With the widespread use of IVF (in vitro fertilization) as a treatment for infertility, both male and female, medical practice has changed with regard to the use of surgery. In particular, the use of reproductive surgery, which is considered less effective or even outdated, has been significantly reduced. On the other hand, the observation that the success rate of IVF increases significantly after removal or disconnection of hydrosalpinges has led to the common decision not only not to repair them, by open or laparoscopic surgery, but to remove them. Nevertheless, reproductive surgery is still necessary for the hysteroscopic or laparoscopic correction of congenital or acquired abnormalities such as a septate uterus, fibroids, adhesions and polyps, while in specific cases surgical correction of peritubal adhesions or phimotic tubes can also be attempted, so that a couple can avoid undergoing an assisted reproduction procedure.
Gynecologic reproductive surgery includes open or endoscopic (hysteroscopic and laparoscopic) procedures aimed at restoring fertility, and they are divided into:
Hysteroscopic procedures
…that is, removal of protruding fibroids or polyps, division of adhesions and septa, as well as catheterization and opening of proximal tubal blockages. With the hysteroscope we see and record the inside of the uterus and can confirm that the cavity is normal, and if there are polyps, adhesions, septa or fibroids inside the uterus, they can be removed or divided right away. With today’s technology we can remove polyps and release adhesions, while with bipolar resectoscopes (for safety reasons) we are able to “shave” even large fibroids from the inside of the uterus.
Especially for fibroids that protrude partly or fully into the cavity, the hysteroscopic approach is not only easier than abdominal myomectomy but also the approach of choice, because it best protects the endometrial cavity from adhesion formation. In addition, after such a procedure, in which the uterine muscle is not cut, a cesarean section is not necessary at delivery. An advanced hysteroscopic procedure, selective tubal catheterization, can also temporarily restore patency in cases of “proximal blockage” of the tubes and allow a couple to achieve pregnancy without having to turn to IVF.
Laparoscopic procedures
..that is, lysis of peritoneal adhesions, lysis of tubal adhesions, fimbrioplasty and neosalpingostomy, all of which aim to restore normal tubal function. Since the 1980s there has been an explosion in the use of laparoscopic gynecologic surgery. In cases of infertility due to tubal problems or adhesions and endometriosis, if IVF is not possible or desired, reproductive laparoscopic surgery can help (photos 1, 2, 3, 4). Although IVF is a very successful tool, in cases where the problem is purely anatomical, and if the couple has both the time and the willingness, laparoscopic correction of the tubes can lead to a pregnancy or even several pregnancies. Of course, since at least 6 months of unprotected intercourse after the correction must pass before laparoscopic repair can be considered unsuccessful, this is a possible solution only for younger couples. Special mention should be made of the major shift in reproductive surgery following the observation that, when hydrosalpinges are present, their laparoscopic removal or ligation increases the chance of IVF success, a 180-degree turn from the attempts to repair them that were made in the past.
Tubal microsurgery
The experienced doctors at our center are also trained in the most delicate techniques of reproductive surgery, namely tubal microsurgery to repair the tubes with neosalpingostomy or fimbrioplasty. In specific cases where, for various reasons, the couple does not want or cannot undergo assisted reproduction procedures, these methods can help them achieve their goal.
Reproductive surgery or straight to IVF: how the decision is made
There is no universal rule. The same finding, for example a partially blocked tube, may lead to surgery in one woman and to IVF in another. The criteria weighed are:
- The woman’s age: after 37 to 38, time matters more. Surgery takes months to pay off, while IVF gives a faster answer.
- Ovarian reserve: a low anti-Mullerian hormone (AMH) indicates that the time available is limited and that any surgery on the ovaries must be done very sparingly.
- Sperm quality: if there is also a severe male factor, repairing the tubes is not enough. IVF with ICSI solves both problems at once.
- Severity of the damage: mild adhesions around the tubes have a good prognosis after they are released. Tubes with a damaged inner lining do not.
- Wish for more children: a successful operation allows natural conception in every cycle, including for future pregnancies.
- The couple’s personal values and preferences: some couples do not want IVF for personal or ethical reasons.
The right decision comes from combining all of these, not from a single finding.
The workup that comes before any fertility surgery
Before a couple goes into surgery, the basic fertility workup must be completed for both partners. It usually includes:
- A transvaginal ultrasound, ideally 3D, to assess the shape of the uterus and the ovaries.
- A check of tubal patency with hysterosalpingography (HSG) or hysterosalpingo-contrast sonography.
- A hormone profile and AMH.
- Semen analysis.
- Pelvic MRI, when a complex abnormality or deep disease is suspected.
Without these, there is a risk of performing surgery that does not solve the real problem, or of delaying a treatment that would be more effective.
Corrections to the uterine cavity
The uterine cavity is the “soil” where the embryo will implant. Anything that distorts it can prevent implantation or increase the risk of miscarriage.
Uterine septum
This is a congenital abnormality in which a fibrous or muscular wall partly or completely divides the cavity. It is divided hysteroscopically, without abdominal incisions. The data on whether this improves fertility in women without a history of miscarriage are conflicting. The procedure is mainly considered for women with recurrent miscarriage or preterm births, and the decision is individualized.
Intrauterine adhesions (Asherman syndrome)
After curettages, especially after a miscarriage or postpartum hemorrhage, the walls of the uterus can stick together. The result is much lighter or absent periods, difficulty conceiving and miscarriages. Treatment is hysteroscopic lysis of the adhesions, often followed by hormone therapy to regenerate the endometrium and a follow-up hysteroscopy. Severe forms may require more than one session.
