Role of laparoscopy in management of infertility

in era of ART

Prof. Aboubakr ElnasharBenha university Hospital, Egypt

CONTENTS

1. Introduction

2.Diagnostic laparoscopy

3.Operative laparoscopy

Introduction

In the 1990s

Laparoscopy was the final step in the routine

diagnostic approach for the evaluation of infertile

couples (Rowe et al.1993).

Currently

{advancement of new perspectives in ART}

The process of evaluating infertile couples has

changed.

The most widely accepted approach to infertility is

no longer based on diagnosing an exact aetiology

The scope and the sequence of modern infertility

evaluation focus on the most efficient and cost-

effective tests. (Gomel and McComb 2010).

The investigation of infertile couples should be

Rapid

inexpensive,

using minimally invasive tests(Gomel and McComb 2010).

The focus of treatment for infertility has shifted from

the systematic correction of each identified factor to

applying the most efficient therapy, which may be

ART (Speroff and Fritz 2011).

Basic investigations of infertility:

Mid-luteal phase progesterone

HSG

Conventional semen analysis.

Infertility is described as ‘unexplained’ when

standard investigations are normal(NICE, 2013)

Laparoscopy

reserved for further diagnosis or

may be used in combination with endoscopic

surgery (Crosignani and Rubin 2000).

ART:

may be performed on suboptimally investigated

couples.

reduced the need for reproductive surgery as a

primary surgical treatment of infertility.

Advantages

prevention of a delay in treatment

minimal initial testing

Disadvantage

abnormalities that are associated with subfertility can

be overlooked.(Bosteels et al. 2007).

DIAGNOSTIC LAPAROSCOPY

Laparoscopy as a diagnostic tool in infertility has

diminished markedly

Today, we rarely perform diagnostic laparoscopy in

infertile women. (Tulandi , 2017)

1. The benefit of diagnostic laparoscopy with no risk

factors for intra-abdominal adhesions: small.

2. Treatment of stage I or II endometriosis: small

increase in PR.

3. Alternative treatments of infertility are available

Superovulation with IUI

IVF.

10

Indications

1. Abnormal HSG or US

2. Young women with history or symptoms

suggestive of pelvic disease. Even if HSG

indicates patency in one or both tubes1. A history of PID,

2. Ectopic pregnancy.

3. Pelvic surgery.

4. Chronic pelvic pain

3. Three cycles of superovulation with IUI are

unsuccessful. diagnostic laparoscopy or

IVF treatment (ASRM, 2012; Tulandi T 2017)

4. After failed IVF-

Laparoscopy after failed IVF:(Littman et al., 2005).

Pathology in 50%

endometriosis or adhesions

No RCTs have confirmed this rate.

Diagnostic laparoscopy can be avoided in

1. Older women

2. Multiple infertility factors.

3. Severe ♂ factor.

{1. These women are better served by IVF, instead of a

surgical approach to treatment

2. The presence of endometriosis and adhesions does

not markedly influence the effectiveness of IVF}.

Laparoscopy should be omitted in couples with

unexplained infertility

1.Laparoscopy may reveal

minimal or mild endometriosis or

peritubal adhesions:

Surgery or medical tt has not been proven to

improve fecundity.

2. In women with unexplained infertility

laparoscopy did not increase the PR(Badawy et al, 2010)

Treatment

indicated if duration > 2 y or >35 y

3 cycles of Gnt & IUI

if unsuccessful: IVF(Bhattacharya et al., 2008; Collins et al., 1995).

This approach

most cost effective

efficient treatment protocol. (Fatum, et al . 2002; Balasch 2000; Badawy et al 2008) .

As a result, laparoscopy is not routine work-up for

infertility.

The role of diagnostic laparoscopy in the management

of infertility is limited.

Findings and benefits:

1. General view of the pelvic organs

2. Minimal and mild endometriosis

not detected on TVS or HSG

treated laparoscopically

3. Bowel and/or pelvic peritoneal adhesions

4. Milder forms of distal tubal occlusive disease

1. fimbrial agglutination or

2. fimbrial phimosis determine fimbrial function in

addition to the patency of tubes, which is vital

for ovum retrieval(Speroff and Fritz 2011).

