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Hydrosalpinx and IVF: a Randomized Study (192 Cases)

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Togas Tulandi Department of Obstetrics and Gynecology McGill University Montreal, Quebec, Canada Declared receipt of honoraria or consultation fees by Ethicon Inc. What is left of Reproductive Surgery? Togas Tulandi MD, MHCM Professor of Obstetrics and Gynecology & Milton Leong Chair in Reproductive Medicine McGill University Redefining Reproductive Surgery Togas Tulandi MD, MHCM Professor of Obstetrics and Gynecology & Milton Leong Chair in Reproductive Medicine McGill University Vi ringrazio per avermi invitato a Milano What is Reproductive Surgery? • Surgery to correct anatomical disorders of the reproductive tract. • In practice, it has been limited to primary treatment of infertility for women with tubal disorders or endometriosis. Case 1 A 26 year old woman 5 IVFs and one miscarriage I. Reproductive Surgery as a primary treatment Pregnancy rate 12 mths after surgery • Adhesiolysis: 40% • Salpingostomy: 30.% • Endometriosis: 30.7% • Tubal anastomosis: 79.4% • IVF: 40.6% per cycle, ectopic rate 1.8% Procedure Authors No. Intra-uterine Ectopic rate rate Neo-salpingostomy Canis et al 87 33.3% 6.9% Fimbrioplasty Saleh & Dlugi 88 35% 1% Tubal anastomosis Yoon et al 186 79.4% 3.2% Ablation of state I & II Marcoux et al 172 30.7% 4% endometriosis Parazzini 51 23.5% 0% Excision of Beretta et al 32 50%* NA endometrioma Alborzi et al 52 59.4%* NA Fenestration Beretta et al 32 15%* NA Alborzi et al 48 23.3%* NA IVF Authors No. PR per transfer Ectopic rate SART 2007 67,922 40.6% 1.8% Reproductive Surgery as a primary treatment 1. The place of reproductive surgery as a primary treatment of infertility is limited 2. There is little place of laparotomy 3. Laparoscopic Tubal Anastomosis Reproductive Surgery I. Reproductive Surgery as a primary treatment II. Reproductive Surgery to enhance IVF outcome III. Reproductive Surgery for Fertility Preservation II. Reproductive Surgery to enhance IVF outcome 1. Hysteroscopy 2. Laparoscopy IVF with and without hydrosalpinx: Meta analysis • 5592 patient with hydrosalpinx (group I) • 4588 no hydrosalpinx (group II) • Pregnancy rate: 19.7 % (I) vs. 31.2% (II) • Miscarriage rate: 43.7% (I) vs. 31.1% (II) Camus et al, 1999 Hydrosalpinx and IVF: A randomized study (192 cases) % 50 40 30 Salpingectomy 20 No salpingectomy 10 P < 0.05 0 Clinical Delivery Pregnancy Strandell et al, 1999 RCT hydrosalpinx Authors Total Laparosc PR per PR per RR Live birth Live RR (year) No. opy transfer transfer or rate no birth or ptis no after OR surgery afer OR surgery surgery Strandell et 204 Salpingec 27.3% 35.5% 1.3 18.2% 28.0% 1.54 al (38) tomy Déchaud et 60 Salpingec 25.0% 36.8% NA 18.7% 34.2% NA al (39) tomy Kontoravdis 65 Salpingec 14.3% 55.3% 7.4 7.1% 48.9% 12.5 et al, 2006 tomy (40) 65 Proximal 14.3% 44.4% 4.8 7.1% 37.8% 7.9 tubal occlusion Hydrosalpinx and IVF: A meta-analysis • 5 RCT, 646 women • Clinical pregnancy rate after salpingectomy prior to IVF: OR 2.31, 95%CI 1.48 to 3.62 • Proximal tubal occlusion: OR 4.66, 95%CI 2.47 to 10.01 • Aspiration of hydrosalpinx: OR 1.97, 95%CI 0.62 to 6.29 Johnson et al, Cochrane, 2009 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 operated side operated side after contralateral side contralateral side before before after Proximal tubal occlusion • 20 women with hydrosalpinx • Occluded in 31 of 32 tubes • Birth rate per transfer: 12/21 embryo transfer (57%) Galen et al, 2011 Endometrioma and IVF • Does the presence of endometrioma affects the results? • Is IVF outcome affected after removal of endometrioma? Endometrioma, number of oocytes and embryo quality Oocytes Embryo quality (Almog et al, 2011) (Reinblatt et al, 2011) Bilateral Outcome Controls P value Ovary with Ovary with no endometriomas P value endometrioma endometrioma Oocytes collected 11.2 ± 1.6 12.3 ± 1.05 P= 0.57 MIIs oocytes 9.5 ± 1.7 13.2 ± 0.96 P = 0.07 Number of antral follicle 7.7 ±1.0 8.5±0.9 0.3 Fertilization rate (%) 66 ± 0.09 73 ± 0.03 P = 0.83 Number of retrieved oocyte 6.0± 0.4 6.1 ±0.5 0.8 Cleavage rate (%) 89.8 ± 7.9 98.4 ± 0.93 P = 0.40 Number of embryo 2.75 ± 0.3 2.77 ± 0.16 P = 0.95 Number of retrieved oocyte when transferred) 5.8±1.4 6.6±1.1 0.5 endometrioma size >25mm Good embryos 65.6 ± 6.8 74.5 ± 7.5 P = 0.34 transferred (%) The presence of ovarian endometrioma does not affect the number of collected oocytes or embryo quality. Effects of surgical treatment of endometrioma on IVF outcome Tsoumpou et al, 2009 No difference Carmona et al, 2011 Hart et al, 2010 Endometrioma and IVF • Small endometrioma does not have to be removed before IVF • Careful laparoscopic excision is superior to fenestration and coagulation • Surgery is associated with similar IVF pregnancy rate than no surgery. Do we need a hysteroscopy before IVF treatment? • 678 asymptomatic women undergoing 1st IVF: intrauterine abnormality in 11% (Fatemi et al, 2010) • Karayalcin et al (2010): 22. 