Isthmocele after cesarean section
In some women, the cesarean scar does not heal completely and leaves a small niche in the uterine wall. Blood collects there, causing spotting after the period, and it may affect implantation. When there are symptoms or secondary infertility, the defect is repaired hysteroscopically or laparoscopically, depending on the thickness of the remaining wall.
Ovarian surgery with fertility in mind
The ovaries have no “spare parts”. Every egg a woman will use in her lifetime is already there. That is why ovarian surgery in a woman who wants a child follows a simple rule: the less intervention, the better.
Cyst removal that protects healthy tissue
When a cyst must be removed, the surgeon carefully separates its wall and preserves as much normal ovarian tissue as possible. Limited cauterization and the use of sutures or hemostatic materials instead of extensive diathermy help avoid needlessly reducing the reserve. In some cases, egg freezing is also discussed before ovarian surgery as a safety net.
Laparoscopic ovarian drilling
In women with polycystic ovaries who do not ovulate with first-line medications, laparoscopic drilling is an alternative. Small, targeted applications of energy to the surface of the ovary reduce androgen production, and in many women spontaneous ovulation is restored for a period of time. The advantage is that it does not require monitoring every cycle and does not increase the risk of multiple pregnancy. The procedure must be done in moderation, because excessive application can harm the reserve.
After surgery: timeline and reassessment
Reproductive surgery does not end when you leave the clinic. Planning the period that follows is just as important.
- After hysteroscopic surgery: the cavity heals quickly and trying usually starts within one to two cycles. After lysis of severe adhesions, a follow-up check comes first.
- After laparoscopic tubal surgery: natural attempts start early. Most pregnancies, when they happen, occur within the first year.
- After removal of a fibroid from the uterine wall: a wait of a few months is needed for the uterus to heal.
- When we change strategy: if pregnancy is not achieved within a reasonable time, which is shorter the older you are, the next step is assisted reproduction. The surgery is not “wasted”, because it often also improves the conditions for IVF.
After tubal surgery, every positive pregnancy test should be followed by an early ultrasound, because the risk of ectopic pregnancy is higher.
Risks and limits of reproductive surgery
These procedures are mostly minimally invasive and safe. However, there are specific limits you should know about:
- New adhesions can form after any pelvic surgery, which is why the technique must be delicate and atraumatic.
- Surgery corrects anatomy, not egg or sperm quality.
- Tubes with severe damage to their inner lining do not become functional again, even if they are opened.
- General surgical risks, such as bleeding, infection or injury to nearby organs, are rare but real.
Preparing as a couple before surgery
Fertility surgery only makes sense if it is followed by an attempt to conceive under the best possible conditions. That is why preparation starts before surgery:
- Folic acid daily, ideally three months before trying.
- Both partners quitting smoking. Smoking harms eggs, sperm and healing.
- Managing body weight, where needed. Even moderate weight loss improves ovulation in overweight women.
- Checking immunity to rubella and chickenpox, and vaccination if needed, before pregnancy.
- Scheduling the surgery in the first half of the cycle, after the period, so that pregnancy is ruled out and the endometrium is thin.
These simple steps do not replace treatment, but they increase the chance that the attempt that follows will succeed.
Questions to ask your surgeon before fertility surgery
- Exactly which problem will the surgery correct, and how much is it responsible for the difficulty conceiving?
- What is the alternative if I do not have surgery, and how much time does each option “cost”?
- Is there a chance that a tube or ovarian tissue will need to be removed? Will I be asked for consent in advance?
- When can I start trying, and how long should I wait before we move on to IVF?
- Will I get photos or a description of the findings, so that my next doctor can see them if needed?
The answers to these questions give you a realistic picture of what surgery can offer in your case.
Frequently Asked Questions
What is reproductive surgery?
It is the set of procedures that correct anatomical problems in the uterus, fallopian tubes and ovaries that prevent conception or the progress of a pregnancy.
Which procedures does it include?
Removal of polyps, fibroids and uterine septa, lysis of adhesions, treatment of endometriosis and tubal surgery.
What method is used?
Almost always minimally invasive, with laparoscopy or hysteroscopy, to protect the tissues and allow a quick recovery.
Do I need surgery before IVF?
In some cases yes, for example with a hydrosalpinx, a polyp or a fibroid that distorts the uterine cavity, because they reduce implantation rates.
When can I try for pregnancy after surgery?
From the next cycle after a simple hysteroscopy, up to several months after removal of large fibroids. Your surgeon will set the exact timing.
Does the risk of ectopic pregnancy increase after tubal surgery?
Yes. A tube that has been damaged or operated on can delay the passage of the fertilized egg. That is why, after a positive pregnancy test, an early ultrasound is needed to confirm that the pregnancy is inside the uterus.
Will I need a cesarean section after uterine surgery?
It depends on the procedure. After hysteroscopic removal of a polyp or small fibroid, vaginal delivery is usually possible. After removal of a fibroid that went deep into the wall, a planned cesarean section is often recommended. The surgeon makes the recommendation based on the operative report.
Is there an age limit for reproductive surgery?
There is no strict limit, but after 38 to 40 the time it takes for surgery to pay off becomes precious. At this age, procedures that improve the conditions for IVF are preferred over procedures aimed at natural conception.
Can reproductive surgery involve the man too?
Yes. Conditions such as varicocele or blockage of the sperm ducts are treated surgically by a urologist-andrologist. That is why semen testing is always done before any surgery on the woman.