Role of Robotics in the Management of Infertility

  • Sami Gokhan KilicEmail author
  • Bekir Serdar Unlu
  • Mertihan Kurdoglu


The relatively new field of robotic surgery is being used to manage a number of conditions related to female infertility.

Abdominal cerclage. Incompetent cervix is the inability of the uterine cervix to retain a pregnancy in the second trimester, in the absence of uterine contractions. Transvaginally or transabdominally performed cervical cerclages are the mainstay of surgical treatment. Transabdominal cerclage is generally reserved for when anatomy limits cerclage placement or transvaginal cervical cerclage procedures have previously failed. Open or minimally invasive options are available for transabdominal surgery, but robot-assisted cervical cerclage is rapidly gaining acceptance with its record of safety and procedure success.

Tubal reversal. Tubal ligation is widely accepted contraception method for women, in which pregnancy is prevented by disrupting fallopian tube patency. Although it is considered to be permanent, requests for reversal of the procedure (recanalization) are not infrequent. After robotic tubal reanastomosis, the overall pregnancy rate was found to be 71% at 2-year follow-up. Quicker recovery time and return to work, early hospital discharge, and smaller incisions are the main advantages of minimally invasive surgery over open surgery.

Reconstruction of uterine anomalies. Any disruption of Müllerian duct development during embryogenesis can result in Müllerian duct anomalies. Robotic technology has advantages over classical laparoscopy-related methods for surgical correction of Müllerian anomalies, especially in sigmoid vaginoplasty and robotic metroplasty. The use of a robot-assisted technique may enhance the safety of uterine transplantation surgeries in the future by facilitating the microvascular anastomosis, vaginal anastomosis, and ligaments fixation.


Robot-assisted surgery Robotic surgery Müllerian anomalies Congenital malformations Tubal reversal Tubal ligation Cervical insufficiency Pregnancy loss Robotic-assisted cervical cerclage 

