Dr Sujoy Dasgupta was invited to moderate a panel discussion on "Fertility Management: Synergy between Endoscopists and Fertility Specialists " in a CME by Torrent held on 27 May 2023.

1. Synergy between Endoscopists and
Fertility Specialists
Moderators
• Sujoy Dasgupta
• Tanuka Das Gupta
Panelists
• Avishek Bhadra
• Indranil Saha
• Manas Dutta
• Paramita Hazari
• Shovan Deb Kalapahar
Expert
• Abhinibesh Chatterjee

2. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
M Sc, Sexual and Reproductive Medicine (South Wales, UK)
Consultant: Reproductive Medicine, Genome Fertility
Centre, Kolkata
Managing Committee Member, BOGS, 2022-23
Executive Committee Member, ISAR Bengal, 2022-24
Clinical Examiner, MRCOG Part 3 Examination
Winner, Prof Geoffrey Chamberlain Award, RCOG World
Congress, London, 2019

3. www.aicog2023.co
DR.TANUKA DAS
CONSULTANT GYNAECOLOGIST &
OBSTETRICIAN
MBBS,MS,DNB,MRCOG,FMAS
Peerless Hospital ,kolkata & Freelancing
endoscopic surgeon
Specialization
Fellowship in advanced Laparoscopy (Pauls
Hospital,Kochi)
Training at Lap advanced retroperitoneal
dissection .(Dr Limbachiya,ahmedabad)
Training of Lap Urogynaecology
(SHIMIST,sonipat)
Trained in transvaginal Ultrasound

4. Dr. Avishek Bhadra
MBBS (Gold Medalist), MS (Gold Medalist),
DNB, MNAMS, FIAOG, MICOG, MRCOG
Assistant Professor, Dept. of
G&O
Medical College, Kolkata
Managing Committee Member,
The Bengal Obstetric &
Gynaecological Society
Secretary, Website & Bulletin
Subcommittee, BOGS
Life Member, Indian Association
of Gynaecological Endoscopists
Visiting Consultant & Minimally
Invasive Surgeon

6. DR. MANAS
DATTA
MBBS DNB
(G&O)
Consultant
Gynaecologist and
Obstetrician and
Laparoscopic Surgeon

8. DR.SHOVANDEB KALAPAHAR
MBBS,MS(G&O),DNB(G&O),FNB(REPRODUCTIVE
MEDICINE).
CONSULTANT,INSTITUTE OF REPRODUCTIVE
MEDICINE,SALTLAKE.
CONTRIBUTED CHAPTERS IN DIFFERENT INFERTILITY
BOOKS.
PRESENTED PAPERS IN DIFFERENT NATIONAL AND
INTERNATIONAL CONFERENCE.

9. DR ABHINIBESH CHATTERJEE
MBBS, DGO, DNB, FRCOG(UK),
Diploma in Gyn Lap (Germany), FMAS
• Consultantat Columbia Asia Hospital, Kolkata
• Trainedin India,UK and Germany in advanced
gynaecological endoscopicsurgery
• Member of AAGL (USA)
• Chairman of Endoscopy Committee of BOGS
• Limca record holder for removing maximum fibroids from
single uterus
• Conducted many Hystero-Laparoscopic workshops and has
helped in many state and national level live workshops and
conferences.
• Has presented and published many papers and also is
author of two books and contributed chaptersin
international books as well.
• Presentation at FIGO in 2012 &2015
• Video presentation at RCOG world congress at Birmingham in
2017 and London in2019

11. Case Scenario 1
• Mrs AC, 33-yr-old
woman having regular
cycles
• Trying for pregnancy for
3 years
• c/o severe and
progressively increasing
dysmenorrhoea and
dysparaeunia
• TVS-

12. Line of management?
• Laparoscopy
• IVF, embryo freezing
and then consider
laparoscopy
• IVF only
• Hormonal therapy for 3
months, then reevaluate
 Dienogest
 GnRH agonists

13. Factors to decide the mode of
treatment?
• Ovarian reserve- Age,
AMH, AFC
• Semen parameters
• Tubal patency
• Severity of symptoms
• Past surgery
• Previous fertility
treatment
• Patient’s wishes
Mrs AC
 Age 33, AMH- 2.5 ng/ml,
AFC- 8+10
 Normozoospermia
 Tubes not yet checked
 Pain not responded to
NSAID
 No previous surgery
 Received 6 cycles of
letrozole for OI
 Relief of pain and wants to
conceive

14. Endometriosis and Subfertility
Hormonal Suppression
• Clinicians should NOT
prescribe ovarian
suppression treatment to
improve fertility
• Most of the hormone
therapies will prevent
pregnancy
• Ovarian suppression does
NOT improve subsequent
ovarian response (ESHRE,
2022)
Surgery
• Still controversial if
cumulative pregnancy rate is
more after surgery but time
to achieve pregnancy was
significantly shorter (ESHRE,
2022)

