease and/or early-stage endometriosis can benefit from surgical correction.

Reproductive surgery is not in a phase of decline. On the contrary, modern technology has expanded its usefulness in the diagnosis, treatment, and preservation of fertility in many patient populations. It is imperative that reproductive endocrinology training programs refocus on surgical training in addition to teaching assisted reproductive technologies.

I want to thank all the contributors to this issue as well as Bruce Carr for inviting me to edit this issue. This work has reaffirmed my belief that surgery will continue to be of great benefit to our patients suffering from reproductive difficulties.