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REPRODUCTIVE ENDOSURGERY ROLE OF MINIMALLY INVASIVE SURGERY IN THE TREATMENT OF INFERTILITY PRIYA PATEL MD FRCSC
REPRODUCTIVE ENDOSURGERYROLE OF MINIMALLY INVASIVE SURGERY IN THE TREATMENT OF INFERTILITY
PRIYA PATEL MD FRCSC
REPRODUCTIVE ENDOSURGERY
Role of laparoscopy and hysteroscopy in infertility:
- Primary evaluation- Laparoscopy – NO1
- Hysteroscopy – MAYBE2
- In women undergoing IVF
- Secondary evaluation- Unsuccessful HSG or SIS
- In the patient with unexplained infertility
- unwilling to consider ART
- has pain as a major symptom
- has failed multiple OI/IUI, or IVF3
- Primary treatment
- Secondary treatment- To enhance IVF outcomes
- Ovarian preservation
2
1. Badawy et al. J Obstet Gynaecol 2010; 30:712-5.2. Kamath et al. Cochrane Database Syst Rev, 2019; 4:CD012856.3. Yu et al. Medicine 2019; 98:13(e14957)
HYSTEROSCOPY
3
ENDOMETRIAL POLYPS
• Perez-Medina T et al, 2005
- RCT of 215 women with endometrial polyp undergoing IUI
- Hysteroscopic polypectomy (n=107) vs. endometrial biopsy (n=109)
- Pregnancy rate was higher (51 vs. 25%)
- More than ½ of women conceived spontaneously within 3m PO
- Independent of size of the polyp
4
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4. Perez-Medina T et al. Hum Reprod, 2005; 20: 1632-5.
SUBMUCOUS FIBROIDS
• Casini et al, 20065
- RCT of women with infertility limited to a single fibroid of ≤4cm
- SM (n=52), SM-IM fibroid (n=42)
- Pregnancy rates were higher
- 43% vs. 27% in the SM group
- 36% vs. 15% in the SM-IM group
• Intrauterine adhesions, 7.5-78%6,7
• Surgical considerations
- Complexity (number, size, depth, location)
- Pretreatment with GnRH agonist
- resectoscope vs. morcellator, warmed irrigant
- 2-stage procedure, abdominal approach
- 2nd look office hysteroscopy or SIS5
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5. Casini ML et al. Gynecol Endocrinol, 2006; 22:106-9.6. Yang JH et al. Fertil Steril, 2008;89:1254-97. Taouboul C et al. Fertil Steril 2009;92:1690-3
UTERINE SEPTA
• Mollo A et al, 20097
- unexplained infertility with uterine septum
- Higher pregnancy and live birth rates (34 vs. 19%)
• Surgical considerations
- Complexity - Thickness
- Length of septum
- Incision vs. resection
- Concurrent laparoscopic guidance
- Staged procedure
- Pre-treatment with GnRH agonist6
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7. Mollo A et al. Fertil Steril, 2009;91: 2628-31.
INTRAUTERINE ADHESIONS
Johary et al, 20148
- Systematic review of 28 studies
- Pregnancy rate 40 - 80%, live birth rate of 30 – 70%
Pregnancy rates are higher9, recurrence rates are lower10 with mild vs. severe adhesions
Considerations
- Cold scissors, concurrent laparoscopy
- Barriers (balloon > IUD > hyaluronic gel)11
- Estrogen therapy
- Second-look office hysteroscopy or SIS
- Risk of morbidly adherent placenta ~10%
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8. Johary J et al. J Minim Invasive Gynecol, 2014;21(1):44-54.9. Roy K et al. Arch Gynecol Obstet, 2010;281:355-61.10. Yang JH et al. BJOG, 2016;123(4):618-23.11. Lin X et al. Eur J Obstet Gynecol Reprod Biol, 2013; 170(2):512-6.
LAPAROSCOPY
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• Duffy et al, 201412
- Decreased overall pain (OR 6.58, 95%CI 3.31-13.10)
- Increased live birth rate (OR 1.94, 95%CI 1.20-3.16)
- NNT=8 (95%CI 5-32)13,14
• Pregnancy rates with excision = electrocoagulation15
• Opoien et al, 201116
- Improved outcomes of subsequent IVF
- Offer lap to infertile women with pain suggestive of mild endometriosis
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MILD-MODERATE ENDOMETRIOSIS
12. Duffy JMN et al. Cochrane Database Syst Rev 2014;4:CD011031.13. Marcoux S et al. N Engl J Med, 1997;337(4):217.14. Parazzini. Hum Reprod, 1999;14(5)1332-4.15. Tulandi T et al. Fertil Steril, 1998;69(2):229.16. Opoien HK et al. Reprod Biomed Online, 2011;23(3):389-95.