5. Confirmation of tubal patency: Spillage of the dye

from each tube

If adhesions or endometriosis are found during

diagnostic laparoscopy

the patient has been consented

an operative laparoscopic at the same time.

Laparoscopic treatment of stage I and II

PR at 36 w after surgery was only 30.7%.(Marcoux et al, 1997)

laparoscopic ablation of endometriosis enhances

fecundity only slightly (odds ratio 1.66).(Cochrane SR, Jacobson et al, 2010)

HSG Vs Laparoscopy:

false-negatives are more

tubal blockages are often false-positives

obstructions diagnosed by laparoscopy are most

likely true positives.

Prognosis of a tubal obstruction (unilateral and/or

bilateral) is poorer when diagnosed with laparoscopy

than with HSG (Speroff and Fritz 2011).

OPERATIVE LAPAROSCOPY

Reproductive surgery

1. Treatment of infertility

2. Enhance the pregnancy outcome of IVF

3. Preservation of fertility

I. TREATMENT OF INFERTILITY

1. Endometriosis

2. Ovarian: LOD

3. Tubal:1. Adhesions: adhesolysis

2. Obstructions: Tubal reanastomosis

3. Distal tubal obstruction

4. Hydrosalpinx

4. Uterine: 1. Moymectomy

2. Adenomyomectomy

II. ENHANCEMENT OF FERTILITY BEFORE IVF1. Treatment of endometrioma

2. Treatment of hydrosalpinx

III. PRESERVATION OF FERTILITY1. Laparoscopic ovarian transposition

2. Ovarian tissue transplantation

I. TREATMENT OF INFERTILITY

1. ENDOMETRIOSIS

1. IVFIndications

1. Age ≥38 y

2. Infertility is long lasting.

3. Diminished ovarian reserve

4. Tubal function is compromised

5. Male factor infertility

6. Bilateral endometriomas

7. Other treatments have failed.

8. Prior surgical treatment

In patients who failed to conceive spontaneously

after surgery: ART is more effective than repeat

surgery. {GPP; Polat et al, 2015)After surgery

{cumulative endometriosis recurrence rates are not increased after COS for IVF/ICSI}(D’Hooghe et al., 2006; Benaglia et al., 2010;Coccia et al., 2010; Benaglia et al., 2011). {C}

2. SurgeryStage I/II:

Operative laparoscopy rather than diagnostic

laparoscopy only, to increase PR(Nowroozi et al., 1987; Jacobson et al., 2010).{A}

Stage III/IV

Operative laparoscopy, instead of expectant

management:

increase spontaneous PR (Nezhat et al., 1989; Vercellini et al.,2006). {B}

Spontaneous PR of (Olive et al., 1985; Nezhat et al., 1989; Vercellini et al., 2006).

After expectant

management

After operative

laparoscopy

Stage

33%52-68%III

0%57-69%IV

Endometrioma

Precycle resection of endometriomas:

does not have benefit

should only be performed for gynecologic

indications.

deleterious impact on ovarian reserve and

response.(Surrey, 2015)

Deep endometriosis

The effectiveness of surgical excision is

not well established with regard to reproductive

outcome (Bianchi et al.,2009; Papaleo et al., 2011).{C}

laparoscopic excision of deep endometriosis

enhances PR, by both spontaneous conception and ART. (Surrey, 2015 ; Centeni et al, 2016)

Operative Laparoscopy (Jozwiak et al, 2015)

an efficient method

most effective particularly at stage III.

Endometriosis

excision or

ablation of the endometriosis lesions

adhesiolysis

can be ablated or excised using Scissors

electrocoagulation,

laser, or

ultrasonic cutting and coagulation device

(eg, Harmonic Scalpel) .

