24
Robotics and Infertility
Sejal Dharia Patel
Surgery in the field of reproduction has tradition-
ally been taught utilizing tradition laparotomy
incision. The advantages of the laparotomy
approach include depth perception and tactile
feedback from the resistance of tissue/organ
dynamics. In addition, there is an ease of intra-
abdominal suturing from the six degrees of
freedom afforded from the human wrist. Although
a laparotomy is advantageous for the surgeon com-
pared to other surgical techniques, there are disad-
vantages for the patient, including a large
abdominal incision, prolonged hospitalization,
increased postoperative analgesic requirements,
and increased morbidity.1,2 This has led some sur-
geons to seek out minimally invasive approaches.
The first laparoscopy was described by Ott from
Petrograd, who inspected the abdominal cavity
using a head mirror and an abdominal wall specu-
lum in 1901, calling the procedure ventroscopy.3
However, it was the first International Symposium
of Gynecologic Endoscopy in 1964 that initiated
interest in laparoscopic tubal sterilization,4 gamete
intrafallopian tubal transfer,5 and other laparo-
scopic gynecologic procedures in the ensuing four
decades.6 Laparoscopy offers advantages to the
patient: improved cosmesis, decreased blood loss,
less postoperative analgesic requirements, shorter
hospitalization time, and quicker recovery.1,2
However, its usefulness is limited due to the steep
learning curve for surgeons. Other obstacles
include limited dexterity, counterintuitive motion,
two-dimensional vision, and ergonomic difficulty.
Tremor amplification can also occur from the use
of long rigid instruments for prolonged periods of
time in a fixed position.7 In laparoscopic surgery,
188
the fulcrum point created by the trocars limits the
surgeon to four degrees of freedom, reducing dex-
terity.8 In addition, because of the fulcrum at the
trocars, the movements of the surgeon’s hands
results in movements in the opposite direction at
the working end of the laparoscope, making move-
ments counterintuitive.7 The laparoscopic surgeon
must also accommodate to a two-dimensional
screen, which limits depth perception as compared
to the three-dimensional vision afforded by open
surgery.7 Ergonomics is also impacted by tradi-
tional minimally invasive surgery.8 In a survey by
Society of American Gastrointestinal Endoscopic
Surgeons, 8% to 12% reported pain or numbness in
the arms, wrists, hands, or shoulders after per-
forming laparoscopic surgery,9 which has been
confirmed by electromyographic data.10 These lim-
itations can be overcome if the surgical procedure
is facile and efficient.
Simple reproductive procedures, such as
ovarian cystectomy and cauterization of endo-
metriosis, are examples of procedures that can be
effectively performed through laparoscopy and
have obtained popular acceptance since their
first description in the 1970s.6 It is the more
complex, advanced laparoscopic cases that
present a challenging learning curve, including
microsurgical tubal reanastomosis.
Robotic technology, more specifically, telero-
botic surgical systems, offers the opportunity to
bridge this gap between laparotomy and laparos-
copy by enabling minimally invasive surgery with
three-dimensional vision, ergonomically optimal
positioning, tremor fi ltration, and laparoscopic
instruments with intra-abdominal articulation.11
24. Robotics and Infertility
24.1. Current Applications of
Robotic Surgery in Reproductive
Endocrinology and Infertility
Although reproductive endocrinologists were
among the first to use laparoscopic surgical tech-
niques, the role of robotic surgery in reproduction
has developed after other surgical specialties.
In the subspecialty of reproductive endocri-
nology, a few procedures have been reported
using robotic technology (Table 24.1).
24.1.1. Female
24.1.1.1. Tubal Reversals
One of the original procedures to gain popularity
was the microsurgical tubal reversal. Using the
Zeus® surgical system (Computer Motion), the
first procedure performed was microsurgical
uterine horn anastomoses in six female pigs in
1998.12 This procedure capitalizes on the advan-
tages of the robotic system by providing the fi ne
motor movements required for intracorporeal
suturing, three-dimensional vision, and motion
scaling to assist in microsurgery. Falcone and
colleagues13 performed the first human clinical
trial using the Zeus® robotic system in 1998 on
10 patients with previous tubal ligations who
underwent a robotically assisted laparoscopic
tubal reanastomosis. The setup included place-
ment of the ports in the lower quadrants bilater-
ally for the robotic arms and one port was placed
suprapubically for introduction of suture. To
perform the reanastomosis, 6-0 polygalactin
(Polyglactin 910, Ethicon, Inc., Piscataway, NJ)
was used on the mesosalpinx and 8-0 used on
the fallopian tube. The mean operative time to
perform the anastomosis was 159 ± 33.8 min.
