Update on Reproductive Update on Reproductive SurgerySurgery

Prof T C LIProf T C LIProfessor of Reproductive Medicine & SurgeryProfessor of Reproductive Medicine & Surgery

Sheffield, EnglandSheffield, England

Shenzhen, May 2013

Areas to be coveredAreas to be covered

Management of distal tubal diseaseManagement of distal tubal disease

Ovarian surgery revisitedOvarian surgery revisited

Haemostatic agent Haemostatic agent

Management of distal tubal Management of distal tubal diseasedisease

Salpingostomy

Salpingectomy

IVF?

Management of distal tubal Management of distal tubal diseasedisease

Salpingostomy

Salpingectomy

IVF?

Answer: it depends

MICROSURGICAL SALPINGOSTOMY:MICROSURGICAL SALPINGOSTOMY: JESSOP SERIESJESSOP SERIES

Live birth rate

28/97 (29%)

IU pregnancy rate

33/97 (34%)

Singhal, Li and Cooke

BJOG, 1991

MICROSURGICAL SALPINGOSTOMY

Tubal score Term pregnancy

Stage I 22/56 (39%)

Stage II 20/99 (20%)

Stage III/IV 6/75 (8%)

Winston and Magara BJOG 1991

SALPINGOSTOMY: SALPINGOSTOMY: GOOD PROGNOSTIC GOOD PROGNOSTIC

FEATURESFEATURES

small hydrosalpinxsmall hydrosalpinx

no/minimal peri-tubal adhesionsno/minimal peri-tubal adhesions

normal mucosanormal mucosa

normal/thin wallnormal/thin wall

partial occlusionpartial occlusion

Sapingostomy Sapingostomy 1. mobilise fimbriael end1. mobilise fimbriael end

Sapingostomy Sapingostomy 1. mobilise fimbriael end1. mobilise fimbriael end

Sapingostomy Sapingostomy 1. mobilise fimbriael end1. mobilise fimbriael end

Sapingostomy Sapingostomy 2.locate blocked ostium2.locate blocked ostium

Sapingostomy Sapingostomy 3. incise blocked ostium 3. incise blocked ostium

Sapingostomy Sapingostomy 4. inspect lumen 4. inspect lumen

Sapingostomy Sapingostomy 4. inspect lumen - salpingoscopy 4. inspect lumen - salpingoscopy

Sapingostomy Sapingostomy 5. eversion of fimbrial mucosa 5. eversion of fimbrial mucosa

Sapingostomy Sapingostomy 6. suture 6. suture

Sapingostomy Sapingostomy 6. suture 6. suture

MICROSURGICAL SALPINGOSTOMY

Tubal score Term pregnancy

Stage I 22/56 (39%)

Stage II 20/99 (20%)

Stage III/IV 6/75 (8%)

Winston and Magara BJOG 1991

Salpingoscopy Salpingoscopy Abnormal MucosaAbnormal Mucosa

Management of distal tubal Management of distal tubal diseasedisease

Salpingostomy

Salpingectomy

IVF?

Hydrosalpinges and IVFHydrosalpinges and IVF

The live birth rate of patients with The live birth rate of patients with hydrosalpinges undergoing IVF is hydrosalpinges undergoing IVF is only one-half that of women who do only one-half that of women who do not have hydrosalpinges not have hydrosalpinges

Hydrosalpinx and IVF outcome : a Hydrosalpinx and IVF outcome : a prospective randomized multicentre trial in prospective randomized multicentre trial in Scandinavia on salpingectomy prior to IVFScandinavia on salpingectomy prior to IVF

Strandell et al 1999 Human Reprod 14:2762Strandell et al 1999 Human Reprod 14:2762

GroupGroup PatientPatient PR PR miscarriagemiscarriage Live birthLive birth

SalpingectomySalpingectomy 112112 36.6%36.6% 16.2%16.2% 28.6%28.6%

No No salpingectomysalpingectomy

9292 23.9%23.9% 26.3%26.3% 16.3%16.3%

First IVF cycle, regardless of whether or nothydrosalpinges demonstrable by USS

PR, p=0.067 LB, p=0.045

Hydrosalpinges and IVFHydrosalpinges and IVF

Salpingectomy prior to IVF in women Salpingectomy prior to IVF in women with hydrosalpinges improves with hydrosalpinges improves pregnancy, implantation and live birth pregnancy, implantation and live birth rates rates

1. Is it 1. Is it cost-effective to to routinely remove routinely remove

all hydrosalpinges all hydrosalpinges prior to IVF ?prior to IVF ?

