Laparoscopy and infertility ASHRAF ATIA DEWIDAR

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ASHRAF ARIA DEWIDAR

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LAPAROSCOPY IN INFERTILITY:

LAPAROSCOPY IN INFERTILITY by Dr. Mohammad Khalil O & G Consultant MCH, Hassa , KSA Dr. ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 1

The availability of ART has reduced the need for reproductive surgery as a primary surgical treatment of infertility. When fertility surgery is indicated, laparoscopy is the tool of choice.:

The availability of ART has reduced the need for reproductive surgery as a primary surgical treatment of infertility. When fertility surgery is indicated, laparoscopy is the tool of choice. 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 2

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Only 3 tests are obligatory in the investigation of infertile couples:

Only 3 tests are obligatory in the investigation of infertile couples 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 5 (RCOG Guidelines Recommendation, 1999) (ESHRE Capri workshop, 2000) (National Guideline Clearinghouse, 2000)

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 6

HSG or Laparoscopy?:

HSG or Laparoscopy? 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 7 ( NICE Guideline Fertility2004)

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 8 Women who are thought to have co-morbidities should be offered laparoscopy and dye . (National Institute of Clinical Excellence(NICE)Guideline . Fertility2004 )

Diagnostic laparoscopy in UNEXPLAINED infertility:

Diagnostic laparoscopy in UNEXPLAINED infertility 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 9 There is still a considerable debate regarding the place of laparoscopy for cases of unexplained infertility.

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 10 OPERATIVE LAPAROSCOPY f or female infertility

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Adhesiolysis :

Adhesiolysis 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 13 In the only controlled study examining this issue ( Tulandi T, Collins JA, Burrows E, et al. Am J Obstet Gynecol 1990) .

Treatment of distal tubal occlusion:

Treatment of distal tubal occlusion 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 14 Surgery ( fimbrioplasty or salpingostomy ) may be considered for young women with mild distal tubal disease because, if successful, one surgical procedure can lead to several pregnancies, whereas IVF must be attempted each time pregnancy is desired. IVF should be considered as the first line treatment for moderate to severe distal tubal disease. ( RCOG Guidelines : Grade B Recommendation )

Proximal tubal occlusion (Cornual Obstruction):

Proximal tubal occlusion ( Cornual Obstruction) 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 15 The incidence of true cornual occlusion is low and surgical treatment (resection and anastomosis) is not highly successful

If the Fallopian tubes are not visualized on HSG, a repeat procedure should be done to exclude the possibility of technical problem or tubal spasm:

If the Fallopian tubes are not visualized on HSG, a repeat procedure should be done to exclude the possibility of technical problem or tubal spasm 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 16 In women with true cornual occlusion, IVF is likely to be more successful than tubo-cornual anastomosis.

Tubal re-anastomosis:

Tubal re-anastomosis 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 17 Indications include: Reversal of sterilization Mid-tubal block Previous ectopic Sterilization reversal can be considered in young women (<37) with more than 4 cm of residual tube and prior ring or clip sterilization. In other women, IVF may be a better option. ( Boeckxstaens A, Devroey P, Collins J, Tournaye H. Getting pregnant after tubal sterilization: surgical reversal or IVF? Hum Reprod 2007; 22:2660) .

Laparoscopic management of hydrosalpinx prior to IVF:

Laparoscopic management of hydrosalpinx prior to IVF 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 18 Laparoscopic salpingectomy should be considered for all women with unilateral or bilateral hydrosalpinges prior to IVF treatment as it improves IVF pregnancy rates. (NICE Guideline 2004 Infertility) (Johnson et al-2004) (Cochrane Systematic Reviews-2009, Issue 4)

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 19 Laparoscopic tubal occlusion is an alternative to laparoscopic salpingectomy in improving IVF pregnancy rates in women with hydrosalpinges . Drainage of the hydrosalpinx at the time of oocyte collection is not effective as the tubes will refill rapidly (as little as two days) and the primary pathology is still there. ( Bloechle M, Schreiner T, Lisse K. Hum Reprod 1997; 12:703) .

