Assisted Reproductive Methods

In order to help women to become pregnant, assisted reproductive methods such as IVF may be preferable to conservative surgery for some patients. If conservative surgery is ineffective for patients with an infertility problem, the choice the specialist will give is generally in this direction.

Uterine Surgery (Hysterectomy)

If the patients are under the influence of severe endometriosis, the removal of the uterus or both of the ovaries may be seen as the best approach for a successful treatment. However, hysterectomy is not actually an effective treatment on its own. The oestrogen hormone which is being produced in the ovaries can cause the endometrial tissue to cause severe pain in the female body. For this reason, the ovaries may need to be removed. However, in terms of women of reproductive age, hysterectomy is usually seen as a last resort in all treatment methods. The reason for this is that after this surgery, it is not possible for women to be pregnant ever again.

The application of the combined treatment

In some conditions, during the treatment of chocolate cysts, the patients may need to use medication prior to surgery or after surgery. Such treatments can be applied if the specialist sees well. This is done according to the patient and the severity of the pain. In cases such as the lack of response from this kind of medicine use, performing surgery in order to remove uteral adhesions a large improvement in the patient’s condition and success of the treatment can be achieved. In conditions where patients do not respond positively to drug treatment, the treatment is usually done by cutting the nerves around the uterus to get a more effective treatment. Some patients may also not respond to these treatments. In such conditions the removal of the uterus and ovaries may be necessary. In the implementation of these treatments the patient’s current health condition, age, and pregnancy conditions are taken under consideration.

It is important for patients with chocolate cysts to see a specialist which they can trust and explain their problems comfortably. This way with the specialists help, it is possible to determine the best treatment type possible.

The lifestyle of patients with chocolate cyst and advice which they can do at home

While continuing treatment, or after treatment, in order to reduce the uncomfortable effects, some measures can be taken at home which can be useful.

• Taking a hot bath and a using heated pad, will help reduce the pain and cramp that has occurred and will help with the relaxation of the pelvic muscles.
• Non-steroidal anti-inflammatory drug can be used in order to prevent menstruation pain.
• Exercising regularly, can be effective in relieving symptoms as well.

Under normal conditions, a female’s menstrual cycle should be 21 to 35 days. It is considered to be normal if the menstrual cycle is 21 to 35 days. If the cycle is less than 21 days and the female is experiencing menstrual bleeding every 20 days or less, this is accepted as a frequent mensuration. Women who are seeing their period this frequently may think that it has occurred twice in one month. This one is an expression of imbalance and irregularity of menstrual cycles.

What are the causes of seeing menstrual bleeding frequently?

Menstrual irregularities may be seen due to prior or continuing diseases which women experience. For example, diseases such as fibroids and polyps can disrupt a woman’s hormonal balance. In this case, frequent menstrual bleeding can be experienced. The mental state of the woman can also affect the hormones. Working too hard, stress, trauma, and external factors may cause a negative emotional state. Such situations will lead to irregular menstruation seen too frequently. In women, menstrual bleeding can be seen more frequently in patients with hypothyroidism.

How is frequent menstruation diagnosed and after the diagnosis, what is the importance of the treatment?

Women who have menstrual bleeding 2 times within 1 month or less than 21 days, their cycle should be diagnosed by a specialist. A woman who is facing a menstrual irregularity problem should contact a specialist as soon as possible and find out the reason which is causing the irregularity. After listening to the female’s complaints, the doctor will first check the hormonal values. By looking at the results of the blood tests, the problem is often identified. Stress is often the cause of menstrual irregularities. In this case, support from a specialist psychologist may be needed. If the cause of menstrual irregularities are cysts or fibroids the doctor can recommend medical treatment.

Is frequent menstrual bleeding a risk to the female’s health?

Women who are experiencing frequent menstruation problems should see a specialist when possible. Because the female will be losing more blood when compared to other women and this may cause anaemia.  Often the biggest of menstrual disorders are hormonal based. These hormonal disorders must also be treated.

What happens after?

Women, who have frequent menstruation, can lose too much blood. Due to this situation, women can feel tired and exhausted. Menstruation often affects a woman both physically and spiritually. Seeing their period too frequently may also affect the psychology of the woman. The haemoglobin levels may also be affected in a negative way due to excessive bleeding.

1-How many days will menstrual bleeding last?

