Reproductive surgery

Last updated
Reproductive surgery
Specialty Reproductive medicine
Reproductive Surgeon
Occupation
Names
  • Physician
  • Surgeon
Occupation type
 Specialty
Activity sectors
 Medicine, Surgery
Description
Education required
Fields of
employment
 Hospitals, Clinics

Reproductive surgery is surgery in the field of reproductive medicine. It can be used for contraception, e.g. in vasectomy, wherein the vasa deferentia of a male are severed, but is also used plentifully in assisted reproductive technology. Reproductive surgery is generally divided into three categories: surgery for infertility, in vitro fertilization, and fertility preservation. [1]

Contents

A reproductive surgeon is an obstetrician-gynecologist or urologist who specializes in reproductive surgery. [2]

Reproductive surgeries will be referred to based on biological sex, and terms such male and female will be used to denote to men and women respectively.

Uses

Reproductive surgery aims to address concerns spanning from male and female fertility to gender-affirming care. [3] [4] Uses for reproductive surgery may encompass different abnormalities, dysfunctions, and areas of focus that are unable to be treated solely through medication or nonsurgical treatment. [4] Screening measures may be completed to determine the necessity of surgery. For example, intrauterine pathology may be assessed by utilizing techniques such as hysteroscopy to identify complications for reproductive surgical interventions. [4]

Assisted reproductive technology (ART) supports enhancement of fertility success through processes such as in vitro fertilization (IVF). [4] Screening and reproductive surgery also have a role in identifying and addressing abnormalities, such as notable cysts, prior to initiating IVF. [4] Surgical sperm retrieval is an alternative means of semen collection, where other means are not possible in circumstances like posthumous sperm retrieval or male infertility. [5] [6]

These surgical techniques may also be utilized as a form of permanent contraception referred to as sterilization. [7] A vasectomy or tubal ligation would be examples of this procedure for male and female individuals respectively. [8] [9] Reproductive surgeons can potentially perform a reverse vasectomy to restore male reproductive function following the vasectomy. Individuals may choose to reverse the procedure due to pain experience after the surgery. [9]

People might find themselves wanting to preserve their fertility. Biological material such as sperm or oocyte are capable of being surgically collected and preserved cryogenically. [6] Fertility preservation also provides individuals who are receiving gender-affirming surgeries the option of preserving gametes if having biological children is desired following the procedures and hormonal therapy. [6] [7]

Reproductive surgery is also considered for complications such as endometriosis, polycystic ovary syndrome, ectopic pregnancy, and vas deferens obstruction. [1]

History

Albeit an increase in overall use of assisted reproductive technology (ART), surgeries on the fallopian tubes and ovaries have decreased, leading to a rise in insecurity in the field of reproductive surgery. [10] Reproductive surgery in women has largely been complementary to other ART methods such as medication, except for in tubal infertility, where surgery remains the main treatment. [11] Although reproductive surgery has been most relevant for severe symptoms, there has been a strong interest in greater analysis surrounding this topic of research. [10]

Reproductive surgery first began with fertility sparing surgeries, such as uterine myomectomy, and was transitioned later into the addition of surgeries for infertility and the advancement of success rates for fertility. Hysterectomies and myomectomies date back to ancient times, where fascination grew around fertility sparing surgeries, specifically for young women who were able to conceive but were considered to have suspected ailments. [10] However, the lack of knowledge of medicine eventually led to mortality, thereby causing myomectomies to become more uncommon. Overtime, various advancements and extensive research allowed for the discovery of minimally invasive myomectomies, which became popular among women who were capable of bearing children. [10]

Laparoscopy continues to be a common procedure approach as it is minimally invasive and is thought to be associated with a decrease in hospital stay and surgical complications. [10] The development of newer technology and surgical techniques allowed for the increase in success rates for various other surgeries, such as endometriosis and adenomyosis surgeries or adnexal surgeries.

