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Role of Laparoscopic Surgery in Infertility

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Role of Laparoscopic Surgery in Infertility Vol. 10, No. 2, 2005 Middle East Fertility Society Journal © Copyright Middle East Fertility Society REVIEW Role of laparoscopic surgery in infertility Bulent Berker, M.D.* Ali Mahdavi, M.D.† Babac Shahmohamady, M.D.‡ Camran Nezhat, M.D.§ Center for Special Minimally Invasive Surgery, Stanford University Medical Center, Palo Alto, California, USA Recent advances in endoscopic surgical Currently, laparoscopy is perceived as a minimally techniques and the increased sophistication of invasive surgical technique that both provides a surgical instruments have offered new operative panoramic & magnified view of the pelvic organs methods and techniques for the gynecologic and allows surgery at the time of diagnosis. surgeon (1). Recent years have witnessed a marked Laparoscopy has become an integral part of increase in the number of gynecological gynecologic surgery for the diagnosis and endoscopic procedures performed, mainly as a treatment of abdominal and pelvic disorders of the result of technological improvements in female reproductive organs. Endoscopic instrumentation. The addition of a small video reproductive surgery intended to improve fertility camera to the laparoscope (videolaparoscopy) may include surgery on the uterus, ovaries, pelvic greatly enhanced the popularity of operative peritoneum, and the Fallopian tubes. The aim of endoscopy because of the possibility of operating this review is to critically review the role of in a comfortable, upright position and using the laparoscopy in the management of infertility magnification capabilities of the camera (2,3). patients. *Bulent Berker, M.D., Post Doctoral Fellow, Center for Special Minimally Invasive Surgery, Stanford University ENDOSCOPIC TUBAL SURGERY Medical Center, Palo Alto, California 94304 † Ali Mahdavi, M.D., F.A.C.O.G. Minimally Invasive Surgery Fellow, Division of Gynecologic Oncology, Department of A variety of procedures is collectively known Obstetrics, Gynecology and Reproductive Science, The Mount as tubal surgery; salpingo-ovariolysis is division of Sinai Medical Center, 1176 Fifth Avenue, Box 1173, New adhesions involving Fallopian tube and ovary; York, NY 10029 ‡ Babac Shahmohamady, M.D., Post Doctoral Fellow, Center salpingostomy is the refashioning of a distal tubal for Special Minimally Invasive Surgery, Stanford University ostium for distal tubal occlusion and is designed to Medical Center, Palo Alto, California 94304 keep the Fallopian tube open; tubal reanastomosis § Camran Nezhat, M.D., President Society of Laparo- is the rejoining of Fallopian tubes typically endoscopic Surgeons, Director of Center for Special Minimally performed for reversal of sterilization; cornual Invasive Surgery, Clinical Professor of OB/Gyn, Clinical Professor of Surgery, Stanford University School of Medicine anastomosis and utero-tubal implantation are Corresponding Author: Camran Nezhat, M.D. FACOG, recognized surgical treatments for corneal FACS, 900 Welch Road, Suite 403, Palo Alto, CA 94304, occlusion (4). All these procedures can be easily Email: [email protected], Tel: (650) 327-8778, Fax: (650) and effectively performed by laparoscopic surgery. 327-2794 94 Berker et al. Role of laparoscopic surgery in infertility MEFSJ Adhesiolysis may increase the intrauterine pregnancy rate and decrease the ectopic pregnancy rate; however a Adhesions involving the fallopian tube are recent systematic review of randomized controlled implicated as a cause of infertility. The decision to trials has failed to show a significant benefit of treat such disease to increase fertility rates may be second-look laparoscopy with adhesiolysis based on certain prognostic factors associated with following pelvic reproductive surgery (4). Future future fecundity. Regardless of whether performed randomized controlled trials are necessary to give via microsurgical techniques or via laparoscopy, an adequate answer to this clinical approach. data show that the removal of filmy adhesions is In addition to the severity of the pre-existing associated with improved fecundity. In the only disease, postoperative adhesion formation is the controlled study examining this issue, salpingo- most important determinant of the success of ovariolysis was performed in 69 infertile women infertility surgery and is largely responsible for the with pelvic adhesions, while 78 women with a majority of failures associated with these similar degree of adhesions were not treated (5). procedures. An inverse relationship exists between The cumulative pregnancy rate at 24 months the grade of adhesions and pregnancy rates, follow-up was significantly higher in treated regardless of the condition of the adnexa. Increased women, 45 versus 