It is accepted to be normal if the bleeding is seen between 2 to 7 days. If the bleeding only 1 day or less the female should see a specialist as soon as possible.

The amounts of bleeding will vary according to every individual. It is also very difficult for it to be detected. Using more than 5 hygienic pads is considered to be too much. The sufficient amount that should be used during the day should be around 1 to 5. The most important detail in this condition is how long the menstrual bleeding will last.

Menstrual bleeding will occur approximately every 21 to 35 days. There is no rule pointing out that the bleeding should occur between 28 to 30 days. For this reason, seeing menstrual bleeding every 21 to 35 days is considered to be normal.

2-What should be the normal amount of blood seen during menstrual period?

To determine or measure the amount of bleeding is a bit difficult under normal conditions. The reason for this is every woman’s hygienic pad replacement frequency is different from another. If needed to speak generally using more than 3 to 5 pads during the day is considered heavy bleeding. This is not stated for the patients who are extremely uncomfortable of blood and change their hygienic pads even if there are only two drops. If only 1 pad is sufficient during the day, this is considered to be normal too. The important part is that it lasts for 2 days or more.

3-How frequently should menstrual bleeding occur?

Between the beginning of the female’s last period, there should be minimum 21 days up to 35 days maximum. Every female’s cycle will not occur every 28 or 30 days. A 21 or 35 day cycle, is considered to be normal. What needs to be noted at this point is the first day of the last period and the first day of the next period should be noted in order to calculate the menstrual cycle.

4-How should the menstrual cycle be during puberty?

It is considered to be extremely normal to have menstrual irregularities during puberty. After the first menstruation, within the first 2 to 3 years no intervention is required. For this reason, girls who have started seeing their first period will not need to panic about menstrual irregularities. However, if heavy bleeding occurs or the bleeding is severe, a specialist should be contacted as soon as possible. If the bleeding lasts more than 7 days because it is intense it can cause anaemia.

There are 3 embryonic cell layers in early stages of life. These layers differentiate and form cells and tissue groups which eventually forms organs. These layers are called germ cell layers. Germ cells are located in the testicles in males and the ovaries in women. These cells are responsible for the production of egg and sperm cells. These tumours that develop from the germ cells are capable of hosting many different textures. The dominant layer is called the ectoderm germ layer. In this layer, various tissues such as skin and skin appendages will develop. Therefore, the common benign germ cell tumours which are seen in the ovaries are called “dermoid cysts”.

The dermoid cysts can carry pieces from germ cells but usually the dominant layer is the ectoderm. Therefore, portions of the skin and skin appendages are seen more commonly. Sue to the sebaceous glands in the skin, dermoid cysts take form as yellow-brown, oily and dense liquid. Most of the time there can be hair, teeth, bone, cartilage, nerves located within the cyst. The size of the cyst can differ depending on every individual.

Clinic and diagnostic

Dermoid cysts are usually asymptomatic and are usually diagnosed while the person goes for other examinations, during an ultrasound examination, radiographic examination or can be discovered during surgery. Approximately 65% patients experience no symptoms. The most common symptom that can be experienced is abdominal pain. In addition, abdominal bloating and abnormal uterine bleeding can be experienced as well. There can also be symptoms such as back pain or problems urinating. However these symptoms are seen rarely.

How are dermoid cysts treated?

Dermoid cyst should be treated in surgery. These cysts should be removed as soon as they are noticed. The operation can be made in the form of laparoscopic or open surgery. However, in appropriate cases, the laparoscopic approach should be preferred. Because they are usually observed in women of reproductive age, only the cyst should be removed the ovarian tissue should not be removed or damaged in any way. If the cyst ruptures during the surgery the abdomen should be cleaned carefully. It is important that the materials containing the cyst cell are not left in the abdominal area. Otherwise, a chemical peritonitis may occur. From this perspective, dermoid cyst operations are operations that require specific experience and attention.

1-When can I have sexual intercourse after giving natural birth?

After both normal birth and C-section, the female body will need time to get back to its natural balance. This period after birth is also called lochia which is a period that will last for about 4 to 6 weeks. During the lochia period, the cervix will close. If there are any incisions or stitches, these will recover during this period as well. For this reason, it is not recommended for the female to have sexual intercourse before she has recovered completely.