Chromopertubation established patency in 17 of
19 tubes reanastomosed with a pregnancy rate of
TABLE 24.1. Robotic procedures in reproductive medicine.
Female reproductive surgery Male reproductive surgery
Tubal reanastomosis Vasovasotomy
Myomectomy Vasoepididymostomy
Ovarian transposition Varicocele ligation
Gonadectomy
189
50%. They then compared their robotic reanasto-
moses to traditional laparoscopic reanastomosis
and found that operative times were significantly
longer (two hours) with use of the Zeus® robotic
system, but all other outcomes were compara-
ble.14 Degueldre and colleagues15 then performed
a feasibility study with the da Vinci® Surgical
System (Intuituive Surgical Inc., Sunnyvale, CA)
on eight patients. The mean operating time was
181.5 min and although follow-up was limited to
four months, two of the eight patients achieved a
pregnancy and five of eight patients demonstrated
at least unilateral patency. Subsequently, Dharia
and colleagues16 performed a feasibility study in
a fellowship training program using the da Vinci®
Surgical System on 18 patients who desired rever-
sal of tubal sterilization and compared these
to 10 patients who underwent a traditional open
microsurgical reanastomosis. Main outcome
measures included pregnancy rates, tubal patency,
postoperative analgesic requirements, time to
recovery of independent activities of daily living
and time to return to work.
After induction of general anesthesia, the
patient was placed in a modified dorsal lithotomy
position in Trendelenburg, and mobilization of
the uterus was provided with an intrauterine
cannula. The da Vinci® surgical tower was posi-
tioned between the patient’s lower extremities
and port placement as described in Figure 24.1.
Peritoneal access was obtained using a 12-mm
trocar through the umbilicus. Two lateral 8-mm
ports (Intuitive Surgical Inc.) were placed in the
mid axillary line 2 cm below the umbilicus and
separated by a minimum of 8 cm between port
sites. At this point, a diagnostic laparoscopy was
performed to assess the feasibility of the re-
anastomosis with lysis of adhesions if necessary.
An accessory 10-mm port, placed on the left side
between the umbilical and the lateral port was
used for irrigation, placement, and removal of
sutures.
Once the setup is completed, two microforceps
are placed in each axillary port. The initial step
is to prepare the distal tubal segment. This is
done by stripping off its serosa using microscis-
sors. With the serosa stripped off, the tip is
resected to express the lumen with protrusion of
endosalpinx. Attention is then turned proximally.
The microforceps is switched out with cautery
190 S.D. Patel

100
90
80

Number of Pills
70
60
50 Robotic
P=0.0001
40 Open
30 P=0.0003
20
10
0
Lortab Motrin

FIGURE 24.2. All patients who underwent a robotic tubal anasto-

mosis were discharged home within four hours as compared to
patients who underwent a open reversal, who on average were
hospitalized for 36 hours.

activities of daily living were significantly shorter

FIGURE 24.1. For robotic tubal reversals: Once peritoneal access
is obtained, a 12-mm camera port (black) is placed at the umbili-
cus. Subsequently, two da Vinci® ports (blue) are placed in the
midclavicular line, 1 to 2 cm below the level of umbilicus, lateral
to the rectus muscle. An additional accessory port (red) on the left
side of patient is used for irrigation, placement, and removal of
sutures.
and the proximal segment is dissected free from
the mesosalpinx. The occluded segment is opened
with laparoscopic endoshears placed in the axil-
lary port. Proximally, chromopertubation dem-
onstrated patency of the proximal tubal segment.