16 percent in the untreated rate of adhesion formation has been reported in the group. Although adhesiolysis was done at majority of patients underwent reproductive laparotomy, equivalent results can be expected surgery by laparotomy (7,8). When performed by with laparoscopic adhesiolysis. In one study, one laparotomy, reproductive pelvic surgery hundred sixty-seven patients with pelvic adhesions procedures are frequently complicated not only by suffering from inability to conceive underwent adhesion reformation but also by de novo adhesion operative laparoscopy and CO2 laser adhesiolysis formation. However, endoscopic surgery fulfills (6). According to the severity of adhesions, the the important microsurgical principles of gentle patients were categorized by diagnostic handling of tissue, constant irrigation, meticulous laparoscopy as mild, group I; moderate, group II; hemostasis, and precise tissue dissection without and severe, group III. After laparoscopic the need for laparotomy, which is itself a adhesiolysis, all patients were followed for one significant invasion of the peritoneal cavity. In year. Pregnancy occurred in 51 (70.8%), 28 their study, Nezhat et al. demonstrated that (48.3%), and 8 (21.6%) patients in group I, II, and endoscopic reproductive surgery was very III, respectively. Laparoscopic adhesiolysis still effective in reducing peritoneal adhesions, was remains a useful and effective procedure for associated with a low frequency of postoperative infertile couples with pelvic adhesions. adhesion recurrence and mostly avoided the Salpingo-ovariolysis as a fertility-enhancing formation of de novo adhesions at most surgical procedure is done by separating periadnexal sites (9). adhesions with laparoscopic scissors, electrocautery or the laser. Before being divided, Hydrosalpinx the adhesions can be stretched with laparoscopic forceps and an intrauterine canula. Vascular Hydrosalpinx is a chronic pathological adhesions should be coagulated before being condition of the Fallopian tube, and is a major separated. Endoscopic surgery is precise enough cause of infertility. In most patients, the fimbriated that adhesions can be excised without destroying end of the tube adjacent to the ovary is occluded surrounding tissue or damaging vital structures and the distal half of the tube is distended with such as the ureters, bladder and bowel. Removal of fluid (10). The main causes of hydrosalpinx are all adhesions and restoration of the normal pelvic inflammatory disease, ectopic pregnancy, anatomic relationship of the pelvic organs will previous abdominal operations, and a history of certainly enhance the fertility (1). It has been peritonitis and tuberculosis (11). Distal occlusion claimed that second-look laparoscopy with may also result from endometriosis (12). The adhesiolysis following pelvic reproductive surgery presence of hydrosalpinx can be diagnosed by Vol. 10, No. 2, 2005 Berker et al. Role of laparoscopic surgery in infertility 95 hysterosalpingogram or by laparoscopy with or hydrosalpinx prior to IVF. A Cochrane review without chromopertubation. A meta-analysis of all confirmed that the odds of pregnancy were the studies comparing hysterosalpingography to increased with laparoscopic salpingectomy for the gold standard of laparoscopy with hydrosalpinges prior to IVF (OR = 1.75, 95 chromopertubation showed the percent CI 1.07 to 2.86), as were the odds of hysterosalpingogram to have a sensitivity of 65% ongoing pregnancy/live birth (OR = 2.13, 95 in the diagnosis of tubal obstruction and a percent CI 1.24 to 3.65) (18). All these data specificity of 83% (13,14). Laparoscopy provides demonstrate that laparoscopic salpingectomy for both the certain diagnosis and the treatment of hydrosalpinges is the preferred procedure for hydrosalpinx at the same session. improving pregnancy rates. Distal tubal occlusion with a hydrosalpinx has Endoscopic surgery in the management of tubal been reported to be associated with a lower obstruction implantation rate per embryo as well as with a Fallopian tube disorders are responsible for lower clinical pregnancy rate. One meta-analysis over 20 to 30% of female infertility world wide. In demonstrated the deleterious effects of the literature, there have been many techniques hydrosalpinx on achieving pregnancy in women used in the treatment of tubal disease. These range undergoing IVF. It was shown that the clinical from observation to laparotomy, gaseous pregnancy rate was about 50 percent lower and the insuflation, hydrotubation, microsurgery to the miscarriage rate was more than twofold higher in more recent laparoscopic surgery, modern patients with hydrosalpinx (1144 IVF cycles) microsurgery using the CO2 laser and the micro compared to the patients without hydrosalpinx endoscopic procedures. Currently, a 50% overall (5569 IVF
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