Supplementary material

Video 9.1



  1. 1.
    Moss C, Isley MM. Sterilization: a review and update. Obstet Gynecol Clin N Am. 2015;42(4):713–24.CrossRefGoogle Scholar
  2. 2.
    Hillis SD, Marchbanks PA, Tylor LR, et al. Poststerilization regret: findings from the United States collaborative review of sterilization. Obstet Gynecol. 1999;93(6):889–95.PubMedGoogle Scholar
  3. 3.
    Henderson SR. The reversibility of female sterilization with the use of microsurgery: a report on 102 patients with more than one year of follow-up. Am J Obstet Gynecol. 1984;149(1):57–65.CrossRefPubMedGoogle Scholar
  4. 4.
    Hanafi MM. Factors affecting the pregnancy rate after microsurgical reversal of tubal ligation. Fertil Steril. 2003;80(2):434–40.CrossRefPubMedGoogle Scholar
  5. 5.
    Gordts S, Campo R, Puttemans P, et al. Clinical factors determining pregnancy outcome after microsurgical tubal reanastomosis. Fertil Steril. 2009;92(4):1198–202.CrossRefPubMedGoogle Scholar
  6. 6.
    Yoon TK, Sung HR, Kang HG, et al. Laparoscopic tubal anastomosis: fertility outcome in 202 cases. Fertil Steril. 1999;72(6):1121–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Margossian H, Garcia-Ruiz A, Falcone T, et al. Robotically assisted laparoscopic tubal anastomosis in a porcine model: a pilot study. J Laparoendosc Adv Surg Tech A. 1998;8(2):69–73.CrossRefPubMedGoogle Scholar
  8. 8.
    Degueldre M, Vandromme J, Huong PT, et al. Robotically assisted laparoscopic microsurgical tubal reanastomosis: a feasibility study. Fertil Steril. 2000;74(5):1020–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Falcone T, Goldberg JM, Margossian H, et al. Robotic-assisted laparoscopic microsurgical tubal anastomosis: a human pilot study. Fertil Steril. 2000;73(5):1040–2.CrossRefPubMedGoogle Scholar
  10. 10.
    Zite N, Borrero S. Female sterilisation in the United States. Eur J Contracept Reprod Health Care. 2011;16(5):336–40.CrossRefPubMedGoogle Scholar
  11. 11.
    Gargiulo AR. Fertility preservation and the role of robotics. Clin Obstet Gynecol. 2011;54(3):431–48.CrossRefPubMedGoogle Scholar
  12. 12.
    Bedaiwy MA, Barakat EM, Falcone T. Robotic tubal anastomosis: technical aspects. JSLS. 2011;15(1):10–15. PMC3134681.Google Scholar
  13. 13.
    Dharia Patel SP, Steinkampf MP, Whitten SJ, et al. Robotic tubal anastomosis: surgical technique and cost effectiveness. Fertil Steril. 2008;90(4):1175–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Einarsson JI, Hibner M, Advincula AP. Side docking: an alternative docking method for gynecologic robotic surgery. Rev Obstet Gynecol. 2011;4(3–4):123–5. PMC3252883.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Schippert C, Soergel P, Staboulidou I, et al. The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures. Arch Gynecol Obstet. 2012;285(3):863–71.CrossRefPubMedGoogle Scholar
  16. 16.
    Caillet M, Vandromme J, Rozenberg S, et al. Robotically assisted laparoscopic microsurgical tubal reanastomosis: a retrospective study. Fertil Steril. 2010;94(5):1844–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Rodgers AK, Goldberg JM, Hammel JP, et al. Tubal anastomosis by robotic compared with outpatient minilaparotomy. Obstet Gynecol. 2007;109(6):1375–80.CrossRefPubMedGoogle Scholar
  18. 18.
    Lima M, Cantone N, Destro F, et al. Combined laparoscopic and hysteroscopic approach for the treatment of a hybrid Mullerian duct anomaly: a case report. J Laparoendosc Adv Surg Tech A. 2013;23(11):960–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Saygili-Yilmaz E, Yildiz S, Erman-Akar M, et al. Reproductive outcome of septate uterus after hysteroscopic metroplasty. Arch Gynecol Obstet. 2003;268(4):289–92.CrossRefPubMedGoogle Scholar
  20. 20.
    Vallerie AM, Breech LL. Update in Mullerian anomalies: diagnosis, management, and outcomes. Curr Opin Obstet Gynecol. 2010;22(5):381–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Grimbizis GF, Gordts S, Di Spiezio Sardo A, et al. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod. 2013;28(8):2032–44. PMC3712660.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Arleo EK, Troiano RN. Complex Mullerian duct anomalies defying traditional classification: lessons learned. J Fertil. 2013;1:115.Google Scholar
  23. 23.
