Surgical Treatment of Female Infertility

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Mohammed Al-Sunaidi and Togas Tulandi Introduction

Due to widespread availability of assisted reproductive technologies, the need for reproductive surgery in infertile women has declined in recent decades. However, surgery still has a place in the management of infertile women. For example, young women with pelvic adhesions or blocked fallopian tubes that impair their fertility may benefit from early surgical intervention. On the other hand, women over the age of 35 with a long history of infertility or those who require a laparo-tomy for correction of their disorders are better treated with in vitro fertilization.

Compared to laparotomy, reconstructive surgery by laparoscopy is preferable. In fact, most procedures that previously required a laparotomy can be performed by laparoscopy with equal or better results. In addition, laparotomy causes more adhesion formation. The incidence of adhesion formation after a single laparotomy is 47% after appendectomy and up to 91% after pelvic surgery. Almost all patients will develop adhesions after myomectomy by laparotomy, whereas the adhesion rate is about 70% after laparoscopic myomectomy. Laparoscopic surgery lessens adhesion formation due to minimal handling of the internal organs and elimination of operative site contamination with glove powders or lint. In addition there is a lower incidence of infection, and the relatively closed environment of laparoscopy helps to maintain tissue moistness. Moreover, patients prefer the faster recovery time with laparoscopy.

Over the years, many laparoscopic modalities have been advocated including laser and ultrasound-scalpel; however the results are comparable to the use of conventional instruments such as scissors. One of the newest techniques is the use of robotic surgery during laparoscopy. Compared to human wrist movement, the robotic arm allows rotation of 360 degrees. The major disadvantage of robot-assisted endoscopy is the lack of tactile feedback or haptics. The large size of some of the robotic systems may also be a limitation. More importantly, to date there are no published data demonstrating that robotic surgery results in a better pregnancy rate than conventional laparoscopic surgery.

Diagnostic Laparoscopy

Laparoscopy should only be performed after complete investigation of infertility such as semen analysis, hysterosalpingogram and assessment of ovulation. In the era of assisted reproductive technology, laparoscopy is not a routine test. However, it is indicated in young women with an abnormal hysterosalpingogram or a history of salpingitis, sexually transmitted disease, previous pelvic surgery, or endometriosis. The incidence of abnormal laparoscopic findings in infertile females with a normal hysterosalpingogram ranges from 21-68%. Abnormal findings can usually be corrected at the same laparoscopic setting.

Abnormal Hysterosalpingogram
Figure 14.1. Adhesions on the posterior wall of the uterus..

During the course of a diagnostic laparoscopy for infertility, the pelvis is carefully surveyed for the presence of endometriosis, adhesions and uterine abnormities. Tubal patency is checked by injecting dilute solution of methylene blue into the uterine cavity through the cervix. Tubal patency is indicated by the passage of the blue dye from the fimbriated end of the tube.

Laparoscopy Promoting Fertility

Adhesiolysis

Pelvic adhesions can result from pelvic inflammatory disease, previous pelvic surgery, endometriosis or previous appendicitis. Periadnexal adhesions impair tubal mobility and ovum pick-up mechanism (Figs. 14.1 and 14.2). Although pregnancy is possible in women with periadnexal adhesions, liberation of the adhesions can increase the pregnancy rate. When adhesions are extensive or involve vital organs (e.g., ureter or bowel), the patient may be better served by attempting pregnancy through in vitro fertilization.

Treatment of Endometriosis

In infertile women with no other cause of infertility, endometriosis can be found in 40-50% of cases (Figs. 14.2-14.4). Endometriosis can be classified into minimal, mild, moderate and severe or stage I to IV. Its presence regardless of the stage decreases fertility. Compared to women whose endometriosis was not treated, treatment of stage I or II endometriosis is associated with a higher pregnancy rate.

Endometriosis Powdered Burned Appearance

Figure 14.2. Close-up appearance of endometriosis in the cul-de-sac ("gun-powder" spots and white lesions).

Figure 14.2. Close-up appearance of endometriosis in the cul-de-sac ("gun-powder" spots and white lesions).

Gunshot Lesions Endometriosis
Figure 14.3. Endometriosis vesicles on the ovary.

