Written by Lizanne van Waart
Director & Founder of Wijnland Fertility Clinic / ART Counselling
MA. (Psychology) University of Stellenbosch

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus. Endometriosis triggers a chronic inflammatory reaction resulting in pain and adhesions. Adhesions develop when scar tissue attaches to separate structures or organs together. The activity and the complaints due to endometriosis may vary during the woman’s menstrual cycle as hormone levels fluctuate. Consequently, symptoms may be worse at certain times in the cycle, particularly just before and during the woman’s menstrual period.

While some women with endometriosis experience severe pelvic pain, others have no symptoms at all or regard their symptoms as simply being ‘ordinary menstrual pain’. In rare instances, cyclical pain can also involve the upper part of the abdomen e.g., under the ribs or the chest.

It is estimated that between 2% and 10% of the women within the general population have endometriosis and that 30% – 50% of infertile women have endometriosis. Women with endometriosis often experience severe symptoms and significantly reduced quality of life, including restraint of normal activities, pain/discomfort, and anxiety/ depression.

What causes endometriosis?

The cause of endometriosis remains unknown. There are several theories, but none of them has been entirely proven. The most accepted theory is centred on the so-called retrograde menstruation. During menstruation, pieces of endometrium arrive in the abdominal cavity through the Fallopian tubes, adhere to the peritoneal lining and develop into endometriotic lesions.

The hormone estrogen is crucial in this process. Subsequently, most of the current treatments for endometriosis attempt to lower estrogen production in a woman’s body to relieve her of symptoms.

It has been argued that endometriosis is a genetic disease since some families show more patients with endometriosis compared to other families. However, it is unlikely that there exists an ‘endometriosis gene’. Other suggestions are an immune response triggering inflammation.

What are the symptoms of endometriosis?

Because the symptoms of endometriosis are not very specific, the diagnosis of endometriosis cannot be made by the symptoms alone. However, symptoms can give a doctor a first hint towards the diagnosis of endometriosis.

The symptoms of endometriosis are:

  • • Painful menstrual periods (dysmenorrhea)
  • • Non-menstrual pelvic pain or pain occurring when a woman is not menstruating.
  • • Pain during or after sexual intercourse (dyspareunia)
  • • Pain emptying the bladder/painful urination (dysuria)
  • • Pain emptying the bowel (dyschezia)
  • • Painful rectal bleeding or the presence of blood in the urine (haematuria)
  • • Shoulder tip pain
  • • Cyclical lung problems (pneumothorax)
  • • Cyclical cough, chest pain, or coughing of blood (haemoptysis)
  • • Cyclical scar swelling and pain
  • • Fatigue
  • • Infertility
  • • Any other cyclical symptom

Lizanne van Waart, Director and Founder of Wijnland Fertility says: “My mom once told me that once you are mature, you will realise that Silence is more powerful than proving your point – And I felt that.”

Advanced Endoscopic Surgery

Dr Johannes van Waart, Director and Founder of Wijnland Fertility explains that one of the techniques we use at Wijnland to help women become mothers is a technique called endoscopy and/or endoscopic surgery. 

He further explains that an endoscope is a thin tube with a light and camera (and tiny surgical tools in the case of endoscopic surgery) on the end which our experts can use to examine the pelvic area or uterus for any abnormalities and perform minimally invasive surgical interventions.   

Dr Johannes van Waart, Director and Founder of Wijnland Fertility goes into detail by explaining that two main types of endoscopy are used in infertility:

  • • Laparoscopic – which is used in general infertility diagnosis and treatment across the pelvic organs.

Gynaecological laparoscopy is frequently used in cases/suspected cases of:

  • • Abdominal adhesions
  • • Removal/biopsy of ovarian cysts (cystectomy)
  • • Tubal patency checks
  • • Caesarean Section scar/uterine niche defects
  • • Endometriosis surgery 
  • • Laparoscopic hysterectomies
  • • Sterilisation reversals   
  • • Hysteroscopic – which specifically involves the examination of or surgical intervention in the uterus/uterine cavity.

