laparoscopy and fertility

DIAGNOSTIC HYSTERO LAPAROSCOPY

One of the commonest surgical procedure performed for fertility enhancement

Almost 40 percentage of patients undergo DHL during fertility workup

With the advent of high quality instruments and advanced operative techniques laparotomy as a choice for fertility management is done only on exceptional conditions

LAPAROSCOPY & ART With recent improvements in ART

techniques there is a growing tendency that bypasses DHL procedure and proceeds directly to ART.

So routine use of DHL as evaluation for all cases of female fertility is presently under debate.

? Role of laparoscopy in the present scenario.

EVIDENCE BASED

APPROACH

PCOS… Controlled Ovulation induction with or

without IUI still remains the first line of management in case of PCOS.

Diet, life style modifications and insulin sensitizers play a major adjuvant role in management of PCOS

LOD should be considered in cases of failed COI with IUI.

Ovarian drilling Lean PCOS women (BMI ≤25 kg/m2)

achieved higher conception rates than overweight women Duleba et al 2003

PCOS women with BMI ≥35 kg/m2 achieved significantly lower ovulation and pregnancy rates after LOD compared with normal weight women.

Lower pre-treatment LH levels or a lower LH/FSH ratio were more likely to benefit from the treatment for a longer period compared with those who had higher pre-treatment levels as they are more likely to experience early recurrence of their anovulatory status.

Women with a duration of infertility >3 years were less likely to respond to LOD. Li et al 1998

According to Cochrane review LOD is as effective as gonodotrophins in women with clomiphene resistant PCOS.

Reduction in multiple pregnancy rates compared to gonadotrophins make this option attractive

Over enthusiastic and repeated LOD’s should be avoided as there are concerns of long term effect on ovarian function

Endometriosis.. Research has not firmly proved that removing

mild endometriosis improves fertility as the two major studies report conflicting results(ACOG Practice Bulletin 2010)

For moderate to severe endometriosis surgery will improve your chances of pregnancy (ASRM committee opinion 2012)

Optimal laparoscopic treatment requires not only surgical skill, but also comprehensive knowledge of pelvic anatomy and a good understanding of endometriosis and its progression.

Large endometriomas may need to be removed surgically prior to IVF but smaller ones are generally best left in place.

Surgery for very severe endometriosis or repeat surgery is generally not beneficial and may cause harm by reducing ovarian reserve and these patients better respond to ART. (ASRM committee opinion 2012)

Two RCT’S on patients with mild to moderate endometriosis

Meta analysis demonstrated an advantage of laparoscopic surgery in terms of clinical pregnancy and live birth rate.

Use of laparoscopic surgery in the treatment of sub fertility related to mild to moderate endometriosis may improve future fertility (Cochrane review 2009)

Ovarian cysts… Analysis of the epidemiologic data drawn

mainly from comparative studies and cohorts, shows that the role of cysts in infertility is controversial.

The effects of surgical treatment are often more harmful than the cyst itself to the ovarian reserve.

Surgery is indicated only in case of large cysts with associated potential complications.

When a surgical option is nonetheless chosen a conservative laparoscopic approach is more suitable.

while performing surgery the context of the infertility is essential, and surgeons and specialists in reproductive medicine should decide management jointly. (American Society for Reproductive Medicine 2014)

Nine RCT’s on lap Vs laparotomy Three RCT’s on lap vs minilaparotomy One study on cost effectiveness Laparoscopy for benign ovarian tumours

is associated with reduced post operative pain and complications and better fertility outcome due to reduced post operative adhesions and is cost effective (Cochrane review 2009)

Myoma uterus… Fertility outcomes are decreased in women

with sub mucosal and deeply infiltrating intramural fibroids and warrant consideration of myomectomy in the subfertile patient. (Curr opin obstet gynecol 2013).

Intramural fibroids appear to decrease fertility with an increased risk of spontaneous miscarriage but the results of therapy are unclear. Myomectomy may be considered before ART to alleviate these detrimental effects. (womens health lond engl 2009).

Studies have demonstrated that subserosal fibroids did not negatively impact fertility.