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 20 ENDOMETRIOSIS (Implants &/or endometrioma )

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 21 black-blue, powder-burn appearance. Diagnosis in most cases is simple, without the need for a biopsy. Endometriotic lesions that lack the powder-burn appearance (Jansen & Russel,1986) (American Society For Reproductive Medicine (ASRM) 1996)

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Endometriotic Cyst (Endometrioma) (Chocolate cyst):

Endometriotic Cyst ( Endometrioma ) (Chocolate cyst) 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 23

Operative laparoscopy for endometriosis:

Operative laparoscopy for endometriosis 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 24 Laparoscopic treatment (excision or ablation) of minimal or mild endometriosis improves pregnancy rates regardless of the treatment modality. ( Jacobson et al , Cochrane Library Review, 20 JAN 2010) (SOGC Clinical Practice Guidelines 244, 2010) The effect on fertility of surgical treatment of deeply infiltrating endometriosis is controversial.

The most effective treatment of endometriomas is excision. Excision might be associated with decreased ovarian reserve, especially if the cyst wall is adherent to the ovarian tissue. Fenestration and ablation can be performed in such cases. (less effective in improving fertility, reducing pain & recurrence) :

The most effective treatment of endometriomas is excision . Excision might be associated with decreased ovarian reserve, especially if the cyst wall is adherent to the ovarian tissue. Fenestration and ablation can be performed in such cases. (less effective in improving fertility, reducing pain & recurrence) 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 25 Small endometriomas of less than 4cm in diameter does not impair IVF oucome Laparoscopic excision of ovarian endometriomas more than 3 cm in diameter may improve fertility. (SOGC Clinical Practice Guidelines 244, 2010) ( Alborzi S, Momtahan M, Parsanezhad ME, et al. Fertil Steril 2004).

PCOS: Laparoscopic Drilling:

PCOS: Laparoscopic D rilling 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 26

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 27 Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS. (RCOG Guidelines : Grade A) (National Institute of Clinical Excellency (NICE) 2004) A strategy of minimizing the number of diathermy points to: 4/ovary For 4 s At 40 W ( Armar et al. Fertil Steril 1990;53:45–9.)

Advantage of Drilling Over Gonadotropin Therapy:

Advantage of Drilling Over Gonadotropin Therapy 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 28

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 29 Ovulation rate: 80 % Pregnancy rates at 12 m: 54 to 68%. Felemban A, Tan SL, Tulandi T . Fertil Steril 2000; 73:266 . Encouraging results, but long-term effects are not known; so, it is only recommended in:-

Uterine leiomyoma:

Uterine leiomyoma 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 30 Myomectomy of SM or IM myomas with sub-mucosal component significantly improves pregnancy rates (43.3% vs 27.2% and 40% vs 15% respectively) ( Casini ML et al, 2006) Laparoscopic suturing is more demanding. This can be overcome by robotic-assisted laparoscopic myomectomy. ( Agdi M, Tulandi , 2010)

Role of laparoscopy in male infertility:

Role of laparoscopy in male infertility 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 31 Varicocele is the most common correctable cause of infertility in adult males. Varicoceles are present in 15% of the normal male population and in approximately 40% of men presenting with infertility. Surgical treatment is the gold standard of management & it eliminates over 90% of the varicoceles .

Conclusion I The role of diagnostic laparoscopy in management of infertility is limited. However, it can be useful in infertility evaluation of young women with a history of PID, EP, pelvic surgery or chronic pelvic pain:

Conclusion I The role of diagnostic laparoscopy in management of infertility is limited. However, it can be useful in infertility evaluation of young women with a history of PID, EP, pelvic surgery or chronic pelvic pain 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 32

Conclusion II Certainly, some women would have a correctable problem found at laparoscopy that would not be discovered with any other fertility screening test. :

Conclusion II Certainly, some women would have a correctable problem found at laparoscopy that would not be discovered with any other fertility screening test. 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 33

Conclusion III A significant number of patients, such as those with tubal factor and endometriosis, can benefit from operative laparoscopy.:

Conclusion III A significant number of patients , such as those with tubal factor and endometriosis, can benefit from operative laparoscopy. 10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 34

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10/21/2013 Dr Mohammad Khalil DR A DEWIDAR 35 THANK YOU

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