Excision:

more complete removal than electrocoagulation,

which is especially important for women with pelvic

pain(Tulandi et al, 2017)

CO2 laser vaporization of endometriosis, instead

of monopolar electrocoagulation

{higher cumulative spontaneous PR }(Chang et al., 1997).{C}

Hormonal treatment

Before surgery to improve spontaneous PR:

No

{evidence is lacking}(GPP)

For pain

Yes(GPP)

After surgery to improve spontaneous PR

No (Furness et al., 2004).{A}

2. Ovarian

Laparoscopic ovarian diathermy in PCOS

Wt reduction

CC or letrozole

Obese &overweight

Normal weight &No wt loss & No ovulation

LOD GnT

No ovulation after 3 cycles.

No pregnancy after 6 cycles.

No pregnancy

after 6 cycles.

No pregnancy after spontaneous,

CC or GnT ovulation

ICSI

Other surgical indication

Difficult follow up

Less aggressive

No desire for

surgery

Add metforminIGT &IR

Treatment for anovulatory infertility in PCOS

1. Weight reduction.

1. Lifestyle modifications

2. Pharmacological

3. Bariartric surgery

2. Oral anti-estrogens .

1. CC

2. Letrozole

3. Tamoxifen

Insulin sensitizers

1. Metformin

2. Myoinsitol

3. Gonadotropins.

laparoscopic ovarian drilling.

4. IVF and ICSI.

Results:

Ovulation rate: 80%

PR

at 12, 18, and 24 months of

54 to 68, 62 to 73, and 68 to 82% respectively [Felemban et al, 2000].

Although these results are encouraging, long-term effects are not known.

Indications:

1. Failure of ovulation despite an adequate trial of

CC and metformin

2. Normal weight

{often unsuccessful in obese women}

3. Absence of other causes of infertility

3. TUBAL

Classification of Tubal disease

British Fertility Society

Minor

Proximal occlusion

without tubal fibrosis

Distal occlusion without

tubal distension

Healthy mucosal

appearance at HSG,

salpingoscopy

Flimsy

peritubal/ovarian

adhesions.

Intermediate

Unilateral severe

tubal damage

Limited dense

adhesions of tubes

& ovaries

Severe

Bilateral severe tubal

damage

Extensive tubal fibrosis

Tubal distension >1.5 cm

Abnormal mucosal

appearance

Bipolar occlusion

Extensive dense

adhesion

Tubal pathology

1. Proximal

2. Distal or

3. Bipolar (proximal and distal).

Tubal surgery

1. Destructive tubal surgery

1. Salpingectomy

2. Tubal disconnection

2. Reconstructive tubal surgery

1. Adhesiolysis

2. Resection Anastomosis

3. Reversal of sterilization

4. Fimbrioplasty

5. Neosalpingostomy

Tubal infertility: corrective surgery or IVF?(ASRM, 2015)

1. Age of the woman

2. Number of children desired

3. Patient preference.

1. Ovarian reserve

2. Number and quality of sperm in the ejaculate

3. Presence of other infertility factors

1. Site and extent of tubal disease

2. Risk of ectopic pregnancy

3. Other complications

1. Experience of the surgeon

2. Success rates of the IVF program

3. Cost

Surgery may be considered for

young women

mild distal tubal disease

{if successful, one surgical procedure: several

pregnancies whereas IVF must be attempted each

time pregnancy is desired}.

IVF is more likely than surgery to be successful in

women with

bilateral hydrosalpinx

older women

{rapid decline in fertility with advancing age}

women with severe disease:

severe hydrosalpinx

extensive and dense adhesions

both proximal

and distal tubal occlusion

{PR after reconstructive surgery in women with bipolar

tubal blockage: 12 % at 2.5 years follow-up}

IVF vs tubal surgery

(ASRM, 2015)

No adequate trials comparing PR

Surgery is associated with

delayed conception

increased ectopic PR.

IVF

higher per-cycle PR.

ectopic pregnancy 1.8 % which is similar to that in

the general population.

