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Current Controversies in Tubal Disease, Endometriosis, and Pelvic Adhesion

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Current Controversies in Tubal Disease, Endometriosis, and Pelvic Adhesion Current controversies in tubal disease, endometriosis, and pelvic adhesion Jeffrey M. Goldberg, M.D.,a Tommaso Falcone, M.D.,a and Michael P. Diamond, M.D.b a Women's Health Institute, Cleveland Clinic, Cleveland, Ohio; and b Department of obstetrics and Gynecology, August University, Augusta, Georgia Reproductive surgery for proximal and distal tubal occlusion, as well as for reversal of tubal ligation, may be an alternative or an adjunct to IVF. Surgery for adenomyosis and endometriosis, including endometriomas, may be considered for the treatment of infer- tility and/or pelvic pain but carries the risks of surgical complications and diminished ovarian reserve. A greater understanding of the pathogenesis of postoperative peritoneal adhesion formation is needed to develop more effective preventive measures to optimize the clinical results of surgery. (Fertil SterilÒ 2019;112:417–25. Ó2019 by American Society for Reproductive Medicine.) Key Words: Reproductive surgery, fallopian tube, endometriosis, adenomyosis, peritoneal adhesions Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility- and-sterility/posts/50039-28456 hile many may feel that by an ‘‘IVF for everything’’ philosophy. by repeat HSG or chromotubation at W reproductive surgery should As a result, many reproductive endocri- laparoscopy, indicating that the block be abandoned as a primary nologists no longer perform re- was due to spasm of the uterotubal ostia treatment option for enhancing fertility productive surgery and relegate the or an obstructing plug (2, 3). in favor of IVF, a position we strongly treatment of myomas and endometri- Hysteroscopic tubal cannulation disagree with, it is still necessary as a osis to minimally invasive gynecologic achieves patency in over 85%, but complimentary treatment for opti- surgeons. However, fertility-enhancing approximately one third subsequently mizing IVF outcomes for patients with tubal surgery is exclusively the domain reocclude. Nearly half of the patients hydrosalpinges and select cases of en- of reproductive surgeons with no one to establish an ongoing intrauterine dometriomas and myomas. This paper defer to. The following discussion will pregnancy (1). A video demonstrating will defend the role of reproductive sur- attempt to make the case against aban- tubal cannulation is available on The gery even in the face of ever-improving doning the surgical management of Society for Reproductive Surgeons' IVF success rates. Specifically, we will tubal infertility. website (4). discuss tubal surgery and the surgical Tubal disease accounts for 25%– Approximately 25% of women, management of endometriosis and ad- 35% of infertility, with over half of those about 200 million women worldwide, enomyosis, as well as the need to reduce cases due to salpingitis. In addition, have undergone voluntary sterilization postoperative adhesion formation, 10%–25% of tubal infertility occurs at by tubal ligation, with 14% of them which may compromise the outcomes the proximal end (1). Hysterosalpingo- regretting their decision. The rate of of all reproductive surgical procedures. graphy (HSG) is the standard test to regret is highest when performed post- document tubal patency. However, partum as well as in younger women (5). TUBAL SURGERY approximately two thirds of patients Early attempts at reversal of tubal An individualized approach to with proximal block on HSG are sterilization with standard macrosurgi- infertility treatment has been replaced subsequently demonstrated to be patent cal techniques were unrewarding. The promotion of microsurgery in the Received April 19, 2019; revised June 7, 2019; accepted June 17, 2019. 1970s led to high success rates and re- J.M.G. has nothing to disclose. T.F. has nothing to disclose. M.P.D. reports board of directors and stock- mains the gold standard. Initially per- holder for Advanced Reproductive Care, LLC; grants from AbbVie, Bayer, ObsEva; and personal formed through a full laparotomy fees from ZSX Medical, Seikagaku, AEGEA, Actamax, ARC Medical Devices, and Temple Thera- peutics, outside the submitted work. incision with an inpatient hospitaliza- Reprint requests: Jeffrey M. Goldberg, M.D., Women's Health Institute, Cleveland Clinic, 9500 Euclid tion, it is currently accomplished as Avenue, Cleveland, Ohio 44195 (E-mail: [email protected]). an outpatient procedure via minilapar- Fertility and Sterility® Vol. 112, No. 3, September 2019 0015-0282/$36.00 otomy. A video demonstrating tubal Copyright ©2019 American Society for Reproductive Medicine, Published by Elsevier Inc. anastomosis is available on The Society https://doi.org/10.1016/j.fertnstert.2019.06.021 