Gordts_subbed.qxp 30/4/09 11:03 Page 23
The Role of Reproductive Surgery in the Era of In Vitro Fertilisation
a block and give only suspicion of ampullary and tubo-ovarian In our own series,
57
the cumulative pregnancy rate following tubal
adhesions. Although laparoscopy performs better than HSG as a reversal was 43 and 64% after six and 12 months, respectively, and is
predictor of future fertility, it should not be considered to be a perfect very similar to the cumulative pregnancy rate after four IVF cycles. In
test in the diagnosis of tubal pathology.
34
patients below 40 years of age with a partner with normal semen
parameters, pregnancy rate is as high as 84%, and approximately 50%
The beneficial effect of salpingectomy on IVF outcome in cases of thick- of these pregnancies occurred within six months.
walled hydrosalpinges or ultrasonographically visible hydrosalpinges
has been reported by several studies.
35–37
A Cochrane review
38
showed Tubal anastomosis allows the possibility of a spontaneous conception
that salpingectomy pre-IVF resulted in 1.75- and 2.13-fold higher odds without the IVF-related risks and inconveniences of ovarian
of pregnancy and live birth, respectively. As a consequence, in the hyperstimulation, multiple pregnancies and possible higher incidence
presence of hydrosalpinges systematic salpingectomy prior to IVF has of congenital malformations.
59
Furthermore, consecutive pregnancies
been recommended. However, this will deprive some patients with thin- can occur without supplementary costs.
walled hydrosalpinges of the possibility of a spontaneous conception.
Peri-operative inspection of the tubal mucosa during surgery
39,40
led to Uterine Pathology
the development of salpingoscopy for pre-operative evaluation of tubal Hysteroscopy has become the gold standard for evaluating the uterine
factor infertility.
41
The superiority of salpingoscopy in evaluating tubal cavity and is a reliable and safe method. In a prospective study, 530
disease over HSG has been documented.
42
diagnostic mini-hysteroscopies were performed in an office setting
without any form of anaesthesia and a high patient compliance.
60
In various studies
43–47
it has clearly been shown that in a selected Mini-hysteroscopy uses an atraumatic insertion technique, saline as
group of hydrosalpinges salpingostomy achieved acceptable distension medium and a small-diameter hysteroscope of ≤3.5mm
intrauterine pregnancy rates and correlated with the outer diameter.
61
It allows a non-invasive exploration of the uterine
salpingoscopic classification of mucosal adhesions and fibrosis of cavity prior to every fertility treatment to exclude congenital or
the tubal wall. No pregnancies were obtained in patients operated acquired uterine pathology. In a recent meta-analysis the systematic
on for thick-walled hydrosalpinges; in contrast, in thin-walled performance of a pre-IVF office hysteroscopy resulted in an
hydrosalpinges the prognosis is better. If no mucosal adhesions are improved implantation and pregnancy rate (pooled relative risk 1.75,
present, the intrauterine pregnancy rate is at least 50%, with a 95% CI 1.51–2.03).
62
5% risk for an ectopic pregnancy. In cases of grade 3 salpingoscopic
findings, the intrauterine pregnancy rate is only 20%, with a Myoma
10% risk of an ectopic pregnancy; when severe intra-tubal lesions The frequency of uterine fibroids in patients seeking fertility treatment
are present (>50%), the incidence of an intrauterine pregnancy is is estimated to be 5–10%,
63
and is the sole factor identified in about
less than 5%. 2–4% of patients. The presence of fibroids may affect fertility
and obstetric outcome and is associated with foetal wastage,
When dealing with hydrosalpinges, a tubal mucosal evaluation through abruptio placentae, a high incidence of Caesarian section and
salpingoscopy will add a supplementary dimension to decision- premature delivery.
64
A major problem in the current classification of
making. The question ‘should salpingectomy be performed prior to uterine fibroids is the distinction between intramural and
IVF?’ should be ‘which kind of intervention should be performed prior submucosal fibroids. While subserosal and submucosal leiomyomas
to IVF: salpingectomy or salpingostomy?’ This offers the patient a are likely to originate from the outer myometrium and junctional zone
realistic chance for spontaneous conception whenever possible. myometrium, respectively, the intramural fibroids may originate from
Systematic removal of thin-walled hydrosalpinges visible at ultrasound the outer as well as the junctional zone myometrium. There are major
will deprive some patients of the possibility of a spontaneous clinicopathological differences between outer myometrium and
conception. However, tubal mucosal staging is rarely performed and is junctional zone fibroids.
65,66
This heterogeneous composition of the
not part of the routine exploration at laparoscopy. The difficulties intramural group may explain the uncertain effect of these fibroids in
inherent to the use of the salpingoscope for inspection of the tubal current studies. Lesny et al.
67
demonstrated the correlation between
mucosal at standard laparoscopy represent the most important reason zona thickness and subsequent implantation in IVF cycles. As a
for omitting this examination. The technique is more easily performed consequence, disruption of the junctional zone myometrium can have
using the transvaginal approach as tubes and endoscope are in the important consequences for the normal uterine function. Therefore,
same longitudinal axis, allowing the performance of a salpingoscopy the classification of uterine fibroids in clinicopathological studies may
without supplementary manipulation.
48,49
be based on their relationship with the junctional zone myometrium
rather than on the impact on the uterine cavity.
66
Magnetic resonance
Proximal Tubal Occlusion imaging (MRI) scans and high-resolution ultrasound would be useful
The superiority of restoring normal fecundity after tubal sterilisation to delineate the junctional zone and to determine whether the
by microsurgical anastomosis cannot be denied. Using microsurgical junctional zone myometrium is involved in the disease process.
techniques, restoration of tubal patency after tubal ligation results in
pregnancy rates of 57–84%,
50–55
with a risk of ectopic pregnancy of Uterine Congenital Anomalies
2–7%. Even in patients at an advanced reproductive age, pregnancy The prevalence of uterine anomalies varies from 0.06% in the
rates of 45–50% have been reported.
56,57
Cumulative delivery rates for general population to 13% in women with history of recurrent
IVF and tubal microsurgery in patients <37 years of age after 72 spontaneous miscarriages.
68–71
In an extended prospective study on
months were 52.4% for IVF and 72.2% after tubal surgery, with an a population of women with three or more spontaneous
average cost per delivery of €11,707 for IVF versus €6,015 for miscarriages, uterine septa or arcuata
72
have been observed in 90%
surgical reversal.
58
of cases.
73
Several other studies have confirmed a direct correlation
EUROPEAN OBSTETRICS & GYNAECOLOGY 23
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84