Laparoscopic myomectomy is a feasible technique safe for patients waiting for conception and has proven its interest in case of infertility. (Gynecol Obstet Biol Reprod Paris 2007)

Although there is a risk of uterine rupture following laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique with an extremely low failure rate and good results in terms of the outcome of pregnancy.(J Gynecol Endosc Surg. 2011)

One study on reproductive outcome and two RCT’s on open Vs laparoscopic approach

No significant effect of myomectomy on reproductive outcome and no significant differences between two modalities of treatment

This evidence needs to be viewed with caution due to small number of studies and no RCT to evaluate the role of myomectomy to improve fertility (Cochrane review 2012)

Proximal tubal block… The overall pregnancy rate after successful

hysteroscopic proximal cannulation of at least one tube is 55%.

The mean time to become pregnant after successful unilateral or bilateral hysteroscopic cannulation was 10.5 ± 8.9 months.

Laparo hysteroscopic cannulation for proximal obstruction is a procedure with minimal morbidity and a reasonable successful recanalisation rate. It should be considered as an alternative to in vitro fertilisation. (ANZJOG © 2012)

Canadian Task Force Clinical cases series of 168 women with a proximal tubal block, the successful recanalization rate was 54.2% per tube and 61.9% per patient

Cumulative conception rate was 43.7% at 2 years and for patients with unilateral obstruction is 60.7% .

Successful tubal cannulation led to significant improvement in the pregnancy rate in these women and laparoscopy guided hysteroscopic cannulation is still a viable alternative to in vitro fertilization. (AAGL 2014).

Hydrosalphinx… Five RCT’s involving 646 women on

salphingectomy, tubal occlusion, aspiration Vs no treatment.

Clinical and ongoing pregnancy rates increased with salphingectomy prior to IVF

Tubal occlusion increases clinical but not ongoing pregnancy rate

Effect of US guided aspiration is doubtful and needs to be assessed. (Cochrane 2010)

Ectopic pregnancy… Seventy-nine ampullary tubal ectopic

pregnancies were managed using laparoscopic linear salpingostomy

62% conceived following salpingostomy with a live birth rate of 38 %.

Skilled laparoscopist can remove a small tubal pregnancy in this manner with minimal complications. (Obstet Gynecol 1987)

Systemic methotrexate and laparoscopic salpingostomy were successful in treating the majority of cases with no significant difference between the treatments in the homolateral patency rate (Lancet 1997)

In the surgical treatment of tubal ectopic pregnancy laparoscopic surgery is a cost effective treatment.

An alternative nonsurgical treatment option in selected patients is medical treatment with systemic methotrexate.

Expectant management not adequately evaluated yet. (Cochrane Database Syst Rev 2007)

Meta-analysis shows that laparoscopic surgery is the most cost-effective treatment for tubal EP. Systemic MTX is a good alternative in selected patients with low serum hCG concentrations.( Hum Reprod Update 2008)

Tubectomy reversal… Laparoscopic tuboplasty, when performed

by experienced surgical laparoscopists, represents an effective alternative to microsurgery (Fertil Steril 1991)

Laparoscopic tubal anastomosis is a highly successful procedure. This less invasive approach could be considered the procedure of choice in patients who desire reversal of tubal sterilization. (Fertil Steril 1999)

All cases with laparoscopic tubal sterilization were suitable, whereas all cases with fimbriectomy were unsuitable for recanalization.

In cases with sterilization by Pomeroy's method, 4 out of 10 (40%) conceived, whereas for laparoscopic tubal ligation cases 6 out of 7 (85.7%) conceived (P=0.32) (J Hum Reprod Sci. 2011)

Laparoscopically sterilized patients had better chances of conception (50 %) following reversal than those who were sterilized by Pomeroy's method (30 %). With post-reversal tubal length of >4 cm, pregnancy rate was 50 %. Isthumus-Isthumus and Isthumus-Ampullary anastomosis have 50 % success rates. (J Obstet Gynaecol India. 2012)

Unexplained infertility… Laparoscopy may be omitted in women with

normal HSG as it was not shown to change the original treatment plan as indicated by HSG in 95 % of patients (Lavy et al 2004)