The mesosalpinx was re-approximated with
interrupted 6-0 delayed absorbable (vicryl)
sutures in order to bring the mucosal edges in
close proximity to prevent tension on the
anastomosis.
The mucosal and muscular layers of the tubal
segments are sutured with four interrupted 7-0
in the robotic group. Tubal patency rates for those
not pregnancy were 100% and pregnancy rates
were 62% in the robotic group and 50% in the
patients who had a open procedure, comparable
in both groups.16 Although limited, a preliminary
cost-effective analysis demonstrates comparable
cost per delivery in patients who underwent a
robotic tubal reanastomosis ($92,488.00) as com-
pared to those underwent a traditional open
reanastomosis ($92,205.90).17
24.1.1.2. Myomectomy
Uterine myomas are found in 33% of the popula-
tion, however, only account for approximately 3%
of infertility. This is most commonly found when
35
30
25
Hours

prolene sutures. The use of intra-abdominal

20
articulation allows generous range of motion
with a fine diameter suture. The serosa is closed 15
separately with a running 7-0 prolene suture. 10
Patency is determined by chromopertubation. P= 0.0001
5
Our patients were similar in regards to demo-
graphics including age, body mass index, years 0
from tubal ligation, and type of tubal ligation. Robotic Open
Our operative times were significantly greater in FIGURE 24.3. All patients were given fixed amounts of prescrip-
the patients who underwent robotic-assisted tion narcotics and anti-inflammatory medication and tracked
surgery, however, hospitalization time (Figure their medication usage. Patients who underwent a robotic tubal
24.2), analgesic requirements (Figure 24.3), time reversal used approximately one third of the medication allotted
to recovery, and time to return of independent as compared to those who underwent a open procedure.
24. Robotics and Infertility
the myomas is local in the submucosal cavity or
when the myoma is obstructing the tubal ostia.
There are multiple therapeutic options, however,
for those seeking to preserve fertility the most
predominant form of therapy is a surgical myo-
mectomy. Traditionally, myomectomies were
performed through a laparotomy incision. Then
popular support emerged for laparoscopic myo-
mectomies to provide the advantages of a mini-
mally invasive approach to patients. However,
some of the earlier series reported an increased
incidence of uterine rupture during pregnancy.
This was attributed to the difficulty in laparo-
scopic suturing, which resulted in fewer sutures
and a weaker closure.
Advincula and colleagues18 reported their pre-
liminary experience with the use of the robot for
laparoscopic myomectomies (port placement;
Figure 24.4). In this report of 35 patients, the
mean weight of the leiomyoma was 223 ± 244 g
[95% confidence interval (CI), 135–310], the mean
number of leiomyomas was 1.6 (range, 1–5), and
the mean diameter was 7.9 ± 3.5 cm (95% CI, 6.6–
FIGURE 24.4. For robotic myomectomies: Once peritoneal access
is obtained, a 12-mm camera port (black) is placed at the umbili-
cus. Subsequently, two da Vinci® ports (blue) are placed in the
midclavicular line, 1 to 2 cm below the level of umbilicus, lateral
to the rectus muscle. An additional accessory port (red) on the left
side of patient is used for placement of the tenaculum and morcel-
lation. An additional accessory port can be utilized if needed for
placement, removal of sutures, and irrigation.
191
9.1). The mean blood loss was 169 ± 198 mL. The
mean operative time was 230 ± 83 min (95% CI,
201–260). Five cases required between 350 and
400 min to complete the procedure. There was a
trend toward decreased operative times with
experience. There were three conversions to
laparotomy.
There are no published comparative clinical
trials of robotic surgery with laparoscopic myo-
mectomy or hysterectomy. However, when we
compare these robotic results to published trials19
without the robot there does not appear to be any
advantage with these prototypes. It is possible
that these robots may be more useful to the
surgeon who is presently performing these pro-
cedures by laparotomy to perform them by lapa-
roscopy rather than in the hands of the expert
laparoscopic surgeon.
24.1.1.3. Others
There are case reports of the use of the robot with
other less common procedures. In a case report,
the da Vinci® Surgical System was used without
complication to perform an ovarian transposi-
tion in a patient before she received radiotherapy
for a stage 1B-1 cervical cancer.20 Three inter-
rupted 3-0 silk sutures were used to suture the
transected utero-ovarian ligament to the psoas
muscle.