Cost-effectiveness of salpingectomy prior Cost-effectiveness of salpingectomy prior to IVF, based on a RCTto IVF, based on a RCT

Strandell et al 2005 Human Reprod 20:3284Strandell et al 2005 Human Reprod 20:3284

GroupGroup PatientPatient Cost per LBCost per LB

SalpingectomySalpingectomy 5151 Euro 22823Euro 22823

No salpingectomyNo salpingectomy 4444 Euro 29517Euro 29517

Up to three IVF cycles, in women withhydrosalpinges demonstrable by USS

Cost-effectiveness of salpingectomy prior Cost-effectiveness of salpingectomy prior to IVF, based on a RCTto IVF, based on a RCT

Strandell et al 2005 Human Reprod 20:3284Strandell et al 2005 Human Reprod 20:3284

GroupGroup PatientPatient Cost per LBCost per LB

SalpingectomySalpingectomy 5151 Euro 22823Euro 22823

No salpingectomyNo salpingectomy 4444 Euro 29517Euro 29517

Up to three IVF cycles, in women withhydrosalpinges demonstrable by USS

More cost-effective

1. Is it 1. Is it cost-effective to to routinely remove routinely remove

all hydrosalpinges all hydrosalpinges prior to IVF ?prior to IVF ?

YesYes

2. Should proximal tubal 2. Should proximal tubal occlusion replace occlusion replace salpingectomy?salpingectomy?

Complications of salpingectomyComplications of salpingectomy

Impairment of ovarian blood supply, Impairment of ovarian blood supply, leading to reduced ovarian response to leading to reduced ovarian response to ovarian stimulation in IVFovarian stimulation in IVF

Bowel injuryBowel injury

A case of salpingectomyA case of salpingectomy

Large hydrosalpinx visible on ultrasoundLarge hydrosalpinx visible on ultrasound

One failed IVF treatmentOne failed IVF treatment

Laparoscopic surgery Laparoscopic surgery

Dense adhesions between L tube and Dense adhesions between L tube and bowel and pelvic side wallbowel and pelvic side wall

2 hour operation, salpingectomy2 hour operation, salpingectomy

Day 3, sepsis, bowel leakDay 3, sepsis, bowel leak

Colostomy, ITU for 1 weeksColostomy, ITU for 1 weeks

Complications of salpingectomyComplications of salpingectomy

Impairment of ovarian blood supply, Impairment of ovarian blood supply, leading to reduced ovarian response to leading to reduced ovarian response to ovarian stimulation in IVFovarian stimulation in IVF

Bowel injuryBowel injury

More likely if there were severe adhesions

Disadvantages of proximal tubal Disadvantages of proximal tubal occlusionocclusion

Pain may get worsePain may get worseRisk of recurrent infection and pyosalpinx Risk of recurrent infection and pyosalpinx May require further surgery to remove the May require further surgery to remove the diseased tube at a later datediseased tube at a later dateThe data on possible benefit is not as robust The data on possible benefit is not as robust as that of salpingectomyas that of salpingectomy

2. Should proximal tubal 2. Should proximal tubal occlusion replace occlusion replace salpingectomy?salpingectomy?

Only if there are severe adhesions

3. Should hysteroscopic tubal 3. Should hysteroscopic tubal occlusion replace occlusion replace salpingectomy?salpingectomy?

Essure

3-8 expanded outer coils visible in uterinecavity

43

21

4 expandedouter coils

3. Should hysteroscopic tubal 3. Should hysteroscopic tubal occlusion replace occlusion replace salpingectomy?salpingectomy?

No, there are concerns about implantation and premature

labour

4. Is aspiration of 4. Is aspiration of hydrosalpinges fluid as effective hydrosalpinges fluid as effective

as salpingectomy?as salpingectomy?

Ultrasound-guided hydrosalpinx aspiration, RCT

Hammadien et al, Human Reprod 2008 Hammadien et al, Human Reprod 2008

Aspiration No aspiration

P value

Biochemical pregnancy

14/32 (43.8%)

7/34 (20.6%)

0.04

Clinical pregnancy

10/32 (31.3%)

6/34 (17.6%)

0.2

4. Is aspiration of 4. Is aspiration of hydrosalpinges fluid as effective hydrosalpinges fluid as effective

as salpingectomy?as salpingectomy?