15. Surgery for Endometriosis-
Subfertility
rASRM stage I/II
endometriosis
Operative laparoscopy could be offered
Improves the rate of ongoing pregnancy
Endometrioma Operative laparoscopy may increase their
chance of natural pregnancy
No data from comparative studies exist
Possible decline in ovarian reserve
Deep
endometriosis
No compelling evidence exists
Operative laparoscopy may represent a treatment
option in symptomatic patients wishing to conceive
(RCOG, 2017; NICE, 2017; ESHRE, 2022)

16. Aspects of surgery

17. Before surgery
Planned procedure
• Cystectomy/ Drainage
• Adhesiolysis
• Tubal patency
Other investigations
• Do not systematically request
second-level diagnostic
investigations in women with
known or suspected non-
subocclusive colorectal
endometriosis or with
symptoms responding to
medical treatment (ETIC, 2019)
Counselling and consent
• Laparotomy
• Oophorectomy
• Additional procedure
• Unexpected pathology-
hydrosalpinx
• Recurrence

18. During surgery
• Energy sources
• Minimizing ovarian damage
• Ovarian reconstruction
• Anti-adhesion barrier

19. After laparoscopy- Attempt of
natural conception or IVF?
• To identify patients that
may benefit from ART
after surgery, the
Endometriosis Fertility
Index (EFI) should be
used as it is validated,
reproducible and cost-
effective.
• The results of other
fertility investigations
such as their partner’s
sperm analysis should be
taken into account (ESHRE,
2022)

21. Adamson and Pasta. 2010

22. Post-operative treatment plan?
• Counselling?
• Ovarian suppression
after surgery?
 Chance of recurrence
 Better not to delay
pregnancy
 Women seeking pregnancy
should NOT be prescribed
postoperative hormone
suppression with the sole
purpose to enhance future
pregnancy rates (ESHRE, 2022)

23. Mrs AC is now pain-free
• Visited 4 doctors over the period of next 2
years.
• Received different brands of letrozole for
ovulation induction- total 12 cycles
• She returns after 2 years
• Now (age 35), she wants IVF

24. Mrs AC
AMH 0.9 ng/ml, AFC 4+3
• In endometriosis, with
and without a history of
ovarian surgery, ovarian
reserve markers were
worse (lower AMH and
higher FSH) compared to
women with male factors
Romanski PA, Brady PC, Farland LV, Thomas AM, Hornstein MD. The effect of
endometriosis on the antimüllerian hormone level in the infertile population. J
Assist Reprod Genet. 2019 Jun;36(6):1179-1184.

25. Endometrioma-related reduction in
ovarian reserve (ERROR)
Kasapoglu I, Ata B, Uyaniklar O, Seyhan A, Orhan A, Yildiz Oguz S, Uncu G.
Endometrioma-related reduction in ovarian reserve (ERROR): a prospective longitudinal
study. Fertil Steril. 2018 Jul 1;110(1):122-127.

26. Endometriosis- surgery or not
Yılmaz Hanege B, Güler Çekıç S, Ata B. Endometrioma and ovarian reserve: effects of
endometriomata per se and its surgical treatment on the ovarian reserve. Facts Views
Vis Obgyn. 2019 Jun;11(2):151-157.

27. Scan finding of Mrs AC
• TVS- B/L
endometrioma
(6 cm in right side, 4
cm left side)
 Anything else to note in
the scan
• Accessibility of the
follicles
 Next plan?
1. IVF directly?
2. Laparoscopy before
IVF?

28. Surgery before IVF?
In infertile women with
endometrioma > 3 cm only
consider cystectomy prior to
ART to improve
1. endometriosis-associated
pain or
2. the accessibility of
follicles (ESHRE, 2022)
Concern about
endometrioma puncture
during OPU?
• In women with
endometrioma, clinicians
may use antibiotic
prophylaxis at the time of
oocyte retrieval, although
the risk of ovarian abscess
following follicle
aspiration is low (0-1.9%)
(ESHRE, 2022, RCOG 2017)

29. RCOG Scientific Impact Paper (2017)
Directly ART
• Asymptomatic women,
• women of advanced
reproductive age,
• those with reduced
ovarian reserve,
• B/L endometriomas,
• a history of prior ovarian
surgery
Surgery before IVF
• Highly symptomatic
women,
• with an intact ovarian
reserve,
• unilateral and large cysts,
• cysts with suspicious
radiological and clinical
features.
29