The role of robotic surgery has also been inves-
tigated in the pediatric and fetal population. Gutt
and colleagues21 performed a bilateral gonadec-
tomy in a 16-year-old pediatric patient with a
gonadoblastoma. Using the da Vinci® Surgical
System, the operative time was 95 min and no
complications were reported.
24.1.2. Male
The role of robotics in male infertility has cen-
tered around vasectomy reversals and a reported
case of a varicocele ligation. The first reported
vasovasotomy utilizing a single-layer closure in a
model system (rat) was presented in 2001 by
Schoor, Ross, and Niederberger.22 Subsequently,
two additional authors evaluated the feasibility
and the efficacy of robotic microsurgical vasova-
sotomy and vasoepididymostomy in a rat model
utilizing either a single layer versus a multilayer
192
closure.23,24 In a prospective, randomized study
using the male Wistar rat, Schiff and coworkers
utilized 24 male rats and randomized them to a
microsurgical multilayer vasovasotomy or a
longitudinal vasoepidymostomy as compared to
the robotic approach. Their finding included
no complications in either group. The robotic
approach for vasovasotomy was significantly
faster than the conventional technique (68.5 vs.
102.5 min; p = 0.002). In terms of outcomes,
patency rates were equal and sperm granulomas
were found in a higher percentage of those
patients who underwent a traditional vasovasot-
omy. There was no difference in the robotic versus
open vasoepididymostomy outcome parame-
ters.24 This equivalence in data was followed by a
comparison between robotic and traditional
microsurgical vasovasotomy in ex vivo human
vas specimens. This study utilized 10 samples
and a modified single-layer technique. The mean
operative time and adverse haptic events were
longer and larger, there was a complete elimina-
tion of tremor. The patency rates were also com-
parable. Their experience with robotics to account
for the learning curve association with adverse
haptic events was not extensive.25
One reported technique (in a rat model)
involves positioning the da Vinci® surgical cart
at a 10° angle and to the rabbits abdominal wall.
Motion scaling was set a 5 : 1. The anastomosis
was performed using four, 10-0 nylon double-
armed fishhook needles for the mucosa, which
were placed, and ligated down using the surgical
system and black diamond microforceps. At least
six additional sutures were placed to support the
anastomosis at the muscularis layer. The sutures
were cut using the Pott scissors. After the anas-
tomosis was completed on one side, the testicle
was returned to the scrotum on that side and the
contralateral side was prepared and anastomosed
in a similar fashion.
To our understanding, there is no published
data relating to the clinical use of microsurgical
vasovasotomy in humans, although both animal
and ex vivo data appear promising.
24.1.2.1. Others
Cadiere and colleagues reported on one case of
robotic-assisted varicocele ligation using the da
S.D. Patel
Vinci® Surgical System, stating its feasibility and
ease with the ability to eliminate tremor, possess
three-dimensional vision, and the ability to
articulate in anyone of second degrees of
freedom.26
24.2. Conclusion
The role of robotics in gynecology appears to
enable the surgeon to provide a minimally inva-
sive approach to the patient, whilst performing
the procedure according to the standard, the tra-
ditional open approach. With U.S. Food and Drug
Administration (FDA) approval relatively recently
applied to gynecology, robotics in gynecology
will continue to evolve and the surgical outcomes
and cost effectiveness will determine its eventual
role in obstetrics and gynecology.
References
1. Yuen PM, Yu KM, Yip SK, et al. A randomized
prospective study of laparoscopy and laparotomy
in the management of benign ovarian masses. Am
J Obstet Gynecol 1997;177:109–114.
2. Lo L, Pun TC, Chan S. Tubal ectopic pregnancy:
an evaluation of laparoscopic surgery versus lapa-
rotomy in 614 patients. Aust N Z J Obstet Gynecol
1999;39:185–187.
3. Gunning JE. The history of laparoscopy. J Reprod
Med 1974;12:222–226.