No No

5. 5. If the hydrosalpinx is small and If the hydrosalpinx is small and not visible on ultrasound, is it still not visible on ultrasound, is it still

necessary to perform necessary to perform salpingectomy?salpingectomy?

Hydrosalpinx and IVF outcome : a Hydrosalpinx and IVF outcome : a prospective randomized multicentre trial in prospective randomized multicentre trial in Scandinavia on salpingectomy prior to IVFScandinavia on salpingectomy prior to IVF

Strandell et al 1999 Human Reprod 14:2762Strandell et al 1999 Human Reprod 14:2762

GroupGroup PatientPatient PR PR miscarriagemiscarriage Live birthLive birth

SalpingectomySalpingectomy 112112 36.6%36.6% 16.2%16.2% 28.6%28.6%

No No salpingectomysalpingectomy

9292 23.9%23.9% 26.3%26.3% 16.3%16.3%

First IVF cycle, regardless of whether or nothydrosalpinges demonstrable by USS

PR, p=0.067 LB, p=0.045

5. 5. If the hydrosalpinx is small and If the hydrosalpinx is small and not visible on ultrasound, is it still not visible on ultrasound, is it still

necessary to perform necessary to perform salpingectomy?salpingectomy?

YesYes

Ultrasound may fail to diagnose hydrosalpinx

6. 6. UNILATERAL TUBAL UNILATERAL TUBAL DISEASEDISEASE

Is surgery still worthwhile?Is surgery still worthwhile?

Unilateral Hydrosalpinx with a Contra-lateral Patent Tube

McComb & Taylor 2001 Fertil Steril 76:1279 McComb & Taylor 2001 Fertil Steril 76:1279

23 women with unilateral hydrosalpinx 23 women with unilateral hydrosalpinx underwent salpingostomyunderwent salpingostomy

IU pregnancy rate 43.5%IU pregnancy rate 43.5%

Conclusion – unilateral salpingostomy in Conclusion – unilateral salpingostomy in women with a contra-lateral patent tube women with a contra-lateral patent tube improves fertilityimproves fertility

Case HistoryCase History33 year old woman33 year old woman

one one miscarriagemiscarriage at 7 weeks at 7 weeks

Infertility for 15 monthsInfertility for 15 months

Conceived spontaneously, but Conceived spontaneously, but miscarriedmiscarried again at 8 week gestationagain at 8 week gestation

Investigation – L tube normal. R hydrosalpinx, Investigation – L tube normal. R hydrosalpinx, grossly dilated, intraluminal adhesions, grossly dilated, intraluminal adhesions, salpingectomy. salpingectomy.

Three months later, spontaneouslyThree months later, spontaneously conception, conception, term deliveryterm delivery

6. 6. UNILATERAL TUBAL UNILATERAL TUBAL DISEASEDISEASE

Is surgery still worthwhile?Is surgery still worthwhile?

YesYes

77. How to do salpingectomy . How to do salpingectomy properly?properly?

Salpingectomy : Surgical tips 1Salpingectomy : Surgical tips 1

Main Risk:Main Risk: devascularization of the ovary devascularization of the ovary

Operate close to the tube, away from ovarian Operate close to the tube, away from ovarian vessels and suspensory ligamentvessels and suspensory ligament

Salpingectomy : surgical tips 2 Salpingectomy : surgical tips 2

Other Risk:Other Risk: incomplete removal, with development incomplete removal, with development of ectopic pregnancy following ARTof ectopic pregnancy following ART

Do a complete salpingectomy !Do a complete salpingectomy !

Areas to be coveredAreas to be covered

Management of distal tubal diseaseManagement of distal tubal disease

Ovarian diathermy for PCOSOvarian diathermy for PCOS

Haemostatic agent Haemostatic agent

PCOS & Ovarian DiathermyPCOS & Ovarian Diathermy

Why bother doing laparoscopic Why bother doing laparoscopic diathermy or drilling of the ovaries?diathermy or drilling of the ovaries?

How should it be done?How should it be done?