    Iverson R, Decherney A, Laufer M. Surgical management of congenital uterine anomalies. In: Barbieri R, editor. UpToDate. Waltham: Wolters Kluwer; 2016.Google Scholar
  24. 24.
    AFS. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril. 1988;49(6):944–55.CrossRefGoogle Scholar
  25. 25.
    Cunningham FG, Leveno KJ, Bloom SL, et al. Congenital genitourinary abnormalities. In:Williams obstetrics. New York: McGraw-Hill Education; 2014. p. 36–45.Google Scholar
  26. 26.
    Nahum GG. Uterine anomalies. How common are they, and what is their distribution among subtypes? J Reprod Med. 1998;43(10):877–87.PubMedGoogle Scholar
  27. 27.
    Reichman D, Laufer MR, Robinson BK. Pregnancy outcomes in unicornuate uteri: a review. Fertil Steril. 2009;91(5):1886–94.CrossRefPubMedGoogle Scholar
  28. 28.
    Heinonen PK. Uterus didelphys: a report of 26 cases. Eur J Obstet Gynecol Reprod Biol. 1984;17(5):345–50.CrossRefPubMedGoogle Scholar
  29. 29.
    Smith NA, Laufer MR. Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome: management and follow-up. Fertil Steril. 2007;87(4):918–22.CrossRefPubMedGoogle Scholar
  30. 30.
    Tong J, Zhu L, Lang J. Clinical characteristics of 70 patients with Herlyn-Werner-Wunderlich syndrome. Int J Gynaecol Obstet. 2013;121(2):173–5.CrossRefPubMedGoogle Scholar
  31. 31.
    El Saman AM, Shahin AY, Nasr A, et al. Hybrid septate uterus, coexistence of bicornuate and septate varieties: a genuine report. J Obstet Gynaecol Res. 2012;38(11):1308–14.CrossRefPubMedGoogle Scholar
  32. 32.
    Iverson R, Decherney A, Laufer M. Clinical manifestations and diagnosis of congenital anomalies of the uterus. In: Barbieri R, editor. UpToDate. Waltham: Wolters Kluwer; 2016.Google Scholar
  33. 33.
    Guirgis RR, Shrivastav P. Gamete intrafallopian transfer (GIFT) in women with bicornuate uteri. J In Vitro Fert Embryo Transf. 1990;7(5):283–4.CrossRefPubMedGoogle Scholar
  34. 34.
    Marcus S, Al-Shawaf T, Brinsden P. The obstetric outcome of in vitro fertilization and embryo transfer in women with congenital uterine malformation. Am J Obstet Gynecol. 1996;175(1):85–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Markham SM, Waterhouse TB. Structural anomalies of the reproductive tract. Curr Opin Obstet Gynecol. 1992;4(6):867–73.CrossRefPubMedGoogle Scholar
  36. 36.
    Pellerito JS, Mccarthy SM, Doyle MB, et al. Diagnosis of uterine anomalies: relative accuracy of MR imaging, endovaginal sonography, and hysterosalpingography. Radiology. 1992;183(3):795–800.CrossRefPubMedGoogle Scholar
  37. 37.
    Acien P, Acien M, Sanchez-Ferrer M. Complex malformations of the female genital tract. New types and revision of classification. Hum Reprod. 2004;19(10):2377–84.CrossRefPubMedGoogle Scholar
  38. 38.
    Chen YJ, Twu NF, Horng HC, et al. Robotic modified Jones metroplasty for uterine unification. J Minim Invasive Gynecol. 2010;17(6):S11–2.CrossRefGoogle Scholar
  39. 39.
    Gungor M, Afsar S, Ozbasli E, et al. The robotic metroplasty in a patient with hybrid septate variant anomaly. J Robot Surg. 2016;10(3):271–4.CrossRefPubMedGoogle Scholar
  40. 40.
    Wright C, Hanna MK. Thirty-six vaginal constructions: lessons learned. J Pediatr Urol. 2014;10(4):667–71.CrossRefPubMedGoogle Scholar
  41. 41.
    Committee on Adolescent Health Care. Committee opinion: no. 562: Mullerian agenesis: diagnosis, management, and treatment. Obstet Gynecol. 2013;121(5):1134–7.CrossRefGoogle Scholar
  42. 42.
    Dargent D, Marchiole P, Giannesi A, et al. Laparoscopic Davydov or laparoscopic transposition of the peritoneal colpopoeisis described by Davydov for the treatment of congenital vaginal agenesis: the technique and its evolution. Gynecol Obstet Fertil. 2004;32(12):1023–30.CrossRefPubMedGoogle Scholar
  43. 43.
    Gauwerky JF, Wallwiener D, Bastert G. An endoscopically assisted technique for construction of a neovagina. Arch Gynecol Obstet. 1992;252(2):59–63.CrossRefPubMedGoogle Scholar
  44. 44.
    Mcindoe A. The treatment of congenital absence and obliterative conditions of the vagina. Br J Plast Surg. 1950;2(4):254–67.PubMedGoogle Scholar
  45. 45.
    Popp LW, Ghirardini G. Creation of a neovagina by pelviscopy. J Laparoendosc Surg. 1992;2(3):165–73.PubMedGoogle Scholar
  46. 46.