The IVF ectopic rate, however, doubles in those

with tubal factor.

PR per cycle after IVF: 40.6%.

Tubal obstruction due to sterilization

Tubal anastomosis vs IVF

significantly higher cumulative PR

more cost efficient, even in women 40 y or older.

Sterilization reversal

young women

with more than 4 cm of residual tube

prior ring or clip sterilization.

In other women, IVF may be a better option.Laparoscopic approach

(for the usual advantages of laparoscopic surgery) if a surgeon experienced in laparoscopic tubal anastomosis is available.

Otherwise, laparotomy can be performed with good results.

Proximal tubal obstruction

The evidence is fair to recommend tubal cannulation

young women

no other significant infertility factors.

In women with true cornual occlusion, IVF is likely to

be more successful than tubocornual anastomosis.

Hydrosalpinx:

Mild:

The evidence is fair to recommend

Laparoscopic fimbrioplasty or

neosalpingostomy in

young women

no other significant infertility factors.

Irreparable =not candidates for corrective tubal

surgery.

There is good evidence for recommending

laparoscopic salpingectomy or

proximal tubal occlusion

to improve IVF pregnancy rates.

Fimbrioplasty —

performed for treatment of fimbrial phimosis

Fimbrial phimosis:

partial obstruction of the distal end of the fallopian

tube.

The tube is patent, but there are adhesive bands

that surround the terminal end.

The longitudinal folds of the tube are usually

preserved.

Fimbrioplasty

dividing the peritoneal adhesive bands that surround

the fimbria.

Gentle introduction of an alligator laparoscopic

forceps into the tubal ostium

opening and withdrawal of the forceps helps to

stretch the tube and release minor degrees of fimbrial

agglutination

4. Uterine

1. Myomectomy

Myomectomy is recommended in

FIGO types

0, 1, 2, 3, 2-5

4, 5 if ≥4 cm(Zepiridis et al, 2016)

Myomectomy

1. Smaller fibroids after multiple IVF failures

2. Complications of operation are not expected (Galliano et al, 2015)

ABOUBAKR ELNASHAR

(Zepiridis et al, 2016)

ABOUBAKR ELNASHAR

Abdominal and laparoscopic approach

equally effective in fertility restoration

Laparoscopy:

better postoperative course

less morbidity. (Galliano et al , 2015)

ABOUBAKR ELNASHAR

2. Adenomyomectomy

Management of women with adenomyosis-

associated infertility(Tsui et al, 2015).

1.Routine infertility investigation plus ORT

Normal: long agonist protocol and natural

conception

Abnormal: IVF

2. Failed natural conception or IVF:

repeat IVF

3. Failed IVF:

conservative surgery

IVF after 3 m

(Horng et al, 2014)

Route of surgery

For localized adenomyosis=Type I

The first series:

through laparotomy [Fedele et al,1993; Tadjerouni et al, 1995 ]

Nowadays:

safely and effectively performed

laparoscopically. (Huang et al, 2015)

For Diffuse adenomyosis= Type II

Most authors:

Best performed via laparotomy

{digital palpation of the uterus to:

identify affected areas

selective and piecemeal removal of lesions]

Some authors:

advancements in MIS: laparoscopic and

robotic approaches feasible [Huang et al, 2015; Kwon et al, 2015].

II. ENHANCE FERTILITY BEFORE IVF

1. Indications for Resection of a Suspected

Endometrioma prior to IVF (Surrey et al, 2015)

1. Rapid growth

2. Suspicious features noted on ultrasound

3. Painful symptoms that can be attributed to the

mass

4. Potential for rupture in pregnancy

5. Inability to access follicles in normal ovarian

tissue.

Although endometriomas can be detrimental to the

ovarian reserve, surgical therapy may further lower a

woman's ovarian reserve. (Keyhan et al, 2015)

Endometrioma

does not appear to adversely affect IVF outcomes

less than 4 cm in diameter does not impair IVF

outcome.

