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

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

3. Management of distal tubal disease?
Salpingostomy
IVF
Salpingectomy

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

5. MICROSURGICAL SALPINGOSTOMY: JESSOP SERIES

6. MICROSURGICAL SALPINGOSTOMY

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

8. Sapingostomy 1. mobilise fimbriael end

9. Sapingostomy 1. mobilise fimbriael end

10. Sapingostomy 1. mobilise fimbriael end

11. Sapingostomy 2.locate blocked ostium

12. Sapingostomy 3. incise blocked ostium

13. Sapingostomy 4. inspect lumen

14. Sapingostomy 4. inspect lumen - salpingoscopy

15. Sapingostomy 5. eversion of fimbrial mucosa

16. Sapingostomy 6. suture

17. Sapingostomy 6. suture

18. MICROSURGICAL SALPINGOSTOMY

19. Salpingoscopy Abnormal Mucosa

20. Management of distal tubal disease?
Salpingostomy
IVF
Salpingectomy

21. 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

22. 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= LB, p=0.045

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

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

25. 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

26. 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

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

28. 2. Should proximal tubal occlusion replace salpingectomy?

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

30. 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

31. 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

33. 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

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

35. 3. Should hysteroscopic tubal occlusion replace salpingectomy?

36. Essure 3-8 expanded outer coils visible in uterine cavity1 2 3
3-8 expanded outer coils visible in uterine cavity 4

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

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

39. 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

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

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

42. 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= LB, p=0.045

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

44. Ultrasound may fail to diagnose hydrosalpinx

45. 6. UNILATERAL TUBAL DISEASE Is surgery still worthwhile?

46. 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

47. 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

48. 6. UNILATERAL TUBAL DISEASE Is surgery still worthwhile?
Yes

49. 7. How to do salpingectomy properly?

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

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

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

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

55. 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

56. 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

57. 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

58. LOD vs GONADOTROPHIN ECONOMIC CONSIDERATIONS
Li et al 1998, BJOG

59. 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

60. 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

61. 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)

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

63. How many punctures should one make?

64. 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

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

66. 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

67. 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

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

69. OVARIAN DIATHERMY

70. 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

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

72. Management of distal tubal disease
Ovarian surgery revisited
Haemostatic Agent

75. 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.

76. What is Floseal?

77. 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

78. 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.

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

80. 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.

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

82. THANK YOU