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Click photo to enlarge Microsurgery Infertility SURGERY
FOR FEMALE INFERTILITY Surgery
in infertility has seen a sea change in the past decade because of wider
application of microsurgical techniques. Thus salpingolysis, salpingostomy,
repair of fallopian tube and vas deferens following resection of localized
obstruction, and vaso-epididymal anastomosis are surgeries in which
magnification has radically changed the outcome. Microvascular transfer
of very high abdominal testis into scrotum is now a possibility for
those cases of cryptorchidism in whom conventional surgery finds the
testicular vessels too short for adequate descent. A
thorough pre operative physical and psychological assessment of the
patient and her partner is of paramount importance for the success of
any procedure. Age, previous obstetric history, pelvic inflammatory
disease, whether patient is ovulating regularly and whether the partner
is fertile should be assessed before hand. Operating notes of the sterilization
procedure helps as results of mid tubal Pomeroy procedure are far better
than diathermy close to the cornual junction. We
routinely perform our tubal recanalizations by a very low Pfanenstiel
incision just above the inguinal ligament ( Panty line incision ) because
at the end of the procedure we routinely excise the infra-umblical fold
of loose skin and fat and perform a mini abdominoplasty. We are of the
opinion that an improved body contour augments the patient’s self esteem
and keeps the partner more involved and interested. Once
the tubal block is identified only finest instruments are used for tissue
handling and damage is thus kept to a minimum. Constant irrigation of
peritoneal surfaces with heparinised Ringer lactate solution to avoid
blood clots, bipolar coagulation and magnification are now used. Relatively
minor trauma to serosa can result in avoidable adhesion formation after
surgery, this being the most serious consequence of tubal surgery. So
finger manipulation, big traumatic instruments and soabs are best avoided.
The blocked segment is excised with a new triangular blade and the mesosalpinx
is freshened. Serial sections of the tube are removed under magnification
till a clear open lumen is visualized on either sides. We make it a
point not to do any intra-luminal stenting or instrumentation for the
fear of damaging the mucosa. In one side the serosa is gently pulled
with No.2 Jewels forceps and snipped to let the mucosa and muscles protrude
out by 2mm and in the other side the mucosa and muscles are pulled out
and snipped to let the serosal layer project out. Now we do a two layered
anastomosis using 8-0 nylon for muscle layer, not touching the mucosa
, and 6-0 vicryl for the serosal layer. Thus a two layered staggered
anastomosis is established and because it is done under magnified vision
no patency tests are necessary. For reversal of sterilization at tubo-cornual junction every attempt is made to preserve the utero-tubal junction and yet produce a leak proof anastomosis. All scarring in the uterine wall is removed under magnification and diameter discrepancy is handled by a small longitudinal incision into the intramural tube. All pathological tissues should be removed from the cornu to avoid re-occlusion. Mere patency is insufficient. The signs that all diseased tissue have been removed are 1. Four or five mucosal folds can be seen in the cornual lumen 2. No mucosal polyps visible and no diverticulum present 3. Fine blood vessels can be seen running in the epithelium close to its cut edge 4. All white gritty fibrous tissue has been resected A
stay suture of 6-0 vicryl holds the mesosalpinx just beneath the tube
to the uterine wall to relieve tension on the 8-0 proline sutures at
3,6,9 and 12’O clock positions which are positioned thereafter to approximate
the muscular layer. Serosal layer of 6-0 vicryl completes the anastomosis.
At times the intramural portion of the tube may be completely
obliterated by dense scar tissue and a cornual anastomosis is thus rendered
impossible. In such situations an utero-tubal implant is performed. Post
operatively antibiotics, steroids and rest in bed are essential. Hydrocortisone
sodium phosphate 200 mg. intra-peritoneally during surgery and dexamethasone
for four days after surgery is our routine. There is no room for hydrotubation
after tubal microsurgery. Patients should be encouraged to have intercourse
as soon as they are comfortable after tubal surgery. There appears to
be no extra risk of ectopic pregnancy and sexual activity may encourage
tubal motility. Good results depend upon assiduous follow up, fortnightly for three months and three monthly intervals thereafter. Particular attention to the endocrine status and stimulation of ovulation whenever required should be done. Repeated sperm counts of the partner as well as post coital tests should be performed. Those
who fail to become pregnant in 6 months need a hystero-salpingogram
and, if required, a subsequent laparoscopy. Microvascular transplantation of human fallopian tube as a homograft after proper ABO and HL-A tissue typing is on the anvil. Wood et. al. in 1978 reported the first successful transplant which survived for six months but then suffered delayed allograft rejection. Microvascular homotransplantation of ovary was performed by Chow in 1982 in which a 44 year old lady donated an ovary to a 20 year old girl with congenital absence of ovary. The graft survived and in 2 years time the signs of ovarian deficiency decreased. SURGERY
FOR MALE INFERTILITY Surgery
for male infertility particularly vas re-canalization and vaso-epididymal
anastomosis also show vast improvement in the results when performed
under magnification by a trained personnel. Gentle tissue handling,
use of fine sutures, two layered staggered anastomosis with no suture
or stent in the lumen and secure haemostasis forms the basis of
microsurgery in these situations. A testicular biopsy should be taken
as a routine to determine spermatogenesis. Ambulation within 24 hours
with a proper scrotal support, sexual intercourse after 3 weeks and
semen analysis after six weeks is our protocol. Sperm count while relatively
high in the early post-operative period may gradually decrease in the
first 6 months and the couple should take the maximum advantage of this
early sperm count. The tripod of proper case selection, meticulous microsurgical technique and very careful follow up should always be remembered as this alone decides the success of the surgical treatment of infertility.
Penile
Reconstruction
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