9% among 2500 women. – Polyp 6-7% – Submucous myoma 1-4% – Adhesions 1-2% – Septum 2-3% • After 2 failed IVF: 26% (Demirol & Gurgan, Hysteroscopy polypectomy (RCT, Perez-Medina et al, 2005) Life Table analysis: • Pregnancy rate after 4 IUI: 51.4% (Control 25.4%) • 65% conceived immediately after polypectomy before IUI • Independent of the size of the polyp • Fertility after myomectomy (RCT, Casini et al, Gynecol Endocrinol 2005) • 181 patients randomized to surgery (laparotomy and/or hysteroscopy) vs. no surgery • Pregnancy rate at 12 mths Hysteroscopic myomectomy • Casini et al, 2005 : 52 patients. Hysteroscopic myomectomy with or without removal of intramural fibroids increased pregnancy rate (RR 1.9, 95% CI 1.0- 3.7) • Shokeir et al, 2010: 215 patients; RR: 2.1; 95% CI 1.5- 2.9 •Varasteh et al, 1999 : Live birth rate: 2cm: 25%, 2- 3cm:41.7%, >3cm: 75% RCT of polypectomy or myomectomy Authors (year) No. Hysteroscopy PR no PR after RR /P patien surgery surgery value ts Pérez-Medina et 215 Polypectomy 25.4% 51.4% 2.1 al, 2005 Casini et al, 2006 52 Myomectomy 27.2% 52.2% <0.05 Shokeir et al, 215 Myomectomy 28.2% 63.4% 2.1 2010 Non Cavity distorting intramural myoma and first IVF treatment (Sunkara et al, 2010) No significant effect on the live birth rate Non Cavity distorting myoma and IVF • Inconclusive evidence • No evidence of myomectomy increases live birth rates Uterine Septum •Prospective study of infertile women with septum vs. idiopathic infertility (Mollo et al, 2009). Pregnancy rate after metroplasty 34.1% vs. 18.9%. • 88 women with idiopathic infertility: pregnancy rate after metroplasty: 80% (Shokeir, 2011) •289 ETs before and 538 ETs after metroplasty (Tomazevic et al, 2010) Pregnancy rates before 9.6% vs. after metroplasty 43.6% (OR 7.3, P<0.001), delivery rates 1.9% vs. 38.6% Intrauterine adhesions • Pregnancy rate after removal of adhesions – Mild adhesions: 58% – Moderate adhesions: 30% – Severe adhesions : 33.3% Roy et al, 2010 Reproductive Surgery to enhance IVF outcome 1. Hysteroscopy at least after one failed IVF 2. Hysteroscopic correction of intrauterine pathology increases the live birth rate. 3. Laparoscopic removal of hydrosalpinx increases the live birth rate. 4. Small endometrioma does not have to be removed before IVF 5. Non-distorted uterine myoma does not impair pregnancy rate III. Fertility Preservation Surgery Case 1: A 29 year old woman with rectal carcinoma Estimated dose that leads to permanent ovarian failure in most women Wallace et al, 2005 • Radiosensitivity of the oocyte is <2 Gy • At the age of 20 years, the estimated dose is 16.5 Gy • At 30 years 14.3 Gy • Radiotherapy for rectal cancer is usually over 45 Gy. Ovarian Transposition • GU cancer, low intestinal Ca and some Hodgkin disease • Radiation • Permanent sterility Lateral Ovarian Transposition Huang et al Grafting cryopreserved ovarian tissue • Orthotopic site • Heterotopic site III. Fertility Preservation Surgery 1. Laparoscopy Ovarian Transposition 2. Laparoscopy removal of ovarian tissue for cryopreservation 3. Laparoscopic ovarian tissue transplantation • 2 and 3 are experimental • Orthotopic is better • The future? REPRODUCTIVE SURGERY Primary surgical Surgery to enhance IVF Surgery for Fertility treatment for infertility outcome Preservation Tuboplasty Surgery for hydrosalpinx Neosalpingostomy, Salpingectomy Ovarian transposition fimbrioplasty, tubal anastomosis Salpingo-ovariolysis Proximal tubal occlusion Ovarian tissue removal for cryopreservation Hysteroscopic tubal Ovarian transplantation occlusion Surgery for endometriosis Hysteroscopy Polypectomy Myomectomy Metroplasty Adhesiolysis REPRODUCTIVE SURGERY Primary surgical treatment for Surgery to enhance IVF Surgery for Fertility infertility outcome Preservation Tuboplasty Surgery for hydrosalpinx Neosalpingostomy, fimbrioplasty, tubal anastomosis Salpingectomy Ovarian transposition Salpingo-ovariolysis Proximal tubal occlusion Ovarian tissue removal for cryopreservation Hysteroscopic tubal Ovarian transplantation occlusion Surgery for endometriosis Hysteroscopy Polypectomy Myomectomy Metroplasty Adhesiolysis • “the possibility of having a biological child in the future may ease the patients to go through with chemotherapy or radiation and provides a positive stimulus to recovery” (Dow, Partridge 2004) .
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