Treatment can be achieved with excision, ablation with electrocautery, laser, or harmonic scalpel. Pregnancy rates are similar with all of these modalities. Medical treatment by ovarian suppression with gonadotropin releasing hormone agonist (GnRHa) will improve the symptoms of endometriosis, but it delays

Posterior Cul Sac
Figure 14.4. Obliteration of the posterior cul-de-sac due to endometriosis.

conception for several months, and there is no evidence that pregnancy rates improve.

Ovarian cysts due to endometriosis are called endometriomas (Fig. 14.5). An endometrioma that is > 3 cm in diameter automatically qualifies for a classification of stage III or IV in severity. GnRHa treatment is ineffective in reducing the size of endometriomas of >1 cm. Treatment is surgical. It can be achieved either by fenes-tration and ablation (removal part of the cyst wall followed with coagulation of the inner side of the wall) or excision of the endometrioma cyst wall (Fig. 14.5). Excision of the endometrioma is associated with a higher pregnancy rate than fenestra-tion and ablation. Furthermore, recurrence after fenestration and ablation is more likely than after excision.

In advanced stage IV endometriosis, severe pelvic adhesions enveloping the whole pelvis can be encountered (frozen pelvis). Instead of subjecting the patients to a laparotomy with a low pregnancy rate, the patients are better treated with in vitro fertilization.

Treatment of Distal Tubal Occlusion

The fallopian tube can be occluded proximally at the uterotubal junction, at the mid-portion, or distally. The most commonly encountered tubal obstruction is distal tubal occlusion, usually due to PID. Mid-tubal blockage is usually iatro-genic due to tubal sterilization. Hysterosalpingographic findings of proximal tu-bal occlusion should be interpreted with caution. It could be true tubal occlusion or tubal spasm.

Tubal Obstrucrion
Figure 14.6. Tubal anastomosis has been completed.

Fimbrioplasty

Fimbrioplasty is performed for the treatment of fimbrial phimosis, which is a partial obstruction of the distal end of the fallopian tube. The tube is patent, but there are adhesive bands surrounding its terminal end. The procedure involves dividing the peritoneal adhesive bands that surround the fimbria releasing fimbrial agglutination. In one series, treatment of severe fimbrial phimosis with laparoscopic fimbrioplasty resulted in 51% intrauterine pregnancy rate, 37% live birth rate and 23% ectopic pregnancy rate at two years of follow-up.

Terminal Salpingostomy

Hydrosalpinx is complete distal tubal occlusion. Tubal reconstruction of hydro-salpinx is called terminal salpingostomy. The results depend on the degree of tubal damage. In general, the results are poor. The average pregnancy rate following salp-ingostomy is 30%, with an ectopic pregnancy rate of 5%. However, the rate of pregnancy can be as low as zero if the tube is rigid and thick without mucosal folds, and as high as 80% when tubal damage is minimal.

In general, salpingostomy is recommended only for young women with mild distal tubal disease. Tubal surgery has the advantages of allowing for several pregnancies from a single procedure with no increase in multiple birth rate. In vitro fertilization is a better alternative for older patients, patients with severely damaged tubes and those with infertility due to multiple etiologies.

Surgical Management of Hydrosalpinx Prior to IVF

The presence of hydrosalpinx reduces the probability of achieving a pregnancy in IVF. A meta-analysis showed that hydrosalpinx reduces the pregnancy rate in IVF cycles by 50%. This has been attributed to the leakage of hydrosalpinx fluid into the uterine cavity that could be toxic to the embryo. The fluid might also flush the embryo out of the uterine cavity or impair implantation. Removal of the hydrosal-pinx (salpingectomy) significantly improved the pregnancy and live birth rates (36.6% versus 23.9% without salpingectomy and 28.6% versus 16.3%, respectively).

Patients who benefit most from salpingectomy are those with hydrosalpinges visible on ultrasound (live birth rate 40% versus 17% without salpingectomy). Moreover, salpingectomy of bilaterally visible hydrosalpinges increased the delivery rate 3.5-fold (live birth 55% versus 15.8%), in one study.