The future of reproductive surgery

With respect to the future of reproductive surgeries, greater advancements of surgical techniques and equipment are growing in popularity to increase the potential of fertility success rates. For example, vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new innovative approach that has been used for ovarian torsion, tubal ectopic pregnancy, and ovarian cystectomies. [10] This surgical approach is minimally invasive and has emerged in an effort to reduce pain, risks, and potential for scarring. [12] Another technique that has emerged is radiofrequency ablation (RFA) which has been used for uterine fibroids. It works to necrotize fibroids through the use of laparoscopic and transcervical procedures with two devices, Acessa (Hologic) and Sonata (Gynesonics). However, these two medical devices come with the caveat that fertility may not be preserved in those with uterine leiomyoma. [10] Although not ideal for people who are able to and wanting to bear children, RFA still poses as an alternative successful technique to reducing the volume of fibroids. [13]

A new common interest in alliance with reproductive surgery is the use of regenerative medicine. Although it has not been studied in its entirety, the use of stem cells to restore damaged endometrium has shown promising improvements. [14] [15] Regenerative medicine has been used for premature ovarian failure and will continue to be studied for in vitro fertilization (IVF). [10] With the use of various stem cells, researchers hope to mitigate and treat any future signs of infertility with the use of two specific stem cells, induced pluripotent stem cells (iPSCs) and mesenchymal stem cells (MSC). [16]

Risks/complications

The risks and complications of reproductive surgery depend on patient specific characteristics and the degree of the surgery itself; however, some common complications of general reproductive surgery are hemorrhage, visceral damage, infection, and blot clotting. [17]

In vasectomies, infection and hematomas are the most frequently reported complications of surgery, with the incidence rate of infection being 3-4% and the incidence rate of hematoma ranging around 0-29%. [18] An important note to consider is the fact that the surgical technique of the vasectomy did have an impact on the incident rates of these complications. No-scalpel vasectomy (NSV) is widely recognized due to its low incident rate of complications. [18] Another common complication of vasectomy is post-vasectomy pain syndrome (PVPS). PVPS involves chronic pain that may be persistent or intermittent in one or both of the testicles, and lasting longer than three months after the procedure. [19] While the pathophysiology of PVPS is unknown, various causes include damage to structures of the testis, buildup of pressure from epididymal congestion, and compression of nerves in the testis. The pain in PVPS can manifest in various forms, such as pain and tenderness in the scrotum, pressure or pain after ejaculation, pain with sex, etc. [19] Incidence rates of PVPS are around 1-14%. [18]

In hysterectomies, complications of the procedure include infection, gastrointestinal injury, and venous thromboembolic injury. Similar to vasectomies, one of the most common complications is infection, with the incidence rate being 10.5% for abdominal hysterectomy, 13% for vaginal hysterectomy, and 9% for laparoscopic hysterectomy. [20]

Today, one of the most effective forms of ART is in vitro fertilization (IVF). [21] While it is very effective in those experiencing infertility, there are numerous risks of IVF, such as multiple births, premature delivery, and ovarian hyper-stimulation syndrome. Ovarian hyper-stimulation syndrome is a condition that involves enlargement of the ovaries as the result of the injected fertility drugs causing increased capacity of the blood vessels to allow molecules to go in and out. [21] [22] It can lead to abdominal pain, soreness, and nausea for those experiencing it. [22] The symptoms and severity of ovarian hyper-stimulation syndrome can be classified amongst various grades. Grade 1 involves mild discomfort and abdominal distention, and as the grades increase, severity and symptoms also increase. Grade 4 and grade 5 encompass severe ovarian hyper-stimulation syndrome and involve changes in blood volume and viscosity due to the condition. [22] Those who have a history of heightened response to gonadotropins, history of previous ovarial hyper-stimulation, and/or have a history of polycystic ovary syndrome (PCOS) are at increased risk of developing this complication. [22]

Contraindications

There are no existing medical guidelines that outline the absolute contraindications to reproductive surgery. However, there are relative contraindications recommended in the current literature. There are several circumstances under which having reproductive surgery is contraindicated. This is because surgery itself may cause extensive tissue damage to the person, the success of the procedure is limited (i.e. the condition is invasive or metastatic), or the surgery's potential risk outweighs the potential benefits. [17] However, each person's situation is different and the possibility of reproductive surgery should be consulted with a healthcare professional.