The colour of the bleeding will lighten more and more each day and will continue in the form of vaginal discharge for a while after the birth. The reason for bleeding and discharge which is seen after birth is the healing of the tissue which the placenta has been separated from. Having sexual intercourse while the bleeding is continuing will drastically increase the risk of infection and discharge. It usually is not advised for the female to have sexual intercourse until the lochia period is over.

2-Will it be painful to have sexual intercourse?

The specialists generally do not recommend sexual intercourse for 1,5 months after birth. At the end of this period, the female will have a check-up and after, if there aren’t any complications that can occur then it will be safe to have sexual intercourse. After this period, sexual intercourse should not be painful in any way. If the female is experiencing pain during sexual intercourse, she should contact her doctor and go for another check-up as soon as possible. The specialist will then determine if there are other reasons which may cause pain.

The pain may be caused by an episiotomy or a tear inside the uterus.

On the other hand, feeling physically ready will not always mean that you are mentally ready. Both exhaustion and baby-related thoughts may cause sexual aversion. The prolactin hormone, which is responsible for breastfeeding can also reduce sexual desire. This may even be nature’s way of protecting the female from another pregnancy which will be too soon.

3-Will my muscles loosen around my vagina?

It will. Although the vagina is accepted to be a very flexible organ, the muscles will loosen after giving birth. However, this situation does not pose any problem for many women.

1-What is menopause?

Menopause which is one of the most important periods in a woman’s life, is having an irregular menstrual cycle after the age of 40 until the age of 55 and after a full loss of the period. If a female does not see her period for 12 months this will mean she has entered menopause. Along with the transition to this period, the ovaries will no longer be functional.

2-What are the causes of sexual problems in menopause?

Many women who enter menopause will face a physical and psychological change. There will be considerable changes in the hormone levels in the body. The cause of sexual problems during this period, is mostly because of ovarian function changes and the change in the hormonal levels.

3-Which hormone levels are reduced during this period?

In particular hormones such as oestrogen, testosterone and progesterone will decrease after entering menopause which can lead to sexual problems.

4-The changes in sexual organs during menopause

• Outer lips of the vagina and clitoral will start to go smaller.
• The hair in the genital area is reduced.
• The entrance of the vagina narrows.
• Flexibility and the flexibility of the input portion of the vagina and decreases with time. The layer inside the vagina starts to get thinner.
• The lubrication of the vagina is reduced.
• The colour of the vagina will start fading.
• Shrinkage occurs in the ovaries.

5-The changing structure of the body

Wrinkles that begin to occur with menopause, weight gain, loss of flexibility, factors such as the change of the physical structure of the body can make a female lose interest in her sexual life. However, these issues of sexuality is not the end. A comfortable way to express one’s sexuality without the risk of pregnancy during this period is possible.

6-The most common complaints

• Reduced sexual desire (decreased libido)
• Pain during sexual intercourse
• Vaginal dryness
• Difficulty in having an orgasm
• Loss of sensitivity in the genital area

7-Orgasmic capacity

Contrary to common belief, menopause does not decrease the capacity of orgasm. Only because of the changes on the vagina to reach orgasm may take longer. This also can be described as difficulty in reaching an orgasm.

8-Menstrual irregularity due to the fear of pregnancy

Menstrual irregularities in women due to the fear of conception may cause tension and lack of sexual drive. You should contact your doctor and overcome this tension, and evaluate protection methods.

9-Changes in sexual life during menopause

Due to psychological and physical factors a decrease in the sexual life can be seen. However, menopause is not the end of a woman’s sexuality.

10-How does psychological concerns during menopause affect sexuality?

A woman who may lose interest in sexual intercourse, may think that she has lost her sexual attractiveness. Due to the changing physiology of menopause, menopause treatment can be seen. This period should not be considered the end of womanhood. Also aging is not the beginning of menopause.

11-Can sexual problems which has started with menopause be treated?

During menopause, in problems such as sexuality and other issues it may be necessary to see a doctor. In order to avoid sexual problems that has taken place in this period, the female can apply for different treatments and methods.

12-What are the methods of treatment?

Hormone therapy will help the problems that emerged in this period such as; sexual problems, vaginal dryness and low sexual desire. There are exercises that can be done for the strengthening of the walls of the vagina during sexual intercourse to reduce complaints.

13-What is hormone therapy?