An alternative to salpingectomy is occlusion of the isthmic portion of the tube in the same manner as tubal sterilization. Ultrasound-guided aspiration of the hydrosalpinges fluid has also been advocated, but rapid built up of the fluid can occur. A simpler and yet effective approach is administration of antibiotics to women with hydrosalpinx undergoing IVF. Finally, young women with hydrosal-pinx can be offered salpingostomy if the tubal damage is not extensive.

Treatment of Proximal Tubal Occlusion

Proximal tubal occlusion, suggested by failure of contrast medium to enter the intramural or isthmic portion of either tube, is diagnosed in 10%-20% of hystero-salpingography. This could be due to tubal spasm, mucus plugs, debris, or true cornual blockage. In order to distinguish between true cornual obstruction and other pathologies, several methods including laparoscopy have been advocated. During laparoscopy, tubal patency can be assessed and some surgeons can also perform tubal reconstruction.

Selective Tubal Catheterization

A less invasive technique than tubal surgery is selective tubal catheterization (STC) or transcervical tubal cannulation. It consists of passing a catheter through the cervix into the proximal tubal ostium, and injecting contrast medium. Increased pressure generated by direct injection may overcome obstructions associated with plugging. It could be performed using balloon angiographic catheters or guide wires under fluoroscopic, hysteroscopic or ultrasound guidance.

Due to the high incidence of false positive on hysterosalpingography, STC is the first line of treatment for bilateral proximal "tubal blockage". Approximately, a quarter of patients diagnosed with bilateral proximal occlusion on hysterosalpingography do not have tubal obstruction. Among those with true occlusion, STC leads to an overall pregnancy rate of 34%. True cornual occlusion is usually due to salpingitis isthmica nodosa, where the cornual part of the tube is occluded and replaced by a firm nodule. The cumulative probability of conception after STC was 28%, 59%, and 73% at 12, 18, and 24 months of follow-up, respectively.

In approximately 20% of patients, the tubes cannot be catheterized and the patients are best treated by IVF. Surgical treatment of such a blockage is not highly successful due to the severity of tubal damage or the presence of concomitant distal tube abnormalities. There are two operative procedures to correct proximal tubal blockage, cornual reimplantation and microsurgical tubocornual anastomosis. Traditionally tubal reimplantation is performed by laparotomy and the success rate is poor. Tubocornual anastomosis can also be performed by laparoscopy; however the number of reported cases is small.

Treatment of Mid-Tubal Occlusion

Treatment of mid-tubal occlusion is tubal anastomosis where the occluded portion of the tube is removed followed by anastomosis of the healthy segments (Figs. 14.6 and 14.7). Mid-tubal occlusion is usually due to previous tubal sterilization or previous ectopic pregnancy.

Sterilization reversal is the most successful surgical reconstructive procedure for improving fertility. Factors influencing the success are patient's age, sterilization technique, and tubal length. High pregnancy rates of up to 70% could be achieved in patients with tubal length of >4 cm compared to only 19% in those with shorter tubes.

We consider laparoscopic sterilization-reversal in women younger than 39 years who have >4 cm of residual tube. For others, IVF is a better option.

Laparoscopic Treatment of Polycystic Ovary Syndrome (PCOS)

The first line of treatment for anovulatory women with polycystic ovary syndrome is ovulation induction with ovulation-inducing drugs . This has replaced the outdated surgical treatment with ovarian wedge-resection. A modification of ovarian wedge resection is laparoscopic ovarian drilling (Fig. 14.9). This is performed by creating multiple holes on the surface of the ovary using either electrocautery or laser. As a result, the circulating level of androgen is reduced followed by restoration of pituitary-ovarian axis restoring ovulation. Ovarian drilling is associated with an ovulation rate of 80% and cumulative pregnancy rates at 12, 18, and 24 months of 54-68, 62-73, and 68-82 % respectively.

There are two potential complications associated with ovarian drilling, periadnexal adhesion formation and premature ovarian failure. The incidence of postoperative

Periadnexal Adhesions

Figure 14.7. Tubal insufflation following tubal anastomosis showing methylene blue dye solution.