Uterine atony after fetal extraction, and pre-existing maternal bleeding disorders have been reported as accepted contraindications for cesarean myomectomies in women. [23] [24] Contraindications to reproductive surgery used for tubal surgery and infertility include women ages 43 and older, tubal disease that surgery cannot treat (i.e., surgery cannot be safely performed without hurting the person or the patient has multiple medical conditions that reduces the chance of success), bipolar disease, and abnormal semen analysis. [25]

Many studies examining surgery for endometriosis excluded women who previously received medical or surgical treatment for endometriosis. [26] Women with a pre-operative diagnosis of a deep endometriosis of their bowel or bladder were also excluded from surgery. [27]

For male reproductive surgery for the treatment of varicocele by percutaneous embolization, current literature considers adolescents, allergies to contrast, men with a bilateral grade 3 varicocele, and men with primary infertility as relative contraindications to surgery. [28]

Related Research Articles

<span class="mw-page-title-main">Endometriosis</span> Disease of the female reproductive system

Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Lesions can be found on ovaries, fallopian tubes, tissue around the uterus and ovaries (peritoneum), intestines, bladder, and diaphragm; it may also occur in other parts of the body. Some symptoms include pelvic pain, heavy and painful periods, pain with bowel movements, painful urination, pain during sexual intercourse and infertility. Nearly half of those affected have chronic pelvic pain, while in 70% pain occurs during menstruation. Infertility occurs in up to half of affected individuals. About 25% of individuals have no symptoms and 85% of those seen with infertility in a tertiary center have no pain. Endometriosis can have both social and psychological effects.

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

Infertility is the inability of an animal or plant to reproduce by natural means. It is usually not the natural state of a healthy adult, except notably among certain eusocial species. It is the normal state of a human child or other young offspring, because they have not undergone puberty, which is the body's start of reproductive capacity.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

<span class="mw-page-title-main">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Uterine fibroid</span> Medical condition with benign tumors of uterus

Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus. Most women with fibroids have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bladder, causing a frequent need to urinate. They may also cause pain during penetrative sex or lower back pain. A woman can have one uterine fibroid or many. Occasionally, fibroids may make it difficult to become pregnant, although this is uncommon.

Adenomyoma is a tumor (-oma) including components derived from glands (adeno-) and muscle (-my-). It is a type of complex and mixed tumor, and several variants have been described in the medical literature. Uterine adenomyoma, the localized form of uterine adenomyosis, is a tumor composed of endometrial gland tissue and smooth muscle in the myometrium. Adenomyomas containing endometrial glands are also found outside of the uterus, most commonly on the uterine adnexa but can also develop at distant sites outside of the pelvis. Gallbladder adenomyoma, the localized form of adenomyomatosis, is a polypoid tumor in the gallbladder composed of hyperplastic mucosal epithelium and muscularis propria.

<span class="mw-page-title-main">Hydrosalpinx</span> Medical condition

A hydrosalpinx is a condition that occurs when a fallopian tube is blocked and fills with serous or clear fluid near the ovary. The blocked tube may become substantially distended giving the tube a characteristic sausage-like or retort-like shape. The condition is often bilateral and the affected tubes may reach several centimeters in diameter. The blocked tubes cause infertility. A fallopian tube filled with blood is a hematosalpinx, and with pus a pyosalpinx.

<span class="mw-page-title-main">Reproductive medicine</span> Branch of medicine

Reproductive medicine is a branch of medicine concerning the male and female reproductive systems. It encompasses a variety of reproductive conditions, their prevention and assessment, as well as their subsequent treatment and prognosis.

Poor ovarian reserve is a condition of low fertility characterized by 1): low numbers of remaining oocytes in the ovaries or 2) possibly impaired preantral oocyte development or recruitment. Recent research suggests that premature ovarian aging and premature ovarian failure may represent a continuum of premature ovarian senescence. It is usually accompanied by high FSH levels.

