Transcript Should you operate? Surgery in the fertility patient.

Should you operate? Surgery in
the fertility patient.
Kevin Doody MD
Conflict of interest
• Owner, administrator – Center for Assisted
Reproduction Ambulatory Surgical Center
• Surgeon
Objectives
• When to perform surgery prior to IVF / IUI
• When to avoid surgery prior to IVF / IUI
• When to offer surgery as an alternative to IVF
Major causes of infertility
• Sperm / male infertility
– Obstructive
– Non-obstructive
• Varicocoele
• Egg / hormonal
• Female anatomical
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Peritoneal
Ovarian
Tubal
Uterine
Infertility treatment - strategy
• Correct identifiable contributing factors
• IUI or IVF when cause is not identified
• IUI or ART when identified cause(s) remain
uncorrected
Surgically treatable male factor
• Ejaculatory duct obstruction
• Vasectomy
• Varicocoele
Ejaculatory Duct Obstruction
• Diagnosis
– Low semen volume, low concentration or
azoospermia, low or absent semen fructose
– Trans-rectal sonography demonstrates dilation of
seminal vesicles
• Treatment options
– Transurethral resection of obstruction
– ICSI +/- TESE
Varicocoele
• Diagnosis
– Visual
– Palpation
• Valsalva
– Ultrasound
• Treatment options
– Surgical
– Radiological
– IUI
Peritoneal Disease
• Endometriosis
• Peritoneal adhesions
• Diagnosis
– Screening tests
• Pelvic exam
• Ultrasound
• HSG
– Diagnostic test
• Laparoscopy (gold standard)
Diagnostic laparoscopy –when to
consider
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Pelvic pain
Abnormal HSG
Abnormal pelvic exam
Abnormal sonogram
Prior pelvic surgery
Undiagnosed infertility (weak indication)
Diagnostic hysteroscopy – when to
consider
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Abnormal bleeding
Progressive dysmenorrhea
Abnormal sonogram
Filling defect on HSG
Undiagnosed infertility
Incidental to laparoscopy
Checklist item prior to IUI or ART
Hysteroscopy –office versus O.R.
• Low suspicion or high suspicion of lesion
• Insurance / financial issues
Endometriosis
• Stage I, II
• Stage III, IV
EFI surgery form and a simplified figure for patient education showing the estimated pregnancy
chance per EFI score.
Tomassetti C et al. Hum. Reprod. 2013;28:1280-1288
© The Author 2013. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
[email protected]
Adnexal adhesions
• Diagnosis
– Screening tests
• Sonography
• HSG
– Diagnostic tests
• Laparoscopy
Ovarian Cysts
• Endometrioma
• Dermoid
• Undiagnosed
– Hyperechoic
– Echogenic
– Sonolucent
– Mixed echogenicity
– Present or absence of septations, nodules,
internal color flow
Endometrioma – when to consider
surgery
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Unconfirmed diagnosis
Pain
High AMH
Desire to avoid IVF
Concern about possibility of ovarian access
following retrieval
Endometrioma – surgical options
• Cystectomy
• Drainage +/- ablation
Laparoscopic removal of endometriomas:
Sonographic evaluation of residual functioning
ovarian tissue
Caterina Exacoustos, MD, Errico Zupi, MD, Annalisa Amadio, MD, Beata Szabolcs, MD, Bonaventura De Vivo, MD,
Daniela Marconi, MD, Maria Elisabeyya Romanini, MD, Domenico Arduini, MD
Conclusion: Ovarian stripping of endometriomas, but not of
ovarian dermoids, is associated with a significant decrease in
residual ovarian volume which may result in diminished ovarian
reserve and function.
American Journal of Obstetrics and Gynecology (2004) 191, 68-72
Dermond / teratoma
• Should almost always be surgically handled
(cystectomy)
• Very low risk of diminishing ovarian reserve
unless done by oncologist
• Important to have firm diagnosis of
hyperechoic lesions
Tubal factor
• Proximal obstruction
– S.I.N.
– Surgical sterilization
• Essure
• Post-partum
• Laparoscopic
– Clips / rings
– Cautery
– Distal occlusion
• Hydrosalpinx
S.I.N.
• Surgical management involves ischemic /
cornual resection + re-implantation
• Should be discouraged due to high rate of reocclusion and possibility of ectopic pregnancy
• IVF should be primary approach
Reversal of surgical sterilization
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Allows natural conception
No increased risk of twins
Multiple (monthly) opportunities for pregnancy
Most appropriate for women with favorable sterilization
technique
• Should be strongly considered in patients with diminished
ovarian reserve
– Poor prognosis with IVF
• Should be avoided with partners with poor semen
parameters
• Counseling regarding treatment options is best done by
someone proficient in both IVF and tubal surgery
Proximal occlusion of unknown
etiology
• Laparoscopy + hysteroscopic tubal cannulation
should be primary approach
• Selective salpingography might be considered
if laparoscopy has been previously performed
• IVF if unable to achieve patency or no
pregnancy in 6 – 12 months
Distal tubal occlusion / hydrosalpinx
• Options are salpingectomy + IVF versus
neosalpingostomy
• Decision to perform tubal reconstruction or
salpingectomy is best done intra-operatively
Fibroids – Surgical management
Outpatient
• Hysteroscopic
• Laparoscopic
• Mini-laparotomy
Inpatient
• Laparotomy
• Severe anemia
Leiomyoma – decision to operate
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Size
Location
Abnormal menses / bleeding
Prior myomectomy
Presence of extensive adenomyosis
Invasiveness of procedure
– Inpatient vs outpatient
– Recovery time
– Skill of surgical team
Fibroids - Location
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Pedunculated
Subserosal
Intramural
Submucosal
Intracavitary
Difficult to classify
Fibroids -Size
• Small
• Intermediate
• Large
Laparoscopic myomectomy
Advantages
• Outpatient
• Good visualization of entire
pelvis
• Small incisions
• Can be done with Da Vinci
Disadvantages
• Difficult to detect small
intramural myomas
• Several incisions
• Can be done with Da Vinci
• Liability with morcellation
• Longer OR times
Myomectomy by laparoscopy with
mini-laparotomy
Advantages
• Outpatient
• Good visualization of entire
pelvis
• Ability to palpate small
intramural leiomyomata
• No power morcellation
required
• Cosmetically desirable
• Fast operating times
Disadvantages
• Not state of the art
sounding
• No ability to use “robot”
Hysteroscopic myomectomy-technique
• Morcellator
• Versapoint
• Resectoscope
Summary
• Anatomical issues are commonly encountered in
patients seeking treatment for infertility
• In cases a surgical approach to the treatment of
infertility is warranted
• IVF should be encouraged as the primary treatment
modality in many (but not all) patients with peritoneal
and tubal disease. Salpingectomy is warranted in
patients with hydrosalpinx prior to IVF
• Uterine factors and ovarian cysts should be surgically
corrected in many patients as a primary treatment for
infertility or to optimize ART outcomes