A large part of the problems during menopause are due to the reduced oestrogen hormone. The replacement hormone therapy is a treatment that helps replace the missing hormone in the females body.

14-Effects Of Hormone Therapy

The hormonal therapy which the female sees during menopause does not only affect her sexual life positively but also has many other positive affects. Some of these are; restores sexual desire, relieves vaginal dryness and pain during intercourse. Eliminates the complaints of hot flashes and sleep disorders. It also tries to prevent depression in this way too. It also helps to avoid complaints of urinary incontinence.

15-When should the female start the hormonal therapy?

Menopausal hormone therapy after surgery for patients with surgical interventions can start this therapy in 10 to 15 days. However, the doctor will determine the best time.

16-Psychological support during menopause

If the female who has just entered menopause has concerns about her sexual life or she has excessive anxiety it will be best to start a psychological support therapy. This professional help, will help the female get through this period easier.

17-What can you do for a better sexual life during menopause?

Psychological support must be provided if necessary, and of sexual therapy must be taken. For complaints such as vaginal dryness and local irritation, oral medications can be used. Libido booster drugs can be used too. But like all drugs, it should only be used within a doctor’s recommendation.

18-Do not hesitate to consult your doctor!

Feel free to consult your doctor at any time. There is a solution to all problems and an answer to all your questions brought on by menopause.

19-Talk to your partner!

Couples communication with each other gains more importance in a woman’s menopause period. Healthy and effective communication will make it easier to overcome this process.

20-Menopause is a new beginning!

It is known that a decrease in sexual desire during menopause will happen. Menopause is not a period where the female’s sexuality ends. If the symptoms of menopause reduces the quality of life, the female can start a suitable treatment and the symptoms of menopause can be relieved.

Menstruation is the tissue inside of the uterus being discharged from the body in the form of blood. Another common name for menstruation is period. Medically,  period is the endometrial being discharged every month from the uterus as blood. With the oestrogen hormones effect, after the first period, the lining of the uterus thickens. This situation is called proliferation.

The period in between 2 menstruations is called ovulation. The progesterone hormone will decrease, depending on the inner layer of the uterus which causes the bleeding to occur. The blood is from the inside of the uterus. Young girls who have their periods for the first time might get confused and think that this is something abnormal or a sickness.

There is nothing to fear of because the blood is directly from the uterus and not from the ovaries or the inner layers of the abdominals. After a while the inner layer of the uterus will start to re-thicken and that is how a new cycle (the menstrual cycle) begins.

What do menstrual bleedings contain?

The pieces in the inner layer of the uterus are formations of the menstrual blood. These formations are discharged from the female’s body through the menstrual blood. The bleeding is gradually reduced once the uterine wall starts thickening. The inside of the uterus will be cleansed by the menstrual blood. This is how, the uterus will be completely sterile. At the end of the menstrual blood, the chances of getting pregnant will increase. It must not be forgotten, that the baby cannot develop in a non-sterile womb.

The uterus is sterile and clean

The uterus is extremely clean and sterile because the baby will develop and grow here.  It is not possible for the baby to develop in a non-sterile environment. Under normal conditions, the uterus is cleansed each month by the menstrual cycle. That is why it is not possible for this blood to be unclean in any way.

When does the menstrual cycle start and at what age does it finish?

The first menstrual bleeding can occur between the ages 8 and 16. Generally it is seen when the young female is 12 years old.

The last period will change depending on the reasons related with menopause. Especially women who experience early menopause under the age of 40, may experience irregularities in menstruation. Generally the last menstrual bleeding will occur between the ages 45 and 55.

What is Vaginoplasty?

A vaginoplasty is aesthetic and functional interventions made for the purpose of correcting problems seen due to the abnormal structure or congenital deformity seen in the genital area. A vaginoplasty is a common procedure. However, problems such as losing elasticity around the vagina and having problems during sexual intercourse can be restored by vaginoplasty. All the problems that result from the structure of the vagina, especially psychologically has a direct impact on the lives of women. The weakening of women’s sexual identity, lack of confidence, sexual dysfunctions and the problems that arise can be fixed both psychologically and physically by vaginoplasty.

Why is vaginoplasty applied?

The most common reasons why women get vaginoplasty are being bothered by the sight of the vagina and the inability to enjoy sex. To be bothered by the sight of the genitals may cause lack of self-confidence and serious problems in their sexual life. In this condition, communication may not be enough between couples. Apart from that, it can lead to a considerable drop in the quality of both daily life and sexual life.