Figure 14.7. Tubal insufflation following tubal anastomosis showing methylene blue dye solution.

Ovarian Drilling
Figure 14.8. Polycystic ovary.
Periadnexal Adhesions

Figure 14.9. Laparoscopic ovarian drilling.

Figure 14.9. Laparoscopic ovarian drilling.

adhesion formation is estimated to be 19-43% and may be as high as 82%. This complication is more frequent with laser treatment than with electrocoagulation.

Outcomes with medical treatments have rarely been directly compared with surgical outcomes. In a randomized trial, Palomba et al compared ovarian drilling with metformin treatment. The pregnancy rate at 6 months follow-up in the metformin group was 18.6% and in the ovarian drilling group was 13.4%. The live birth rate was higher in the metformin group (82.1%) than in the surgical group (29%).

The management strategy favored by most reproductive endocrinologists is to advocate weight loss and or medication, including metformin. Laparoscopic ovarian drilling, though often successful, is used sparingly.

Hysteroscopy in Infertility

Hysteroscopy is an operation to examine the uterine cavity using a thin caliber telescope (hysteroscope) introduced through the cervix. It gives information whether the uterine cavity is normal or contains a septum, fibroid, polyp, or adhesions. Hys-teroscopy should be done in early follicular phase of the cycle or approximately 4 weeks after an injection of gonadotropin releasing hormone analog (GnRHa). GnRHa suppresses FSH and estrogen production and subsequently makes the endometrium thin. This allows optimal visualization of the uterine cavity.

Diagnostic Hysteroscopy

Diagnostic hysteroscopy is usually performed under local anesthesia or paracervical block. It is done in the clinic or doctor's office as an extension of a gynecological examination. In some cases the cervical opening needs to be dilated to allow passage of the hysteroscope. Office hysteroscopy involves the use of a small caliber rigid hysteroscope usually 3.5 mm or a fiberoptic 2.4 mm flexible hysteroscope. The most commonly used distending media are normal saline, Ringer's lactate, or carbon dioxide gas. Compared to the use of CO2 gas, liquid distending medium is less irritating and associated with less pain. Furthermore, blood and gas produce bubbles that impair visualization. Endometrial polyps can sometimes be removed in the same setting using a polyp snare or hysteroscopic scissors.

Hysteroscopy is a good diagnostic tool to verify findings that cannot be accurately diagnosed by other imaging techniques including hysterosalpingogram, ultrasound, or magnetic resonance imaging (MRI). Its use is invaluable in infertility. It has been shown that up to 50% of women in whom IVF-ET repeatedly failed were found to have intrauterine abnormalities.

Correction of uterine abnormalities improved the pregnancy rate. In a review of 1000 office-based hysteroscopies prior to IVF, it was found that routine hystero-scopy examination detected uterine abnormalities in 30% of women starting IVF treatment.

Operative Hysteroscopy

For treatment purposes, the operation is done under general or spinal anesthesia in the operating room. A solution of glycine 1.5% or sorbitol 3% is used to distend the uterine cavity. The possible complications of hysteroscopy include uterine perforation, bleeding, infection, and fluid overload in the lung or brain. These complications are rarely encountered; however severe electrolytes imbalance can be fatal.

Lysis of Intrauterine Adhesions

Intrauterine adhesions (Asherman's syndrome) usually occur after repeated curettages particularly those performed in the pregnant state (postpartum or abortion). Asherman's syndrome can present with amenorrhea, hypomenorrhea, infertility or repeated miscarriage. Hysteroscopy is the best tool to diagnose and treat this condition. Adhesions are removed using hysteroscopic scissors or unipolar loop electrode. In order to allow rapid regeneration of the endometrium, a course of estrogen treatment is usually administered after the procedure. In general, 90 percent of patients will resume normal menses and 80 percent will achieve a term pregnancy, depending on the extent and severity of the adhesions.

Excision of Submucous Fibroid or Polyp

Submucous myomas or endometrial polyps can cause excessive uterine bleeding. Furthermore, submucous myomas are associated with infertility or repeated miscarriages (Fig. 14.10). Treatment is by hysteroscopic excision. Varasteh et al. found that hysteroscopic removal of myoma of >2 cm led to a significantly higher pregnancy rate (62.5%) than that of <2 cm (33%). Cumulative live birth rates after removal of myoma of <2 cm were 25.0%, >2 cm were 41.7%, and >3 cm were 75.0%.