Gynaecological hysteroscopy is frequently used in cases/suspected cases of:

  • • Congenital uterine anomalies (reproductive defects present from birth)
  • • Uterine polyps 
  • • Uterine fibroids 
  • • Uterine adhesions/Asherman’s Syndrome

Benefits of endoscopic surgery

Dr Johannes van Waart, Director and Founder of Wijnland Fertility state that laparoscopic and hysteroscopic surgery conveys many benefits over traditional or ‘open’ surgeries and diagnostic procedures. These include:

  • • Fewer complications, as the visual nature of the process, allows the surgeon to see the entire area in detail
  • • Less scarring and no need for stitches
  • • Smaller incisions – ‘keyhole’ surgery   
  • • More accurate diagnosis
  • • Less painful  
  • • Shorter recovery times
  • • The surgeon has the option to initiate therapeutic interventions straight away (during the diagnostic procedure) if indicated 
  • • Reduced risk of infection

What to expect:

It’s important to remember that every case is unique, and not everyone reacts to or recovers from surgery and anaesthesia in the same way. Your health, age, and physical fitness may all have an impact on your experience. 

In the case of laparoscopic surgeries, which are performed under general anaesthesia, you will typically need to take a few days off work to recover, depending on the type of surgery you’re having. 

  • • Minor laparoscopic diagnostics or therapeutic interventions generally mean you can go home the same day, although you will need someone to drive you home and keep an eye on you overnight.  
  • • More complex procedures, such as a laparoscopic hysterectomy, will require you to stay at our facility overnight and may require you to take a week or more off work to rest and allow your body to heal.

Before your surgery or diagnostic procedure, your fertility doctor will discuss the procedure in detail, including details on how many incisions will be made, when you’ll be able to shower again, and whether you need to fast or avoid drinking liquids 24 hours before the procedure.

In the case of hysteroscopic surgeries, which are performed under no/local/sedation anaesthetic (to numb the cervix), you will generally not need to stay overnight and should be able to return to work after a day or two.

Most hysteroscopic procedures only take between 5 and 30 minutes and taking a mild painkiller during/after the procedure is all that’s required.

As with all medical procedures, laparoscopy and hysteroscopy do come with certain risks, which our highly trained fertility surgeons will walk you through before your procedure.

Why choose Wijnland for your endoscopic surgery?

Gynaecological Laparoscopic Surgery 

Dr Johannes van Waart, Director and Founder of Wijnland Fertility explains that laparoscopy is a minimally invasive technique which allows our fertility specialists to inspect (diagnostic laparoscopy) and perform surgical procedures on (operative laparoscopy) the uterus, fallopian tubes, and ovaries.

Depending on the organs we wish to have a look at, a small incision is made inside the belly button, or closer to the upper pubic region. Laparoscopic surgery is also known as keyhole surgery, as the fibreoptic camera on the end of the laparoscope is tiny.

This process allows us to identify any abnormalities which may be preventing women from conceiving, confirm a suspected diagnosis, and/or carry out therapeutic procedures simultaneously.

Laparoscopy is not painful, as it is carried out under general anaesthesia – you will be asleep throughout the entire process. Because the incision and laparoscope are so small, only minor healing is required afterwards, and only barely visible scar tissue results. 

This is one of the reasons gynaecological laparoscopy is often referred to as the ‘gold standard’ in evaluating female fertility.  

Some of the conditions Wijnland’s laparoscopic surgeons can identify and treat through this procedure include:

  • • Uterine fibroids
  • • Ovarian cysts 
  • • Tubal patency
  • • Polycystic ovaries 
  • • Pelvic adhesions 
  • • Endometriosis
  • • Structural abnormalities of the uterus
  • • Sterilisation reversal 

Find out more about some of these conditions and how endoscopic surgery can help.   

Abdominal Adhesions

Abdominal adhesions are areas where scar tissue has formed inside the body, often between the pelvic organs and abdominal wall. This can occur as a result of abdominal surgery, trauma, or some infections. You may have no detectable symptoms at all or might experience (sometimes severe) abdominal pain. These abdominal adhesions can also be the underlying cause of infertility.

Laparoscopy can help to confirm and release abdominal adhesions through a process known as abdominal adhesiolysis. Aside from increasing your chances of getting pregnant, abdominal laparoscopy can also remove the bowel pain often associated with abdominal adhesions. 

Cystectomy

Laparoscopic surgery for the removal of ovarian cysts or masses offers much faster recovery times compared with open surgery and is of course far less invasive. It can be used to alleviate the symptoms associated with conditions such as PCOS – Polycystic Ovarian Syndrome – or when cysts are growing and/or have the potential to become cancerous. 

