Update on Reproductive Surgery Prof T C LI Professor of Reproductive Medicine & Surgery Sheffield, England Shenzhen, May 2013

Areas to be covered Management of distal tubal disease Ovarian surgery revisited Haemostatic agent

Management of distal tubal disease ? Salpingostomy IVF Salpingectomy

Management of distal tubal disease ? Salpingostomy IVF Salpingectomy Answer: it depends

MICROSURGICAL SALPINGOSTOMY: JESSOP SERIES

MICROSURGICAL SALPINGOSTOMY

SALPINGOSTOMY: GOOD PROGNOSTIC FEATURES small hydrosalpinx no/minimal peri-tubal adhesions normal mucosa normal/thin wall partial occlusion

Sapingostomy 1. mobilise fimbriael end

Sapingostomy 1. mobilise fimbriael end

Sapingostomy 1. mobilise fimbriael end

Sapingostomy 2.locate blocked ostium

Sapingostomy 3. incise blocked ostium

Sapingostomy 4. inspect lumen

Sapingostomy 4. inspect lumen - salpingoscopy

Sapingostomy 5. eversion of fimbrial mucosa

Sapingostomy 6. suture

Sapingostomy 6. suture

MICROSURGICAL SALPINGOSTOMY

Salpingoscopy Abnormal Mucosa

Management of distal tubal disease ? Salpingostomy IVF Salpingectomy

Hydrosalpinges and IVF The live birth rate of patients with hydrosalpinges undergoing IVF is only one-half that of women who do not have hydrosalpinges

Hydrosalpinx and IVF outcome : a prospective randomized multicentre trial in Scandinavia on salpingectomy prior to IVF Strandell et al 1999 Human Reprod 14:2762 First IVF cycle, regardless of whether or not hydrosalpinges demonstrable by USS Group Patient PR miscarriage Live birth Salpingectomy 112 36.6% 16.2% 28.6% No salpingectomy 92 23.9% 26.3% 16.3% PR, p=0.067 LB, p=0.045

Hydrosalpinges and IVF Salpingectomy prior to IVF in women with hydrosalpinges improves pregnancy, implantation and live birth rates

1. Is it cost-effective to routinely remove all hydrosalpinges prior to IVF ?

Cost-effectiveness of salpingectomy prior to IVF, based on a RCT Strandell et al 2005 Human Reprod 20:3284 Up to three IVF cycles, in women with hydrosalpinges demonstrable by USS Group Patient Cost per LB Salpingectomy 51 Euro 22823 No salpingectomy 44 Euro 29517

Cost-effectiveness of salpingectomy prior to IVF, based on a RCT Strandell et al 2005 Human Reprod 20:3284 Up to three IVF cycles, in women with hydrosalpinges demonstrable by USS Group Patient Cost per LB Salpingectomy 51 Euro 22823 No salpingectomy 44 Euro 29517 More cost-effective

1. Is it cost-effective to routinely remove all hydrosalpinges prior to IVF ? Yes

2. Should proximal tubal occlusion replace salpingectomy?

Complications of salpingectomy Impairment of ovarian blood supply, leading to reduced ovarian response to ovarian stimulation in IVF Bowel injury

A case of salpingectomy Large hydrosalpinx visible on ultrasound One failed IVF treatment Laparoscopic surgery Dense adhesions between L tube and bowel and pelvic side wall 2 hour operation, salpingectomy Day 3, sepsis, bowel leak Colostomy, ITU for 1 weeks

Complications of salpingectomy Impairment of ovarian blood supply, leading to reduced ovarian response to ovarian stimulation in IVF Bowel injury More likely if there were severe adhesions

Disadvantages of proximal tubal occlusion Pain may get worse Risk of recurrent infection and pyosalpinx May require further surgery to remove the diseased tube at a later date The data on possible benefit is not as robust as that of salpingectomy

2. Should proximal tubal occlusion replace salpingectomy? Only if there are severe adhesions

3. Should hysteroscopic tubal occlusion replace salpingectomy?

Essure 3-8 expanded outer coils visible in uterine cavity 1 2 3 3-8 expanded outer coils visible in uterine cavity 4

3. Should hysteroscopic tubal occlusion replace salpingectomy? No, there are concerns about implantation and premature labour

4. Is aspiration of hydrosalpinges fluid as effective as salpingectomy?

Ultrasound-guided hydrosalpinx aspiration, RCT Hammadien et al, Human Reprod 2008 No aspiration P value Biochemical pregnancy 14/32 (43.8%) 7/34 (20.6%) 0.04 Clinical pregnancy 10/32 (31.3%) 6/34 (17.6%) 0.2

4. Is aspiration of hydrosalpinges fluid as effective as salpingectomy?

5. If the hydrosalpinx is small and not visible on ultrasound, is it still necessary to perform salpingectomy?

Hydrosalpinx and IVF outcome : a prospective randomized multicentre trial in Scandinavia on salpingectomy prior to IVF Strandell et al 1999 Human Reprod 14:2762 First IVF cycle, regardless of whether or not hydrosalpinges demonstrable by USS Group Patient PR miscarriage Live birth Salpingectomy 112 36.6% 16.2% 28.6% No salpingectomy 92 23.9% 26.3% 16.3% PR, p=0.067 LB, p=0.045

5. If the hydrosalpinx is small and not visible on ultrasound, is it still necessary to perform salpingectomy? Yes

Ultrasound may fail to diagnose hydrosalpinx

6. UNILATERAL TUBAL DISEASE Is surgery still worthwhile?

Unilateral Hydrosalpinx with a Contra-lateral Patent Tube McComb & Taylor 2001 Fertil Steril 76:1279 23 women with unilateral hydrosalpinx underwent salpingostomy IU pregnancy rate 43.5% Conclusion – unilateral salpingostomy in women with a contra-lateral patent tube improves fertility

Case History 33 year old woman one miscarriage at 7 weeks Infertility for 15 months Conceived spontaneously, but miscarried again at 8 week gestation Investigation – L tube normal. R hydrosalpinx, grossly dilated, intraluminal adhesions, salpingectomy. Three months later, spontaneously conception, term delivery

6. UNILATERAL TUBAL DISEASE Is surgery still worthwhile? Yes

7. How to do salpingectomy properly?

Salpingectomy : Surgical tips 1 Main Risk: devascularization of the ovary Operate close to the tube, away from ovarian vessels and suspensory ligament

Salpingectomy : surgical tips 2 Other Risk: incomplete removal, with development of ectopic pregnancy following ART Do a complete salpingectomy !

