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Update on Reproductive Surgery

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.

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Update on Reproductive Surgery

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  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. Sapingostomy1. mobilise fimbriael end

  9. Sapingostomy1. mobilise fimbriael end

  10. Sapingostomy1. mobilise fimbriael end

  11. Sapingostomy2.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. SalpingoscopyAbnormal 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 IVFStrandell et al 1999 Human Reprod 14:2762 First IVF cycle, regardless of whether or not hydrosalpinges demonstrable by USS PR, p=0.067 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 RCTStrandell et al 2005 Human Reprod 20:3284 Up to three IVF cycles, in women with hydrosalpinges demonstrable by USS

  26. Cost-effectiveness of salpingectomy prior to IVF, based on a RCTStrandell et al 2005 Human Reprod 20:3284 Up to three IVF cycles, in women with hydrosalpinges demonstrable by USS 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

  32. 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

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

  34. 3. Should hysteroscopic tubal occlusion replace salpingectomy?

  35. Essure 4 expandedouter coils 1 2 3 4 3-8 expanded outer coils visible in uterinecavity

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

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

  38. Ultrasound-guided hydrosalpinx aspiration, RCTHammadien et al, Human Reprod 2008

  39. 4. Is aspiration of hydrosalpinges fluid as effective as salpingectomy? No

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

  41. Hydrosalpinx and IVF outcome : a prospective randomized multicentre trial in Scandinavia on salpingectomy prior to IVFStrandell et al 1999 Human Reprod 14:2762 First IVF cycle, regardless of whether or not hydrosalpinges demonstrable by USS PR, p=0.067 LB, p=0.045

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

  43. Ultrasound may fail to diagnose hydrosalpinx

  44. 6. UNILATERAL TUBAL DISEASEIs surgery still worthwhile?

  45. Unilateral Hydrosalpinx with a Contra-lateral Patent TubeMcComb & 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

  46. 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, spontaneouslyconception, term delivery

  47. 6. UNILATERAL TUBAL DISEASEIs surgery still worthwhile? Yes

  48. 7. How to do salpingectomy properly?

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

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