Women usually have a hard time expressing their sexuality. Most women prefer not to talk and act shy about her problems rather than talking about it and expressing her problems. Therefore the problems that arise may cause even bigger problems if not expressed. Within the framework of aesthetic concern that occur in the vagina, deformation, deformity, changes in skin colour and reproductive system has a direct impact on the sexual lives of patients. For this reason vaginoplasty, strengthens women psychologically and physically and helps them gain their sexual identity once again.

Women who apply for vaginoplasty feel better psychologically, and have healthier sexual life.

Vaginoplasty is applied to whom?

• Women who are not satisfied with the nominal shape of the genital organs
• Women who previously gave natural birth more than once and lost the elasticity of the vagina
• Correction of the deformation which occurred as a result of an accident or a trauma
• Correction of congenital structural abnormalities
• If the hymen is thick the removal of the hymen

What are the operations that are applied?

• Vaginoplasty
• Kliteroplasty
• Labioplasty
• The expansion of the vagina
• G-spot augmentation with injections in order to increase sexual desire

The endometrium that constitutes the inner part of uterus and enables the menstrual bleeding will have a thickness up to 5mm within the period subsequent to the menstrual cycle. The endometrium will get thicker because of some hormones in the body and reaches up to 10 -15 mm thickness before the menstrual cycle. If the egg discharged from the ovary meets with the sperm and is fertilized, then the embryo will reach the uterus within a period as shorter as 1 week and starts to hold onto the uterus that makes preparations for pregnancy and to continue its development.

If the egg discharged from the ovary is not fertilized by the sperm, the thickened lining of the uterus will be discharged through the vagina with the menstrual bleeding.

Although what is the cause is not known certainly, the endometrial tissue may position in another region other than uterus (e.g. ovary, inner part of abdomen, upper part of the uterus). The endometrial tissues also repeat such attitude they exhibit within the uterus every month when they position in other regions than the uterus. Just as the thickening in the uterus, there are seen thickening in other regions when they position and such thick lining will be discharged through bleeding. Such eruptions that are required not to be will cause formation of bonding between the tissues within the reproductive system and this is defined as chocolate cyst (endometriosis).

Structure of Chocolate Cyst (Endometriosis)

The cysts that are caused by the positioning of the endometrial tissues in the ovaries and the accumulation of the bleeding in the ovaries are called chocolate cysts. The dark brown color of the fluid accumulated in the cystic structure and its appearance like chocolate cause it to be called with this name.

It may be usually seen in either the right ovary or left ovary and very rarely seen in both of the ovaries. The cysts are not included among the malignant and carcinogenic cysts because of their structures. Mostly seen in 4-6 cm diameter, these cysts can reach up to 15 cm.

What are the symptoms of Chocolate Cyst (Endometriosis)?

In the cases of Chocolate cyst or aka endometrioma, the menstrual bleedings may occur with severe pain and one can feel pain during sexual intercourse.

The symptoms that can be seen because of Chocolate Cyst:

These can be listed as below:

• Painful process of menstrual bleedings
• Realizing blood in the urine
• Diarrhea or constipation
• Pain during sexual intercourse
• Feeling pain in the legs
• Low back pain
• Back pain
• Inguinal pain that has become chronic
• Incapability of conception
• Bruises that form anywhere on the body
• Blood in stool
• Burning sensation while urinating
• Nose-bleeding that may be experienced during menstrual cycle.

How does Chocolate Cyst (Endometriosis) Form?

It is thought that the causes of the formation of Chocolate cyst mostly include the genetic causes. Chocolate cyst can rather be seen in 10% of the women within their reproductive period.   The cause for 20-40% of the women to experience sterility problem has been found to be the chocolate cyst.

Appearing with the menstrual bleedings with intense pain and feeling pain during the sexual intercourse, the chocolate cyst may develop without causing any symptoms in some of the cases and may be incidentally detected during a gynecological examination.

Final diagnosis for the chocolate cyst determined as a result of the examination with blood tests and ultrasonography can be established as a result of pathological examination. With their appearance relayed on the gynecological ultrasound images, it can be usually detected easily.

What are the treatment choices for Chocolate Cyst?