In some specific clinical settings solid evidence is available to recommend the use of diagnostic laparoscopy in current fertility practice (Hum reprod update 2007)

80.7 % of patients after normal HSG revealed pathologic abnormalities and because of the potential diagnostic and therapeutic benefits patients with unexplained infertility should undergo DHL prior to ART. (Tsuji et al 2009)

Hystero laparoscopy is an effective diagnostic & corrective tool for pathologies like peritoneal endometriosis, adnexal adhesions, and subseptate uterus which are usually missed by other imaging modalities.(J Hum reprod 2013)

DHL before IUI… Review of 495 patients 21 % of patients had abnormalities which

was treated by laparoscopic intervention followed by IUI

4% of patients advised IVF because of severe abnormalities.

DHL altered treatment decisions in high number of patients and may be of considerable value and further RCT’s are needed to asses its cost effectiveness (Fertil Steril 2003)

Hysteroscopy prior to ART…

One randomized and five non-randomized controlled studies including a total of 3179 participants were included comparing hysteroscopy with no intervention in the cycle preceding the first IVF cycle

Significantly higher clinical pregnancy rate (relative risk, RR, 1.44, 95% CI 1.08-1.92, P=0.01) and LBR (RR 1.30, 95% CI 1.00-1.67, P=0.05) in the subsequent IVF cycle in the hysteroscopy group

Hysteroscopy in asymptomatic woman prior to their first IVF cycle was found to be associated with improved chance of achieving a pregnancy and live birth

Robust and high-quality randomized trials to confirm this finding are warranted (Reprod Biomed Online 2014)

Summary… Laparoscopic ovarian drilling results, at

least in equal pregnancy rates as gonadotropin treatment (RR 1.0, 95% CI 0.83-1.2) added benefit being decreased multiple pregnancy rate (RR 0.16, 95% CI 0.04-0.58).

The laparoscopic treatment of minimal endometriosis might increase the pregnancy rate but the two major studies report conflicting results.

Laparoscopic surgery in the treatment of sub fertility related to mild to moderate endometriosis may improve future fertility

Excision of the endometriotic cyst wall increases the spontaneous conception rate (RR 2.8, 95% CI 1.4-5.5) but caution to be exercised to preserve ovarian reserve.

Myomectomy for submucosal fibroids results in higher pregnancy rates (RR 2.2, 95% CI 1.6-2.9).

The removal of intramural/ subserosal fibroids shows a beneficial trend, albeit not statistically significant results (RR 1.2, 95% CI 0.75-1.9).

Laparoscopy for benign ovarian tumors when chosen offers better fertility outcome and is cost effective

For proximal tubal block laparoscopy guided hysteroscopic cannulation is still a viable alternative to in vitro fertilization.

Laparoscopic surgery is the most cost-effective treatment for tubal ectopic pregnancy and Systemic methotrexate is a good alternative in selected patients

Laparoscopic tubal anastomosis is a highly successful procedure and laparoscopically sterilized patients had better chances of conception

Removal of polyps prior to IUI increases the pregnancy rate (RR 2.2, 95% CI 1.6-3.1).

Laparoscopic tubal surgery for hydrosalpinx prior to IVF increases the pregnancy rate (RR 1.9, 95% CI 1.4-2.7).

Hysteroscopy in patients with recurrent IVF failure increases the pregnancy rates even in the absence of pathology (RR 1.6, 95% CI 1.3-1.9).

Hystero laparoscopy may be an effective diagnostic & corrective tool in cases of unexplained infertility

DHL may be of considerable value before commencing IUI and further RCT’s are needed to asses its cost effectiveness

Hysteroscopy prior to IVF improves chances of pregnancy and randomized trials are required to confirm this finding.

CONCLUSION Laparoscopy still remains an important

diagnostic ant therapeutic tool in the management of sub fertile women.

Optimal and prudent use of this minimally invasive technique may avert costly treatment like IVF but over zealous and unindicted use may compromise future fertility

Although the limited evidence indicates a positive role for some surgical reproductive interventions, we should be very cautious in providing guidelines for clinical practice in reproductive surgery since more research is needed.(cochrane 2011)

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laparoscopy and fertility

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