Areas to be covered Management of distal tubal disease Ovarian diathermy for PCOS Haemostatic agent

PCOS & Ovarian Diathermy Why bother doing laparoscopic diathermy or drilling of the ovaries? How should it be done?

LOD vs GONADOTROPHIN COCHRANE DATABASE 3 RCTS Vegetti et al 1998 Farquhar et al 2002 Bayram et al 2004 CCR 6-12 month after LOD is similar to 3-6 cycles of gonadotrophin therapy

LOD versus FSH 53 (64) 9 51 (60) Bayram et al, 2004 83 (100) 31 (37) 3 Treatment Regimen No of women Pregnant (%) Miscarry Multiple LB LOD strategy LOD 83 (100) 31 (37) 3 - 28 (34) LOD + CC 45 (54) 14 (31) 1 13 (29) LOD + CC + FSH 23 (28) 18 (78) 12 (52) LOD strategy total 83 63 (76) 7 53 (64) FSH 85 64 (75) 9 51 (60) Bayram et al, 2004

Conclusions of study An electrocautery strategy and ovulation induction with recombinant follicle stimulating hormone are similarly effective in inducing ovulation Multiple pregnancies can largely be avoided by electrocautery and clomifene citrate before rFSH

LOD vs GONADOTROPHIN ECONOMIC CONSIDERATIONS Li et al 1998, BJOG

LOD vs GONADOTROPHIN ECONOMIC CONSIDERATIONS gonadotrophins Cost per live birth Farquhar et al, 2004 US $21095 US $28744 Cost per live birth + delivery Wely et al, 2004 Euro 11301 Euro 14489 Cost of term pregnancy : LOD 22-33% lower

NICE Guidelines Ovarian drilling Women with PCOS who have not responded to CC should be offered laparoscopic ovarian drilling because it is as effective as gonadotrophin treatment and is not associated with an increased risk of multiple pregnancy

ADVANTAGES OF LOD Avoids risk of multiple pregnancy Less costly Long term beneficial effects including menstrual regularity, sustained reduction of FAI, sustained restoration of ovulation and further chances spontaneous conception in over 50% of subjects compared with subjects who did not undergo LOD (Amer et al, Human Reprod 2002, 17:2035; Amer et al, Human Reprod 2002, 17:2851)

PCOS & Ovarian Diathermy Why bother doing laparoscopic diathermy or drilling of the ovaries? How should it be done?

How many punctures should one make?

The number of puncture is only one of several variables which determines the amount of electrical energy delivered to the ovary The amount of energy (J) used is calculated as: power (w) x duration (sec) x No of punctures

Laparoscopic Ovarian Diathermy How much electrical energy is required to produce optimal results?

The amount thermal energy used in LOD Gjonnaess (1984): 250 w x 3 sec x > 5 = > 3750 joules Armar et al (1990): 40 w x 4 sec x 4 = 640 joules Dabirashrafi (1989): Severe ovarian atrophy with 8 holes x 400w x 5 sec = 16,000 Joules

The Sheffield Prospective Dose Finding Study Amer, Li & Cooke, 2003 The modified Monte Carlo Up-and-Down design 30 women divided into ten groups, each group with 3 women Dose in each group to be determined by the response of previous group Energy utilised for each puncture is standardised

Conception rates after LOD Sheffield Prospective Study puncture 1 2 3 4

OVARIAN DIATHERMY

ELECTRICAL ENERGY Rockett of London diathermy needle needle 8 mm long, 2 mm diameter monopolar coagulation power - 30 W puncture number 4 duration 5 seconds

With the use of proper techniques, laparoscopic ovarian diathermy is very safe Sheffield series : Adhesions – often minimal ovarian failure – 0/250cases

Management of distal tubal disease Ovarian surgery revisited Haemostatic Agent

Floseal Haemostatic Matrix (Baxter) FLOSEAL is indicated in surgical procedures (other than ophthalmic) as an adjunct to haemostasis when control of bleeding by ligature or conventional procedures is ineffective or impractical.

What is Floseal?

FLOSEAL provides a combination of two independent hemostasis promoting agents. The gelatin granules swell to produce a tamponade effect High concentrations of human thrombin convert fibrinogen into fibrin monomers accelerating clot formation

Identify the source of bleeding at the tissue surface Identify the source of bleeding at the tissue surface. Apply FLOSEAL Hemostatic Matrix FAST to the deepest part of the wound or lesion - the source of bleeding at the tissue surface.

FLOSEAL granules allow high concentrations of thrombin to react rapidly with the patient's fibrinogen and form a mechanically stable clot.

FLOSEAL can be reapplied, if necessary FLOSEAL can be reapplied, if necessary. Once haemostasis is achieved, gentle irrigation should always occur to remove excess product that has not been incorporated into the clot. Do not disrupt the clot by physical manipulation or suction.

When is it useful? Pelvic side wall Rectovaginal space Ovarian cyst wall

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