Excision of ovarian endometrioma ≥ 4 cm is

associated with increased ovarian damage [Tang et al, 2013].

Surgical excision of endometriomas does not improve

IVF outcomes.(Kaponis et al, 2015; Keyhan et al, 2015)

Endometrioma

ORT

If compromised: surgery is not recommended

Counsel women:

risks of reduced ovarian function after surgery{A}

Cystectomy to improve

endometriosis-associated pain or

accessibility of follicles.{GPP}

Cystectomy for endometrioma larger than 3 cm: no evidence for improvement PR (Donnez et al., 2001; Hart et al., 2008; Benschop et al.,2010).{A}

Medical therapy

of an endometrioma larger than 1 cm

not effective [Donnez et al, 2001]

Aspiration

Not effective

recurrence rate of 88% at six months follow-up [Saleh A,

Tulandi, 2000].

ultrasound-guided sclerotherapy.

Using absolute alcohol

low recurrence rate compared with surgery

does not decrease ovarian reserve.

In a metaanalysis of 18 studies, CPR after IVF were

similar for women treated with sclerotherapy and

surgery [Cohen et al, 2017].

Fenestration and ablation

drainage and electrocoagulation of the

endometrioma wall

removal of part of the cyst wall followed by the

coagulation of the inner side of the wall

less effective than excision, both in terms of

improving fertility recurrence and for reducing pain [Vercellini et al, 2003; Alborzi et al, 2004].

Excision of the capsule

The most effective treatment

{increase spontaneous PR}(Hart et al., 2008).{A}

decreased ovarian reserve, especially when the

endometrioma cyst wall is severely adhered to the

remaining ovarian tissue.

In this case:

fenestration technique should be used.

usually start by attempting to perform excision.

if the endometrioma is severely adhered to the

ovarian tissue: adhered tissue is coagulated.(Tulandi et al, 2017)

2. Treatment of hydrosalpinx before IVF

Negative effect on PR, IR, early pregnancy loss &

LBR.

LBR are reduced by 50%

WHY?

The fluid of hydrosalpinx:

1. Mechanical barrier to implantation: embryo

to float

2. Deficient to support the developing embryo

3. Toxic to the developing embryo

Aboubakr Elnashar

III. PRESERVATION OF FERTILITY

in young women at risk of premature ovarian failure,

such as those undergoing

chemotherapy or

radiation therapy for malignancy

1. Laparoscopic ovarian transposition

Indication:

Women with (haematologic, neurologic,

genitourinary, or low intestinal) malignancies

treated with pelvic irradiation.

Does not protect against chemotherapy.

patients <40y

Not recommended above 40y

{high rate of ovarian failure}Location depends on the planned radiation.

Results:

preservation of ovarian function in 88.6% (Elizur et al, 2009)

Among women with early cervical cancer who

underwent laparoscopic ovarian suspension before

radiation, normal ovarian function was found in 50–

63.6%.(Pahisa et al, 2008)

2. Ovarian tissue transplantation

The best method for fertility preservation:

embryo cryopreservation, followed by

oocyte and then

ovarian cryopreservation.

Indication:

For prepubertal females

ovarian cryopreservation is the only alternative

for fertility preservation(Huang et al, 2008)

Method:

In women who wish to conceive,

graft the frozen-thawed ovarian tissue into the

ovarian fossa or

remaining and irradiated ovary.

The tissue becomes functional 3–4 months after

transplantation.(Meirow et al, 2007)

The graft might last up to 3 years, depending on the

amount of ovarian tissue transplanted.

Accordingly, ovarian transplantation should be

carried out only when the patient is ready to conceive.

Results:

8 out of 25 women conceived after ovarian tissue

transplantation. (Bedaiwy et al, 2008)

ABOUBAKR ELNASHAR

You can get this lecture from:1.My scientific page on Face book:

Aboubakr Elnashar Lectures.

https://www.facebook.com/groups/2277

44884091351/

2.Slide share web site

3.elnashar53@hotmail.com

4.My clinic: Elthwara St. Mansura