The aim is always to help preserve the patient’s fertility. It is important to note, however, that a cystectomy can have an impact on your egg count, so our fertility experts will advise you whether it’s the right choice for your unique situation or not. 

Tubal Patency Check

A laparoscopic patency test is used to determine whether the fallopian tubes are blocked or clear (tubal patency). This is often done with the aid of a special dye which is injected through the fallopian tubes.  

Caesarean Section Scar Defect

Some women who undergo a Caesarean section when giving birth may suffer damage to and/or thinning of the muscle of the uterus, which makes falling pregnant again difficult. This defect (called a uterine niche or isthmocele) can usually be detected on an ultrasound, and repaired through laparoscopy. This involves removing the defect and then carefully re-suturing the uterus.  

Endometriosis Surgery

Endometriosis is a condition which can affect the ovaries, fallopian tubes, and pelvic tissue, wherein the lining of the uterus (the endometrium) grows outside of the uterine cavity. These implants cause inflammation, and often severe pain as well as menstrual irregularities, and can lead to difficulty getting pregnant.  

Laparoscopic endometriosis surgery can be extremely beneficial for women who suffer from endometriosis and wish to conceive, especially when combined with hormone therapy and IVF (in vitro fertilisation). In severe cases which require more extensive surgery, Wijnland’s fertility surgeons will walk you through your options to preserve your chances of having a baby.  

Laparoscopic Hysterectomy

A hysterectomy, or complete removal of the uterus, is sometimes necessary due to issues such as a prolapsed uterus, cervical, uterine or ovarian cancer, or pelvic inflammatory disease which is not responding to treatment. 

Laparoscopic hysterectomy is currently regarded as the safest and most advanced method to perform a hysterectomy, as your surgeon has a full view of the surrounding organs throughout the procedure. Some additional benefits include fewer complications, less pain and blood loss, and a decreased chance of infection.    

Sterilisation Reversal

Also known as a tubal ligation reversal or tubal re-anastomosis, this procedure involves using a laparoscope to perform microsurgery on the fallopian tubes, removing the section blocked during sterilisation and reconnecting them (re-anastomosis). 

While this procedure is incredibly advanced, (between 50 to 80% of women who undergo sterilisation reversal go on to have healthy pregnancies) it is important to be aware that it may not always be successful, especially in older women, or when there is not sufficient healthy fallopian tube remaining.

Get in touch/Reach out!      

If you have any questions or would like to make a booking to come in for a consultation with one of our supportive fertility experts, please reach out. 

Beyond clinical treatments/ Positive alternative treatments:

  • • Medical and surgical treatments of endometriosis have been studied widely and are used in clinical practice. Since these treatments have limitations, some women prefer to explore other options. Several of these complementary and alternative therapies are used by women with endometriosis to reduce pelvic pain, and painful menstrual periods (dysmenorrhea), improve the chances of pregnancy and improve quality of life.

You may have heard about complementary and alternative therapies. Lizanne van Waart, Director and Founder of Wijnland Fertility notes that even though these therapies are very popular, they are not often given by doctors.

  • • Acupuncture,
  • • Behavioural therapy
  • • Nutrition (including dietary supplements, vitamins, and minerals), – Fodmap diet
  • • Expert patient programmes
  • • Recreational drugs
  • • Reflexology
  • • Homoeopathy, herbal medicine
  • • Psychological therapy
  • • Traditional
  • • Exercise

Some women who use complementary and alternative treatments may feel the benefit from this, meaning that they have improved quality of life and/or can cope better with the symptoms of endometriosis.

Please feel free to get in touch if you have any questions or would like to come in for a consultation. Our knowledgeable fertility specialists in Stellenbosch are standing by to help! 

The Endoscopy Team at Wijnland Fertility is Dr Johannes van Waart, Dr Ludwig van Zyl and Dr Candice Morrison.

Four Beautiful thoughts of life:

  • • Look back and get Experience
  • • Look forward and see Hope
  • • Look around and find Reality
  • • Look within and find Yourself

—
Written by Lizanne van Waart
Director & Founder of Wijnland Fertility Clinic / ART Counselling
MA. (Psychology) University of Stellenbosch