Transvaginal oocyte retrieval (TVOR), also referred to as oocyte retrieval (OCR), is a technique used in in vitro fertilization (IVF) in order to remove oocytes from the ovary of a woman, enabling fertilization outside the body. Transvaginal oocyte retrieval is more properly referred to as transvaginal ovum retrieval when the oocytes have matured into ova, as is normally the case in IVF. It can be also performed for egg donation, oocyte cryopreservation and other assisted reproduction technology such as ICSI.

The fertiloscope is a type of laparoscope, modified to make it suitable for trans-vaginal application, which is used in the diagnosis and treatment of female infertility.

Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary. Typically the egg cell is not released or picked up at ovulation, but fertilized within the ovary where the pregnancy implants. Such a pregnancy usually does not proceed past the first four weeks of pregnancy. An untreated ovarian pregnancy causes potentially fatal intra-abdominal bleeding and thus may become a medical emergency.

<span class="mw-page-title-main">Fertility testing</span>

Fertility testing is the process by which fertility is assessed, both generally and also to find the "fertile window" in the menstrual cycle. General health affects fertility, and STI testing is an important related field.

Endometriosis and its complications are a major cause of female infertility. Endometriosis is a dysfunction characterized by the migration of endometrial tissue to areas outside of the endometrium of the uterus. The most common places to find stray tissue are on ovaries and fallopian tubes, followed by other organs in the lower abdominal cavity such as the bladder and intestines. Typically, the endometrial tissue adheres to the exteriors of the organs, and then creates attachments of scar tissue called adhesions that can join adjacent organs together. The endometrial tissue and the adhesions can block a fallopian tube and prevent the meeting of ovum and sperm cells, or otherwise interfere with fertilization, implantation and, rarely, the carrying of the fetus to term.

<span class="mw-page-title-main">Prophylactic salpingectomy</span> Surgical technique

Prophylactic salpingectomy is a preventative surgical technique performed on patients who are at higher risk of having ovarian cancer, such as individuals who may have pathogenic variants of the BRCA1 or BRCA2 gene. Originally salpingectomy was used in cases of ectopic pregnancies. As a preventative surgery however, it involves the removal of the fallopian tubes. By not removing the ovaries this procedure is advantageous to individuals who are still of child bearing age. It also reduces risks such as cardiovascular disease and osteoporosis which are associated with removal of the ovaries.

<span class="mw-page-title-main">Victor Bonney</span>

William Francis Victor Bonney FRCP FRCS was a prominent British gynaecological surgeon. He was described by Geoffrey Chamberlain as "a primary influence on world gynaecology in the years between the wars".