Perez-Medina conducted a randomized study comparing the pregnancy rate after intrauterine insemination among women whose endometrial polyp was removed

Endo Polyp Hysteroscopy

Figure 14.10. Hysteroscopic view of a submucous myoma.

Figure 14.10. Hysteroscopic view of a submucous myoma.

or left in situ (control group). They found that after 4 cycles of insemination, the pregnancy rate in the polypectomy group was significantly higher (51.4%) than the control group (25.4%). Furthermore, 65% of women in the polypectomy group conceived prior to the first insemination. The authors postulated that endometrial polyp produces excessive amount of glycodelin impairing implantation. Glycodelin is a protein that facilitates implantation by decreasing natural killer cell activity.

Treatment of Uterine Septum

The presence of uterine septum is associated with recurrent pregnancy loss rather than infertility. Uterine septum is relatively avascular. Hysteroscopic removal of uterine septum in women with recurrent miscarriages is associated with a live birth rate of 70%.

Key Points

In this modern era of assisted reproductive technologies, reproductive surgery still has a place in the management of infertile women. Early surgical intervention can be offered to young women with a history of pelvic inflammatory disease, pelvic adhesions, blocked Fallopian tubes, and endometriosis. Most if not all reconstructive-operations can be performed by laparoscopy. On the other hand, women over the age of 35 with a long history of infertility or those who require a laparotomy are better treated with in vitro fertilization.

Intrauterine abnormalities such as uterine septum, submucous myoma or en-dometrial polyp can impair live-birth rate. This can be improved by hysteroscopic treatment of these abnormalities.

Suggested Reading

1. Al-Fadhli R, Tulandi T. Tubal disease in relation to infertility. In: Falcone T, Hurd WW, eds. Clinical Reproductive Medicine and Surgery. PA: Elsevier, (In Press).

2. Al-Jaroudi D, Herba MJ, Tulandi T. Reproductive performance after selective tubal catheterization. J Min Inv Gynecol 2005; 12:150-2

3. Beretta P, Franchi M, Ghezzi F et al. Randomized clinical trial of two laparoscopic treatments of endometriomas: Cystectomy versus drainage and coagulation. Fertil Steril 1998; 70:1176-80.

4. Hurst BS, Tucker KE, Schlaff WD. Hydrosalpinx treated with extended doxycycline does not compromise the success of in vitro fertilization. Fertil Steril 2001; 75:1017-9.

5. Johnson NP, Mak W, Sowter MC. Surgical treatment for tubal disease. Surgical treatment for tubal disease in women due to undergoing in vitro fertilisation. The Cochrane Database of Systematic Reviews. 2004, (Issue 3. Art. No.: CD002125.pub2).

6. Marcoux S, Maheux R, Berube S et al. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Engl J Med 1997; 337:217-22.

7. Palomba S, Orio Jr F, Falbo A et al. Prospective parallel randomized, double-blind, double-dummy controlled clinical trial comparing clomiphene citrate and metformin as the first-line treatment for ovulation induction in nonobese anovulatory women with polycystic ovary syndrome. J Clin Endocrinol Metab 2005; 90:4068-74.

8. Perez-Medina T, Bajo-Arenas J, Salazar F et al. Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination: A prospective, randomized study. Human Reprod 2005; 20:1632-5.

9. Pirwany I, Tulandi T. Laparoscopic treatment of polycystic ovaries: Is it time to relinquish the procedure? Fertil Steril 2003; 80:241-51.

10. Sacks G, Trew G. Reconstruction, destruction and IVF: Dilemmas in the art of tubal surgery. BJOG 2004; 111:1174-81.

11. Varasteh NN, Neuwirth RS, Levin B et al. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstet Gynecol 1999; 94:168-71.

12. Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer. Fertil Steril 1998; 70:492-9.

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51 Tips for Dealing with Endometriosis

51 Tips for Dealing with Endometriosis

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