VOL. 112 NO. 3 / SEPTEMBER 2019 417 VIEWS AND REVIEWS for Reproductive Surgeons' website (6). It has also been per- While data on neosalpingostomy are limited, reviewing formed laparoscopically with good success in very skilled data from five older noncontrolled studies demonstrated hands, although it is technically challenging. Robotic assis- that two-thirds of the patients classified as good prognosis tance has been incorporated to overcome these difficulties. conceived an intrauterine pregnancy, while an ectopic In fact, the world's first fully robotic surgery was reported pregnancy occurred in only 3. A video demonstrating neosal- in 1999 for reversal of sterilization (7). Retrospective compar- pingostomy is available on The Society for Reproductive Sur- isons between minilaparotomy and robotic surgery for tubal geons' website (26). anastomosis reported that minilaparotomy was quicker and Patients classified as moderate or poor prognosis had less expensive and had a higher, although nonstatistically poor outcomes and are better served with salpingectomy or significant, pregnancy rate (8). Furthermore, patients much proximal ligation followed by IVF (27–31). A more recent prefer the cosmetic appearance of a minilaparotomy to the prospective study compared pregnancy rates in patient with multiple robotic incisions (9). hydrosalpinges treated by bilateral salpingectomy and IVF By whatever means the surgeon elects to accomplish tubal versus neosalpingostomy (32). Neosalpingostomy patients anastomosis, it should be considered the first line of treatment who underwent IVF conceived at the same rate as those in to restore fertility for most cases of tubal sterilization. Preg- the salpingectomy group. Overall, approximately half in nancy rates of 70%–90% have been reported for women each group achieved a pregnancy, but half of the <40 years of age. Even women >40 have a very respect- neosalpingostomy patients conceived spontaneously. able 33%–50% pregnancy rate (10–16). A retrospective In summary, appropriately selected patients can benefit cohort study that compared tubal anastomosis with IVF from a cost-effective, minimally invasive outpatient proced- concluded that the cumulative delivery rate was significantly ure and avoid the need for IVF. Many patients would prefer higher for anastomosis for women <37 years old but that this if given the option. fi > there was no signi cant difference in women 37. In SURGERY FOR ENDOMETRIOSIS AND addition, the cost per delivery was nearly double that for IVF (17). Decision tree models support that the cost of ongoing ADENOMYOSIS pregnancy is only higher for tubal reanastomosis compared Endometriosis is associated with significant quality-of-life with IVF when the woman is > 40 years of age (and and economic burdens on the patient similar to other chronic increased cost for robotic procedures was even accounted for diseases such as diabetes (33). Health care costs are mainly in one analysis) (18). A third study concluded that tubal due to surgery. There are three overlapping phenotypes that anastomosis was more cost-effective even for women >40 we typically encounter during surgery: peritoneal disease (19). The current American Society for Reproductive Medicine (Fig. 1, superficial ovarian and peritoneal disease), ovarian committee opinion on the role of tubal surgery concluded endometrioma, and deeply infiltrating endometriosis (DIE) that there is good evidence to support the recommendation (34). In a recent randomized controlled trial in patients with for microsurgical anastomosis for tubal ligation reversal (20). uniquely superficial peritoneal disease, excision and ablation In addition to being evidence based, tubal anastomosis is showed similar effectiveness for the treatment of pain (Video also preferred by many patients who wish to avoid the risk of 1, available online) (35). As with previous studies, ablation of multiple pregnancy and the inconvenience of the ‘‘high-tech’’ deep lesions is challenged by the proximity to structures such IVF process in favor of a one-time minimally invasive proced- as the ureter that make excision of lesions a more complete ure that enables them to attempt to conceive naturally each approach. month. Unfortunately, there are few reproductive endocrinol- The management of endometriomas is controversial and ogists who still perform tubal anastomosis. The lack of access has changed with new data on the effect of surgery on ovarian to tubal anastomosis is unfortunate not only for our patients reserve. The diagnosis of an endometrioma can often be made today but for future generations of patients as reproductive preoperatively due to the classic appearance on ultrasonogra- surgery is no longer an integral part of many fellowship phy of a unilocular cyst, low-level echogenicity of the cyst training programs.
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