References

  1. 1 2 Tulandi T, Marzal A (2012). "Redefining reproductive surgery". Journal of Minimally Invasive Gynecology. 19 (3): 296–306. doi:10.1016/j.jmig.2012.01.010. PMID   22348901.
  2. ↑ "Reproductive Surgeon". Glossary. The InterNational Council on Infertility Information Dissemination (INCIID). 4 May 2004. Archived from the original on 23 December 2008.
  3. ↑ Antonouli S, Di Nisio V, Messini C, Daponte A, Rajender S, Anifandis G (2023). "A comprehensive review and update on human fertility cryopreservation methods and tools". Frontiers in Veterinary Science. 10: 1151254. doi: 10.3389/fvets.2023.1151254 . PMC   10151698 . PMID   37143497.
  4. 1 2 3 4 5 Raff M, DeCherney A (August 2019). "Reproductive surgery and in vitro fertilization: the future reevaluated". Fertility and Sterility. 112 (2): 197–202. doi: 10.1016/j.fertnstert.2019.06.010 . PMID   31352958. S2CID   198965325.
  5. ↑ Kresch E, Efimenko I, Gonzalez D, Rizk PJ, Ramasamy R (July 2021). "Novel methods to enhance surgical sperm retrieval: a systematic review". Arab Journal of Urology. 19 (3): 227–237. doi:10.1080/2090598X.2021.1926752. PMC   8451700 . PMID   34552774.
  6. 1 2 3 Antonouli S, Di Nisio V, Messini C, Daponte A, Rajender S, Anifandis G (2023). "A comprehensive review and update on human fertility cryopreservation methods and tools". Frontiers in Veterinary Science. 10: 1151254. doi: 10.3389/fvets.2023.1151254 . PMC   10151698 . PMID   37143497.
  7. 1 2 Grin, Leonti; Girsh, Eliezer; Harlev, Avi (March 2021). "Male fertility preservation–Methods, indications and challenges". Andrologia. 53 (2): e13635. doi: 10.1111/and.13635 . ISSN   0303-4569. PMID   32390180. S2CID   218585277.
  8. ↑ Patil, Eva; Jensen, Jeffrey (March 2016). "Permanent Contraception for Women". Seminars in Reproductive Medicine. 34 (3): 139–144. doi:10.1055/s-0036-1571434. ISSN   1526-8004. PMID   26960907. S2CID   8645303.
  9. 1 2 Patel AP, Smith RP (2016). "Vasectomy reversal: a clinical update". Asian Journal of Andrology. 18 (3): 365–371. doi: 10.4103/1008-682X.175091 . PMC   4854082 . PMID   26975488.
  10. 1 2 3 4 5 6 7 8 Bortoletto P, Romanski PA, Petrozza JC, Pfeifer SM (March 2023). "Reproductive surgery: revisiting its origins and role in the modern management of fertility". Fertility and Sterility. 120 (3): 539–550. doi: 10.1016/j.fertnstert.2023.02.031 . PMID   36870592. S2CID   257323053.
  11. ↑ Ketefian A, Hu J, Bartolucci AA, Azziz R (August 2009). "Fifteen-year trend in the use of reproductive surgery in women in the United States". Fertility and Sterility. 92 (2): 727–735. doi: 10.1016/j.fertnstert.2008.06.041 . PMID   18823883.
  12. ↑ Lerner, Veronica T.; May, Grover; Iglesia, Cheryl B. (2023). "Vaginal Natural Orifice Transluminal Endoscopic Surgery Revolution: The Next Frontier in Gynecologic Minimally Invasive Surgery". Journal of the Society of Laparoendoscopic Surgeons. 27 (1): e2022.00082. doi:10.4293/JSLS.2022.00082. ISSN   1938-3797. PMC   9913063 . PMID   36818766.
  13. ↑ Lee, Bruce B.; Yu, Steve P. (2016). "Radiofrequency Ablation of Uterine Fibroids: a Review". Current Obstetrics and Gynecology Reports. 5 (4): 318–324. doi:10.1007/s13669-016-0183-x. ISSN   2161-3303. PMC   5114324 . PMID   27917310.
  14. ↑ Lv, Qiaoying; Wang, Lulu; Luo, Xuezhen; Chen, Xiaojun (June 2021). "Adult stem cells in endometrial regeneration: Molecular insights and clinical applications". Molecular Reproduction and Development. 88 (6): 379–394. doi:10.1002/mrd.23476. ISSN   1040-452X. PMC   8362170 . PMID   34014590.