LOD vs GONADOTROPHINLOD vs GONADOTROPHINCOCHRANE DATABASECOCHRANE DATABASE

3 RCTS3 RCTS

Vegetti et al 1998Vegetti et al 1998

Farquhar et al 2002Farquhar et al 2002

Bayram et al 2004Bayram et al 2004

CCR 6-12 month after LOD is similar to 3-CCR 6-12 month after LOD is similar to 3-6 cycles of gonadotrophin therapy 6 cycles of gonadotrophin therapy

LOD versus FSHLOD versus FSH

Bayram et al, 2004Bayram et al, 2004

Treatment RegimenTreatment Regimen No of No of womenwomen

PregnantPregnant

(%)(%)

MiscarryMiscarry MultipleMultiple LBLB

(%)(%)

LOD strategyLOD strategy

LODLOD 83 (100)83 (100) 31 (37)31 (37) 33 -- 28 (34)28 (34)

LOD + CCLOD + CC 45 (54)45 (54) 14 (31)14 (31) 11 -- 13 (29)13 (29)

LOD + CC + FSHLOD + CC + FSH 23 (28)23 (28) 18 (78)18 (78) 33 11 12 (52)12 (52)

LOD strategy totalLOD strategy total 8383 63 (76)63 (76) 77 11 53 (64)53 (64)

FSHFSH 8585 64 (75)64 (75) 77 99 51 (60)51 (60)

Conclusions of studyConclusions of study

An electrocautery strategy and An electrocautery strategy and ovulation induction with recombinant ovulation induction with recombinant follicle stimulating hormone are follicle stimulating hormone are similarly effective in inducing ovulationsimilarly effective in inducing ovulation

Multiple pregnancies can largely be Multiple pregnancies can largely be avoided by electrocautery and avoided by electrocautery and clomifene citrate before rFSHclomifene citrate before rFSH

LOD vs GONADOTROPHINLOD vs GONADOTROPHINECONOMIC CONSIDERATIONS ECONOMIC CONSIDERATIONS LOD Gonadotrophins

Pregnancy rate

50% in 12

months

Up to 20% per

cycle Cost per maternity

~ £2000

~ £4000

Multiple pregnancy

< 2%

> 20%

Li et al 1998, BJOG

LOD vs GONADOTROPHINLOD vs GONADOTROPHINECONOMIC CONSIDERATIONSECONOMIC CONSIDERATIONS

LODLOD gonadotrophinsgonadotrophins

Cost per live birthCost per live birth

Farquhar et al, 2004Farquhar et al, 2004

US $21095US $21095 US $28744US $28744

Cost per live birth + Cost per live birth + delivery delivery

Wely et al, 2004Wely et al, 2004

Euro 11301Euro 11301 Euro 14489Euro 14489

Cost of term pregnancy : LOD 22-33% lower

NICE Guidelines NICE Guidelines

Ovarian drillingOvarian drilling

Women with PCOS who have not Women with PCOS who have not responded to CC should be offered responded to CC should be offered laparoscopic ovarian drilling because it is laparoscopic ovarian drilling because it is as effective as gonadotrophin treatment as effective as gonadotrophin treatment and is not associated with an increased and is not associated with an increased risk of multiple pregnancyrisk of multiple pregnancy

ADVANTAGES OF LODADVANTAGES OF LOD

1.1. Avoids risk of multiple pregnancyAvoids risk of multiple pregnancy

2.2. Less costlyLess costly

3.3. Long term beneficial effects including Long term beneficial effects including menstrual regularity, sustained reduction menstrual regularity, sustained reduction of FAI, sustained restoration of ovulation of FAI, sustained restoration of ovulation and further chances spontaneous and further chances spontaneous conception in over 50% of subjects conception in over 50% of subjects compared with subjects who did not compared with subjects who did not undergo LOD undergo LOD (Amer et al, Human Reprod 2002, (Amer et al, Human Reprod 2002, 17:2035; Amer et al, Human Reprod 2002, 17:2851)17:2035; Amer et al, Human Reprod 2002, 17:2851)

PCOS & Ovarian DiathermyPCOS & Ovarian Diathermy

Why bother doing laparoscopic Why bother doing laparoscopic diathermy or drilling of the ovaries?diathermy or drilling of the ovaries?

How should it be done?How should it be done?

How many punctures should How many punctures should one make?one make?

The number of puncture is only one of The number of puncture is only one of several variables which determines the several variables which determines the amount of electrical energy delivered to amount of electrical energy delivered to

the ovarythe ovary

The amount of energy (J) used is The amount of energy (J) used is calculated as: calculated as: power (w) x duration power (w) x duration

(sec) x No of punctures(sec) x No of punctures

Laparoscopic Ovarian Laparoscopic Ovarian Diathermy Diathermy

How much electrical energy How much electrical energy

is required to produce is required to produce optimal results?optimal results?