    Urbanowicz W, Starzyk J, Sulislawski J. Laparoscopic vaginal reconstruction using a sigmoid colon segment: a preliminary report. J Urol. 2004;171(6 Pt 2):2632–5.CrossRefPubMedGoogle Scholar
  47. 47.
    Kim C, Campbell B, Ferrer F. Robotic sigmoid vaginoplasty: a novel technique. Urology. 2008;72(4):847–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Boztosun A, Olgan S. Robotic sigmoid vaginoplasty in an adolescent girl with Mayer-Rokitansky-Kuster-Hauser syndrome. Female Pelvic Med Reconstr Surg. 2016;22(5):e32–5.CrossRefPubMedGoogle Scholar
  49. 49.
    Pushkar P, Rawat SK, Chowdhary SK. Robotic approach to vaginal atresia repair in an adolescent girl. Urol Ann. 2015;7(3):396–8. PMC4518385.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Iavazzo C, Gkegkes ID. Possible role of DaVinci robot in uterine transplantation. J Turk Ger Gynecol Assoc. 2015;16(3):179–80. PMC4560477.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Braumann C, Jacobi CA, Menenakos C, et al. Computer-assisted laparoscopic colon resection with the Da Vinci system: our first experiences. Dis Colon Rectum. 2005;48(9):1820–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Denoto G, Rubach E, Ravikumar TS. A standardized technique for robotically performed sigmoid colectomy. J Laparoendosc Adv Surg Tech A. 2006;16(6):551–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Anderberg M, Bossmar T, Arnbjornsson E, et al. Robot-assisted laparoscopic hemihysterectomy for a rare genitourinary malformation with associated duplication of the inferior vena cava—a case report. Eur J Pediatr Surg. 2010;20(3):206–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Persson J, Reynisson P, Borgfeldt C, et al. Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data. Gynecol Oncol. 2009;113(2):185–90.CrossRefPubMedGoogle Scholar
  55. 55.
    Liu XX, Jiang ZW, Chen P, et al. Full robot-assisted gastrectomy with intracorporeal robot-sewn anastomosis produces satisfying outcomes. World J Gastroenterol. 2013;19(38):6427–37. PMC3801313.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Uyama I, Sugioka A, Fujita J, et al. Completely laparoscopic extraperigastric lymph node dissection for gastric malignancies located in the middle or lower third of the stomach. Gastric Cancer. 1999;2(3):186–90.CrossRefPubMedGoogle Scholar
  57. 57.
    Sheyn D, Abouassaly R, Paspulati R, et al. Multidisciplinary approach for management of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome and rectal prolapse. Int Urogynecol J. 2015;26(7):1079–81.CrossRefPubMedGoogle Scholar
  58. 58.
    Cunningham FG, Leveno KJ, Bloom SL, et al. Abortion, early pregnancy. In:Williams obstetrics. New York: McGraw-Hill Education; 2014. p. 350–76.Google Scholar
  59. 59.
    Vyas NA, Vink JS, Ghidini A, et al. Risk factors for cervical insufficiency after term delivery. Am J Obstet Gynecol. 2006;195(3):787–91.CrossRefPubMedGoogle Scholar
  60. 60.
    Saccone G, Perriera L, Berghella V. Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol. 2016;214(5):572–91.CrossRefPubMedGoogle Scholar
  61. 61.
    Warren JE, Silver RM, Dalton J, et al. Collagen 1Alpha1 and transforming growth factor-beta polymorphisms in women with cervical insufficiency. Obstet Gynecol. 2007;110(3):619–24.CrossRefPubMedGoogle Scholar
  62. 62.
    Chan YY, Jayaprakasan K, Tan A, et al. Reproductive outcomes in women with congenital uterine anomalies: a systematic review. Ultrasound Obstet Gynecol. 2011;38(4):371–82.CrossRefPubMedGoogle Scholar
  63. 63.
    Rackow BW, Arici A. Reproductive performance of women with Mullerian anomalies. Curr Opin Obstet Gynecol. 2007;19(3):229–37.CrossRefPubMedGoogle Scholar
  64. 64.
    Kaufman RH, Adam E, Hatch EE, et al. Continued follow-up of pregnancy outcomes in diethylstilbestrol-exposed offspring. Obstet Gynecol. 2000;96(4):483–9.PubMedGoogle Scholar
  65. 65.
    Grobman WA, Gilbert SA, Iams JD, et al. Activity restriction among women with a short cervix. Obstet Gynecol. 2013;121(6):1181–6. PMC4019312.CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Sciscione AC. Maternal activity restriction and the prevention of preterm birth. Am J Obstet Gynecol. 2010;202(3):232.e1–5.CrossRefGoogle Scholar
  67. 67.
    Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA. Cervical pessary for preventing preterm birth. Cochrane Database Syst Rev. 2013;5:Cd007873.Google Scholar
  68. 68.
    Dharan VB, Ludmir J. Alternative treatment for a short cervix: the cervical pessary. Semin Perinatol. 2009;33(5):338–42.CrossRefPubMedGoogle Scholar
  69. 69.
    Goya M, Pratcorona L, Merced C, et al. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial. Lancet (London, England). 2012;379(9828):1800–6.CrossRefGoogle Scholar
  70. 70.
    Herron MA, Parer JT. Transabdominal cerclage for fetal wastage due to cervical incompetence. Obstet Gynecol. 1988;71(6 Pt 1):865–8.PubMedGoogle Scholar
  71. 71.
    Berghella V, Szychowski JM, Owen J, et al. Suture type and ultrasound-indicated cerclage efficacy. J Matern Fetal Neonatal Med. 2012;25(11):2287–90.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Harger JH. Comparison of success and morbidity in cervical cerclage procedures. Obstet Gynecol. 1980;56(5):543–8.PubMedGoogle Scholar
  73. 73.
    Mcdonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp. 1957;64(3):346–50.CrossRefPubMedGoogle Scholar
  74. 74.
    Shirodkar V. A new method of operative treatment for habitual abortions in the second trimester of pregnancy. Antiseptic. 1955;52:299–300.Google Scholar
  75. 75.
    Toaff R, Toaff ME, Ballas S, et al. Cervical incompetence: diagnostic and therapeutic aspects. Isr J Med Sci. 1977;13(1):39–49.PubMedGoogle Scholar
  76. 76.
    Burger NB, Brolmann HA, Einarsson JI, et al. Effectiveness of abdominal cerclage placed via laparotomy or laparoscopy: systematic review. J Minim Invasive Gynecol. 2011;18(6):696–704.CrossRefPubMedGoogle Scholar
  77. 77.
    Wolfe L, Depasquale S, Adair CD, et al. Robotic-assisted laparoscopic placement of transabdominal cerclage during pregnancy. Am J Perinatol. 2008;25(10):653–5.CrossRefPubMedGoogle Scholar
  78. 78.
    Fick AL, Caughey AB, Parer JT. Transabdominal cerclage: can we predict who fails? J Matern Fetal Neonatal Med. 2007;20(1):63–7.CrossRefPubMedGoogle Scholar
  79. 79.
    Umstad MP, Quinn MA, Ades A. Transabdominal cervical cerclage. Aust N Z J Obstet Gynaecol. 2010;50(5):460–4.CrossRefPubMedGoogle Scholar
  80. 80.
    Davis G, Berghella V, Talucci M, et al. Patients with a prior failed transvaginal cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal cerclage. Am J Obstet Gynecol. 2000;183(4):836–9.CrossRefPubMedGoogle Scholar
  81. 81.
    Tulandi T, Alghanaim N, Hakeem G, et al. Pre and post-conceptional abdominal cerclage by laparoscopy or laparotomy. J Minim Invasive Gynecol. 2014;21(6):987–93.CrossRefPubMedGoogle Scholar
  82. 82.
    Zeybek B, Hill A, Menderes G, et al. Robot-assisted abdominal cerclage during pregnancy. JSLS. 2016;20(4):e2016.00072. PMC5118107.CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Estape RE, Schroeder ED, Estape RA, et al. Robotic abdominal cerclage: a case series with pregnancy outcomes. J Minim Invasive Gynecol. 2015;22(6s):S235.CrossRefPubMedGoogle Scholar
  84. 84.
    ACOG. ACOG Practice Bulletin No.142: cerclage for the management of cervical insufficiency. Obstet Gynecol. 2014;123(2 Pt 1):372–9.Google Scholar
  85. 85.
    Walsh TM, Borahay MA, Fox KA, et al. Robotic-assisted, ultrasound-guided abdominal cerclage during pregnancy: overcoming minimally invasive surgery limitations? J Minim Invasive Gynecol. 2013;20(3):398–400.CrossRefPubMedGoogle Scholar
  86. 86.
    Zeybek B, Borahay M, Kilic GS. Overcoming the obstacles of visualization in robotically assisted abdominal cerclage using indocyanine green. J Robot Surg. 2016;10(4):361–4.CrossRefPubMedGoogle Scholar
  87. 87.
    Dawood F, Farquharson RG. Transabdominal cerclage: preconceptual versus first trimester insertion. Eur J Obstet Gynecol Reprod Biol. 2016;199:27–31.CrossRefPubMedGoogle Scholar
  88. 88.
    Pundir J, Coomarasamy A. Preterm labour (PTL). In:Obstetrics: evidence-based algorithms. London: Cambridge University Press; 2016.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Sami Gokhan Kilic
    • 1
    Email author
  • Bekir Serdar Unlu
    • 1
  • Mertihan Kurdoglu
    • 1
  1. 1.Division of Minimally Invasive Gynecology and Research, Department of Obstetrics and GynecologyThe University of Texas Medical BranchGalvestonUSA

Personalised recommendations