In the treatment of chocolate cysts, it is enabled to take out the cyst using open surgery or laparoscopy method as a standard. However, most physicians may aim at the disappearance of the cysts by considering the drug administration as appropriate.

What is the possibility of getting pregnant after Chocolate Cyst treatment?

The chance of getting pregnant after the chocolate cyst surgery for those partners experiencing the problem of infertility is about 40%. However, there are many factors that affect the process of conception. The age of woman, infertility period and various reasons causing infertility may affect the chance of conception. If the age of the patient is over 35 and infertility period is more than 7-8 years, the chance of spontaneous formation of pregnancy after the chocolate cyst surgery will get much lower. For those women who cannot get pregnant within 1 year period of time after chocolate cyst surgery, there can be enabled successful conceptions through in-vitro fertilization treatment.

What is Laparoscopy?

It is the surgical operation performed in the abdomen of the patients through small incisions and relaying the image on the optical device and where carbon dioxide gas is fed into the abdomen to see the tissues in it in a better way, which helps with diagnosis and treatment. In the recent years, the number of infertile women has got increased and the diagnosis and the treatment could be performed easily with the aid of laparoscopy. The reason why it is so much talked about among the people is that it is considered to be a bloodless surgery from a warmer perspective to the nonsurgical operation. In case of physical and physiological eligibility, this operation method may be considered as the most preferable surgery method by the gynecologists.

It is an operation that is not applied to those who are extremely weak or overweight as well as to those people who have severe lung disease and severe cardiac disease. For the operation, carbon dioxide gas is fed into the body for the image to be relayed onto the monitor. If there is not any anatomical disability, the diagnosis or the treatment will be successfully performed and the result will be achieved soon. At this point, the decision will be made by the gynecologists based on all these assessments.

When is the laparoscopy applied?

Laparoscopy is not a method only applied by the gynecology field. However, it is mostly preferred for the problems related to gynecology. It is a method that provides successful results to determine the reason of female sterility, to treat the cause of sterility, to reach the intrauterine problems, to treat these, and even for surgical removal of uterus and for cancer treatments. It is mostly used for determination of the infertility problems among the gynecology patients. It is a method of diagnosis and treatment that is highly prevailing in the infertilities associated with such issues as Endometriosis, ovarian problems, intrauterine adhesion, myomas and extrauterine pregnancy.

How is the laparoscopy applied?

There will be needed operating room conditions. An adequate number of small incisions will be cut on the edge of belly after the general anesthesia has been applied on the specified day. In diagnostic terms, laparoscopy includes the operations which usually take shorter time and are able to give result within 20 minutes. In laparoscopy for treatment purposes, additional apparatuses will be put into operation and the operation will get longer based on the issue. In case of female myoma, it may take about 45 minutes, and in case of excision of the whole womb, it may be extended up to 2,5 hours.

Laparoscopy application may not remain limited to only once. In case of infertility problems, the laparoscopy application may occasionally become a method that can be performed for several times.

With laparoscopy, through a 3 to 5 mm incision to be cut in the female abdomen, the surgical device will enlighten the interior part of abdomen and enable that the womb and ovaries will be observed better. It is easier to get an opinion about the intra-abdominal organs that will get up to 10 times bigger. The structures, myomas, endometriosis, cysts, and carcinogenic structures that grow different can be determined and the treatment is allowed at the same time with the diagnosis. As the determining the formations using the image relayed on the cam will be easy, a surgical operation that make the patients less tired and also, the physicians less tired will be performed.

Which health problems is the laparoscopy is preferred for?

• Oncological types of surgical operations
• In case of extrauterine pregnancy
• If it is required to excise the womb
• In case of endometriosis
• For diagnosis and treatment of the problems occurred in the tubes
• If it is thought that it is required to bind the tubes
• In case of intra-abdominal adhesions
• If it is required to excise such formations as myoma, polyp upon detection of them
• In case of pelvic abscess.

For whom is its application inconvenient?

• The gas that will be fed may create negative effect for those patients who are extremely slim and it may not be deemed convenient for very slim patients.
• The gas may create a negative effect for the patients who are overweight and in this sense, it will not considered to apply to those overweight people.
• No surgical operation will be performed on those people who have chronic lung disease using laparoscopy technique.
• It will not be convenient to apply surgical operation through laparoscopy to those patient who have a certain group of cardiac disease