The amount thermal energy The amount thermal energy used in LODused in LOD

Gjonnaess (1984): 250 w x 3 sec x > Gjonnaess (1984): 250 w x 3 sec x > 5 5 = > 3750 joules = > 3750 joules Armar et al (1990): 40 w x 4 sec x 4 = Armar et al (1990): 40 w x 4 sec x 4 = 640 joules 640 joules Dabirashrafi (1989): Severe ovarian Dabirashrafi (1989): Severe ovarian atrophy with 8 holes x 400w x 5 sec atrophy with 8 holes x 400w x 5 sec = 16,000 Joules = 16,000 Joules

The Sheffield Prospective Dose The Sheffield Prospective Dose Finding Study Finding Study Amer, Li & Cooke, 2003Amer, Li & Cooke, 2003

30 women divided into ten groups, each group with 3 women30 women divided into ten groups, each group with 3 women

Dose in each group to be determined by the response of Dose in each group to be determined by the response of

previous groupprevious group

Energy utilised for each puncture is standardised Energy utilised for each puncture is standardised

The modified Monte Carlo Up-and-Down design

Conception rates after LOD Conception rates after LOD Sheffield Prospective StudySheffield Prospective Study

17%

67%

56%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1 2 3 41

puncture

2 3 4

OVARIAN DIATHERMYOVARIAN DIATHERMY

ELECTRICAL ENERGYELECTRICAL ENERGY

Rockett of London diathermy needleRockett of London diathermy needle

needle 8 mm long, 2 mm diameterneedle 8 mm long, 2 mm diameter

monopolar coagulationmonopolar coagulation

power - 30 Wpower - 30 W

puncturepuncture– number 4number 4– duration 5 secondsduration 5 seconds

With the use of proper With the use of proper techniques, laparoscopic techniques, laparoscopic

ovarian diathermy is ovarian diathermy is very safevery safe

Sheffield series :Sheffield series :Adhesions – often minimalAdhesions – often minimal

ovarian failure – 0/250casesovarian failure – 0/250cases

Management of distal tubal diseaseManagement of distal tubal disease

Ovarian surgery revisitedOvarian surgery revisited

Haemostatic Agent Haemostatic Agent

Floseal Haemostatic MatrixFloseal Haemostatic Matrix(Baxter)(Baxter)

FLOSEAL is indicated in surgical FLOSEAL is indicated in surgical procedures (other than ophthalmic) as an procedures (other than ophthalmic) as an adjunct to haemostasis when control of adjunct to haemostasis when control of bleeding by ligature or conventional bleeding by ligature or conventional procedures is ineffective or impractical. procedures is ineffective or impractical.

What is Floseal?What is Floseal?

FLOSEAL provides a combination of two FLOSEAL provides a combination of two independent hemostasis promoting independent hemostasis promoting agents. agents. – The gelatin granules swell to produce a The gelatin granules swell to produce a

tamponade effecttamponade effect– High concentrations of human thrombin High concentrations of human thrombin

convert fibrinogen into fibrin monomers convert fibrinogen into fibrin monomers accelerating clot formationaccelerating clot formation

Identify the source of bleeding at the tissue Identify the source of bleeding at the tissue surface. Apply FLOSEAL Hemostatic Matrix surface. Apply FLOSEAL Hemostatic Matrix FAST to the deepest part of the wound or FAST to the deepest part of the wound or

lesion - the source of bleeding at the tissue lesion - the source of bleeding at the tissue

surface.surface.

FLOSEAL granules allow high concentrations of FLOSEAL granules allow high concentrations of thrombin to react rapidly with the patient's thrombin to react rapidly with the patient's

fibrinogen and form a mechanically stable clot.fibrinogen and form a mechanically stable clot.

FLOSEAL can be reapplied, if necessary. FLOSEAL can be reapplied, if necessary. Once haemostasis is achieved, gentle Once haemostasis is achieved, gentle irrigation should always occur to remove irrigation should always occur to remove excess product that has not been excess product that has not been incorporated into the clot. incorporated into the clot. Do not disrupt the clot by physical Do not disrupt the clot by physical manipulation or suction.manipulation or suction.

When is it useful?When is it useful?

Pelvic side wallPelvic side wall

Rectovaginal spaceRectovaginal space

Ovarian cyst wall Ovarian cyst wall

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