Reproductive Surgery and Minimally Invasive Gynecology
Hysteroscopy
Hysteroscopy is diagnostic and therapeutic for polyps, submucosal fibroids, synechiae, and septa. Submucosal fibroids (FIGO type 0–2) distort the cavity and are most associated with infertility; resection may improve outcomes. Type 3 fibroids are intramural contacting the endometrium.
Laparoscopy
Laparoscopy addresses endometriosis, adhesions, and ovarian cysts. For endometriosis, excision of deep infiltrating disease may improve pain; fertility benefit is clearest for moderate–severe disease. Ovarian cystectomy for endometrioma should be conservative to preserve reserve.
Traps
- Assuming all fibroids cause infertility-subserosal fibroids generally do not.
- Overlooking fluid management in hysteroscopy (distension media) and risk of hyponatremia.
- Performing extensive ovarian surgery that reduces ovarian reserve.
- Missing that Asherman syndrome requires adhesiolysis and may need postoperative estrogen or barrier.
Worked example
A 34-year-old with infertility and a 3 cm submucosal fibroid: hysteroscopic myomectomy is reasonable, as cavity distortion is linked to implantation failure. Subserosal fibroids would generally be observed.