• Hart et al, 200817
- Cystectomy vs. drainage and coagulation:- Lower recurrence of endometrioma, pain
symptoms, need for further surgery
- Higher spontaneous pregnancy rate in women with infertility (CI 5.21, 95%CI 2.04-13.29)
• Tang et al, 201318
- Unilateral cystectomy prior to IVF - AFC, # dominant follicles, # oocytes retrieved were
decreased in operated ovaries vs. intact ovaries
- These differences were greater in cysts ≥4cm vs <4cm, even after accounting age and AFC
- Size of cyst correlated with incidence of <4 oocytes retrieved from operated ovary
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OVARIAN ENDOMETRIOMA
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17. Hart RJ et al. Cochrane Database Syst Rev, 2008;2:CD004992.18. Tang Y et al. Fertil Steril, 2013;100(2):464-9.
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Endometrioma
Pain Symptoms
Age /
Ovarian Reserve
Fertility History /
Desire
Cyst sizeUni- /
bilateral
Previous ovarian surgery
Cancer risk
LAPAROSCOPY
19. Kho RM et al. Best Pract Res Clin Obstet Gyn, 2018;51:102-10.
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LAPAROSCOPY
20. Tsoumpou I et al. Fertil Steril 2009;92:75-87.
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21. Kho RM et al. Best Pract Res Clin Obstet Gyn, 2018;51:102-10.
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22. Hornstein MD et al. UpToDate, 2019.
• Pritts et al, 200923
- lower implant rates (RR 0.68, 95%CI 0.59-0.80)
• Casini et al, 20065
- RCT of women with infertility limited to a single fibroid of ≤4cm
- no improvement in pregnancy or miscarriage rates
• Tulandi et al24
- Postop adhesions in 94% of posterior, vs. 55% of anterior incisions
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INTRAMURAL FIBROIDS
23. Pritts EA et al. Fertil Steril, 2009;91:1215-23. 24. Tulandi T et al. Obstet Gynecol, 1983;82:213-5.
• Indications- Large (>5cm) Type 2, <1cm from serosa
- Mass effect, including inability to cannulate cavity for embryo transfer
- Symptomatic menorrhagia
- History of obstetric complications
• Considerations- Risk of cancer
- Pre-treatment with GnRH agonist
- Breach of endometrial cavity- Postop office hysteroscopy or SIS
- Suture material
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INTRAMURAL FIBROIDS
• Gordts et al, 200925
- Retrospective study of 164 undergoing tubal reanastomosis
- Overall pregnancy rate 72.5%, 80% with fertile sperm
- Ectopic rate 7.7%
• Boeckxstaens et al26
- Retrospective study of 79 IVF, 84 surgery
- Overall success similar, 52 vs. 59%
- <37yrs, surgery had higher cumulative delivery rates (72 vs. 52%)
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PROXIMAL TUBAL OCCLUSION
25. Gordts S et al. Fertil Steril, 2009;92:1198-1202.26. Boeckxstaens A et al. Hum Reprod, 2007;22:2660-4.
• Johnson et al, 201027
- Salpingectomy before IVF yields 1.75 – 2.13X higher odds of
pregnancy and live birth
- No difference between tubal occlusion and salpingectomy
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HYDROSALPINGES
27. Johnson N et al. Cochrane Database Syst Rev, 2010;20:CD002125.
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ISTHMOCELES
28. Osser OV et al. Ultrasound Obstet Gynecol, 2009;34:90-7.29. Tulandi T et al. J Minim Invasive Gynecol, 2016;23:893-902.
• Incidence28: - 61% after 1, 100% after 3 C/S
• Risk factors29:- low incision, through cervical tissue
- non-full thickness, locking closure
- angulation due to RF, adhesions
• Symptoms- Postmenstrual AUB
- Pelvic pain
- Secondary infertility
- Persistent hydrometra
• Laparoscopic repair- Excision of the scar tissue from the edges
- 2-layer closure of the defect
• Donnez et al, 201730
- Prospective observational study, N=38, with <3mm myometrium
- Myometrial thickness increased - 1.43 ± 0.7 to 9.62 ± 1.8mm
- 91% symptom free
- 44% of infertile women conceived
• Hysteroscopic alternative- Risk of uterine perforation, bladder injury
- Does not increase myometrial thickness
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ISTHMOCELES
30. Donnez O et al. Fertil Steril, 2017;107:289-96.
THANK YOU!
REFERENCES
1. Badawy A et al. Laparoscopy or not for management of unexplained infertility. J Obstet Gynaecol, 30 (2010): 712-715
2. Kamath MS et al. Screening hysteroscopy in subfertile women and women undergoing assisted reproduction. Cochrane Database Syst Rev, 4 (2019), CD012856.