4. Siegler AM, Berenyi KJ. Laparoscopy in gynecol-
ogy. Obstet Gynecol 1969;34:572–577.
5. Steptoe PC. Laparoscopy in gynecology. London:
E & S Livingston Ltd.; 1967:1–3.
6. Peterson EP, Behrman SJ. Laparoscopy of the
infertile patient. Obstet Gynecol 1970;36:363–367.
7. Stylopoulos N, Rattner D. Robotics and ergonom-
ics. Surg Clin N Am 2003;83:1–12.
8. Sturges RH, Wright PK. A quantification of manual
dexterity. Robotics Computer Integr Manufactur-
ing 1989;6:237–252.
9. Berguer R, Forkey DL, Smith WD. Ergonomic
problems associated with laparoscopic surgery.
Surg Endosc 1999;13:466–468.
10. Hagberg M. Electromyographic signs of should
muscular fatigue in two elevated arm positions.
Am J Phys Med 1981;60:111–121.
11. Ballantyne GH. Robotic surgery, telerobotic
surgery, telepresence, and telementoring. Surg
Endosc 2002;16:1389–1402.
24. Robotics and Infertility
12. Margossian H, Garcia-Ruiz A, Falcone T, et al.
Robotically assisted laparoscopic microsurgical
uterine horn anastomosis. Fertil Steril 1998;70:
530–534.
13. Falcone T, Goldberg JM, Margossian H, Stevens L.
Robotically assisted laparoscopic microsurgical
anastomosis: a human pilot study. Fertil Steril
2000;73:1040–1042.
14. Goldberg JM, Falcone T. Laparoscopic microsurgi-
cal tubal anastomosis with and without robotic
assistance. Hum Reprod 2003;18:145–147.
15. Degueldre M, Vandromme J, Huong PT, Cadiere
GB. Robotically assisted laparoscopic microsurgi-
cal tubal reanastomosis: a feasibility study. Fertil
Steril 2000;74:1020–1023.
16. Dharia SP, Steinkampf MP, Whitten SJ, Malizia
BA. Robotic assisted tubal reanastomosis in a Fel-
lowship Training Program [abstract]. ESHRE
Annual Meeting; June 2004; Berlin, Germany.
17. Dharia SP, Steinkampf MP, Whitten SJ, Malizia
BA. Robotically assisted tubal sterilization rever-
sal: surgical technique and cost-effectiveness
versus conventional surgery [abstract]. American
Society for Reproductive Medicine Annual
Meeting; October 2004; Philadelphia, PA.
18. Advincula AP, Song A, Burke W, Reynolds RK.
Preliminary experience with robot-assisted lapa-
193
roscopic myomectomy. J Am Assoc Gynecol Lapa-
rosc 2004;11:511–518.
19. Falcone T, Bedaiwy MA. Minimally invasive man-
agement of uterine fibroids. Curr Opin Obstet
Gynecol 2002;14:401–407.
20. Molpus KL, Wedergren JS, Carlson MA. Roboti-
cally assisted endoscopic ovarian transposition. J
Soc Laparoendosc Surg 2003;7:59–62.
21. Gutt CN, Markus B, Kim ZG, et al. Early experi-
ences of robotic surgery in children. Surg Endosc
2002;16:1083–1086.
22. Schoor RA, Ross L, Niederberge C. Robotic assisted
microsurgical vassal reconstruction in a model
system. World J Urol 2000;21:48.
23. Kuang W, Shin PR, Oder M, Thomas AJ Jr. Robotic-
assisted vasovasotomy: a two-layer technique in
an animal model. J Urol 2004;65:811–814.
24. Schiff J, Li PS, Goldstein M. Robotic microsurgical
vasovasostomy and vasoepididymostomy: a pro-
spective randomized study in a rat model. J Urol
2004;171:1720–1725.
25. Kuang W, Shin PR, Matin S, Thomas AJ Jr. Initial
evaluation of robotic technology for microsurgical
vasovasostomy. J Urol 2004;171:300–303.
26. Cadiere GB, Himpens J, Germay O, et al. Feasibil-
ity of robotic laparoscopic surgery: 146 cases.
World J Surg 2001;25:1467–1477.