  15. ↑ Wang, Jing; Liu, Chi; Fujino, Masayuki; Tong, Guoqing; Zhang, Qinxiu; Li, Xiao-Kang; Yan, Hua (2019). "Stem Cells as a Resource for Treatment of Infertility-related Diseases". Current Molecular Medicine. 19 (8): 539–546. doi:10.2174/1566524019666190709172636. ISSN   1875-5666. PMC   6806537 . PMID   31288721.
  16. ↑ Saha, Sarama; Roy, Partha; Corbitt, Cynthia; Kakar, Sham S. (2021-06-28). "Application of Stem Cell Therapy for Infertility". Cells. 10 (7): 1613. doi: 10.3390/cells10071613 . ISSN   2073-4409. PMC   8303590 . PMID   34203240.
  17. 1 2 Mann Jr WJ (May 2023). Sharp HT, Eckler K (eds.). "Complications of gynecologic surgery". UpToDate. Retrieved 2023-07-25.
  18. 1 2 3 Yang F, Li J, Dong L, Tan K, Huang X, Zhang P, et al. (July 2021). "Review of Vasectomy Complications and Safety Concerns". The World Journal of Men's Health. 39 (3): 406–418. doi:10.5534/wjmh.200073. PMC   8255399 . PMID   32777870.
  19. 1 2 "Post-vasectomy pain syndrome - Symptoms and causes". Mayo Clinic. Retrieved 2023-07-26.
  20. ↑ Clarke-Pearson DL, Geller EJ (March 2013). "Complications of hysterectomy". Obstetrics and Gynecology. 121 (3): 654–673. doi:10.1097/AOG.0b013e3182841594. PMID   23635631. S2CID   25380233.
  21. 1 2 "In vitro fertilization (IVF) - Mayo Clinic". www.mayoclinic.org. Retrieved 2023-07-26.
  22. 1 2 3 4 Kumar P, Sait SF, Sharma A, Kumar M (May 2011). "Ovarian hyperstimulation syndrome". Journal of Human Reproductive Sciences. 4 (2): 70–75. doi: 10.4103/0974-1208.86080 . PMC   3205536 . PMID   22065820.
  23. ↑ Tinelli A, Nezhat CH, Likić-Ladjević I, Andjić M, Tomašević D, Papoutsis D, et al. (2021-12-15). "Myomectomy during cesarean section or non-caesarean myomectomy in reproductive surgery: this is the dilemma". Clinical and Experimental Obstetrics & Gynecology. 48 (6): 1250–1258. doi: 10.31083/j.ceog4806199 . ISSN   0390-6663. S2CID   245235424.
  24. ↑ Goyal M, Dawood AS, Elbohoty SB, Abbas AM, Singh P, Melana N, Singh S (January 2021). "Cesarean myomectomy in the last ten years; A true shift from contraindication to indication: A systematic review and meta-analysis". European Journal of Obstetrics, Gynecology, and Reproductive Biology. 256: 145–157. doi:10.1016/j.ejogrb.2020.11.008. PMID   33232889. S2CID   227168195.
  25. ↑ Coughlan C, Li TC (2011-10-01). "An update on surgical management of tubal disease and infertility" . Obstetrics, Gynaecology & Reproductive Medicine. 21 (10): 273–280. doi:10.1016/j.ogrm.2011.07.002. ISSN   1751-7214.
  26. ↑ Leonardi, Mathew; Gibbons, Tatjana; Armour, Mike; Wang, Rui; Glanville, Elizabeth; Hodgson, Ruth; Cave, Adele E.; Ong, Jozarino; Tong, Yui Yee Felice; Jacobson, Tal Z.; Mol, Ben W.; Johnson, Neil P.; Condous, George (2020-02-01). "When to Do Surgery and When Not to Do Surgery for Endometriosis: A Systematic Review and Meta-analysis". Journal of Minimally Invasive Gynecology. 27 (2): 390–407.e3. doi: 10.1016/j.jmig.2019.10.014 . ISSN   1553-4650. PMID   31676397. S2CID   207833633.
  27. ↑ Alkatout, Ibrahim; Mettler, Liselotte; Beteta, Carmen; Hedderich, Jürgen; Jonat, Walter; Schollmeyer, Thoralf; Salmassi, Ali (2013). "Combined surgical and hormone therapy for endometriosis is the most effective treatment: prospective, randomized, controlled trial". Journal of Minimally Invasive Gynecology. 20 (4): 473–481. doi:10.1016/j.jmig.2013.01.019. ISSN   1553-4669. PMID   23567095.
  28. ↑ Halpern, J., Mittal, S., Pereira, K., Bhatia, S., & Ramasamy, R. (2016). Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Asian journal of andrology, 18(2), 234–238. https://doi.org/10.4103/1008-682X.169985
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.