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Assisted Reproduction and Infertility
The Role of Reproductive Surgery in the Era of In Vitro Fertilisation
Stephan Gordts
Scientific Director, Leuven Institute for Fertility and Embryology
Abstract
Despite the reported successes of assisted reproductive techniques (ART), surgery will continue to play a major role in the field of
reproductive medicine. There is a fundamental difference in their approach: ART always bypasses the problem, whereas surgery tries to
solve the pathology by restoring normal anatomy and as such offering the couple the potential for a spontaneous conception. This potential
is important in view of the risks associated with in vitro fertilisation (IVF), such as ovarian hyperstimulation, multiple pregnancies and higher
incidence of congenital malformations. When IVF is the only possible treatment solution, surgery can improve pregnancy rates, for example
in cases of submucous myoma, congenital uterine anomalies and hydrosalpinges. In order not to lose the necessary surgical skills, specific
training programmes in reproductive surgery must become part of the syllabus for all those involved in reproductive medicine.
Keywords
Reproductive surgery, laparoscopy, fertility, assisted reproductie technology (ART)
Disclosure: The authors have no conflicts of interest to declare.
Received: 18 January 2009 Accepted: 16 March 2009
Correspondence: Stephan Gordts, Leuven Institute for Fertility and Embryology (LIFE), Tiensevest 168, 3000 Leuven, Belgium. E:
lifeleuven@lifeleuven.be
In the wake of the success of in vitro fertilisation (IVF), surgery has Although the latter are very valuable techniques as a first
been almost forgotten. Several factors can explain this overwhelming screening method, their accuracy is certainly questionable in the
success. First, there was the opportunity of new treatment options diagnosis of tubal pathology, pelvic and peritubal adhesions,
for patients desperately trying for a pregnancy after previous failures. peritoneal endometriosis and ovarian endometrioma <1cm. Direct
Second, all of those involved in reproductive medicine were very visualisation of the female pelvis and uterine cavity has been
eager to participate in this exciting new world of gametes and proved to be superior in diagnosing.
2–4
However, standard
embryos, allowing them to gain more knowledge and to search for laparoscopy (SL) (not being an innocuous procedure) has been
new possibilities. Third, the success rate of IVF was over-expressed bypassed by several IVF centres because of its invasiveness and for
by the sometimes misleading information printed in the media, reasons of cost-effectiveness.
creating the illusion that in cases of infertility it was the only available
treatment option. Last but not least, there was the financial interest However, an incomplete investigation carries the risk of not
of doctors, institutes and companies. offering the patient the best available treatment option and of
performing IVF treatments in a suboptimal environment due to
Within this area of idealisation and industrialisation of reproductive missed uterine, tubal or pelvic pathology, with a possible negative
medicine, the judicious exploration of the female partner was impact on implantation and pregnancy. After failed ovulation
abandoned in favour of a liberal referral to IVF/embryo transfer (ET) induction cycles, pelvic pathology with the presence of adhesions
programmes. Surgery could hardly compete. However, reproductive and severe endometriosis was diagnosed in 35% of patients.
5
surgery will continue to play an important role in the optimisation of In a series of 55 patients with repeated IVF failures and
fertility. Now, more data are becoming available expressing some normal hysterosalpingography before starting IVF, Oliveira et al.
6
concerns about the outcome of assisted reproductive technology reported the presence of uterine pathology at hysteroscopy in
(ART) treatments. This should be taken into consideration when 45% of patients.
counselling couples and discussing the different treatment options.
For some couples, surgical treatment may offer a very valuable Everybody agrees that the female partner still needs to be
alternative and also relieve endometriosis-associated morbidity such investigated, but opinions differ greatly as to how and to what
as dysmenorrhoea and dyspareunia or abnormal uterine bleeding in degree the investigations should be performed. The transvaginal
the presence of uterine myoma. endoscopic approach has been proved to be a safe and minimally
invasive endoscopic procedure offering the possibility of a full
Diagnosis infertility diagnosis with direct visualisation of the uterine cavity
Indirect and less invasive imaging techniques, such as transvaginal and pelvic organs.
7–10
Only an accurate diagnosis can offer the
ultrasound, have been promoted to replace endoscopic techniques.
1
guarantee of an accurate treatment.
© TOUCH BRIEFINGS 2009 21
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