31. Case 2
• Mrs PM, 27
years
• Trying for
pregnancy for 2
years
• Cycles regular,
no pelvic pain
• AMH 2.8 ng/ml
• Semen- normal

32. Options for Mrs PM?
• Laparoscopy?
• IVF?
• Noninvasive options?
 Implication of ART bill
 Repeat HSG
 Sonosalpingography
(SSG)
 Hysterosalpingo-Contrast-
Sonography (HyCoSy)

33. Precautions before interpreting HSG
• Spasm of the smooth muscles of the tube → “false”
impression of “fallopian tube block” (Suresh and Narvekar,
2014)
• In 40-60% cases of B/L proximal block diagnosed in
HSG, at least one tube may be found open on further
investigations (repeat HSG, SSG, laparoscopy)
(Hajishafiha et al., 2009; Verhoeve et al., 2010; Foroozanfard and Sadat, 2013)

34. Noninvasive options
Repeat
HSG
• After premedication with antispasmodics
• 60% cases initially “blocked” tubes were found open
(Dessole et al., 2000)
• Increased risk of radiation exposure and hypothyroidism
(Hart et al., 2009)
SSG • Relatively simple procedure, no radiation exposure (Suresh
and Naverkar, 2014, Maheux-Lacroix, 2014)
• Assesses uterine cavity, myometrium and the ovaries
• In 70-80% at least one tube is found open by SSG
(Hajishafiha, 2009; Lanzani, 2009)
• Can avoid both laparoscopy and IVF
HyCoSy • Delineates exact site of block (Luciano, 2011)
• Expensive, not easily available
• Meta-analysis-HyCoSy NOT superior to SSG (Maheux-
Lacroix, 2014)

35. Decisive factors for IVF vs
laparoscopy?
• Age of the woman
• Ovarian reserve
• Sperm parameters
• Number of children desired
• Site and extent of the tubal disease
• Risk of ectopic pregnancy
• Risk of OHSS
• Success rates of IVF programme
• Cost- Financial burden- “two
consecutive medical procedures to
achieve parenthood”
• Expertise of the surgeon
• Patient’s preferences
(Suresh and Narvekar, 2014; ASRM, 2015)
SSG of Mrs PM - no spill in POD

36. Laparoscopy- as the “Gold
standard” test for tubal patency?
• Diagnostic error still can happen in
laparoscopy (Broeze et al., 2010; Saunders et al., 2011; Luca et al.,
2017; ASRM, 2015
• No evidence supporting the concept- “Gold
standard” (Tan et al., 2018; Saunders et al., 2011; Lim et al., 2011;
Suresh and Narvekar, 2014)

37. Aspects of surgery

38. Before surgery
Planned procedure
• Dye test alone
• Additional procedure
Consent
• Consent for additional
unexpected pathology-
ovarian cyst,
hydrosalpinx, adhesion?

39. If the obstruction is not overcome
with gentle pressure
• True anatomic occlusion
is assumed and the
procedure is terminated
• Causes of failed tubal
cannulation (in 93%
cases)
1. SIN
2. chronic salpingitis
3. obliterative fibrosis
4. Tuberculosis Letterie
and Sakas, 1991
• Option 1- IVF
• Option 2- Microsurgical
resection and anastomosis

40. Hysteroscopic Tubal Cannulation
Type of study Authors Successful
cannulation
Concepti
on rates
Ectopic
pregnancy
Case series Ikechebelu et
al., 2018
90.2% per tube and
88.9% per patient
33.3% Nil
Case series Chung et al.,
2018
67.0% per tube and
71.4% per woman
55% No data
Cohort study Mekaru et al.,
2011
25.9% per tube and
37.1% per patient
30.77% 7.69%
Meta-analysis Honore et al.,
1999
85% per tube tube 48.9% 9.2%
• Proximal tubal obstruction
• Young women
• No other significant infertility factors (NICE, 2013; ASRM, 2015)

41. Mrs PM returns after 3 yrs, still
could not conceive
Explanation?
• Tubal patency ≠ normal function of the tube
(Approbato et al., 2020; Tan et al., 2018; Luca et al., 2017)
• All possible explanations for “unexplained
subfertility”

43. Case Scenario 3
• Mrs BG, 33 yr old
• Trying for pregnancy for only 3 years
• Already received several cycles of OI with CC,
letrozole and hMG
• Semen, AMH, HSG- all investigations done
and all are normal

44. What’s next for Mrs BG?
 IUI?
 IVF?
 Laparoscopy?

45. Unexplained subfertility
IUI
• Bypasses cervical factors
• Deposits good number of
motile spermatozoa near the
tubes
• Overcomes “improper”
coital techniques
• “Superovulation” leads to
release of >1 egg and
improves the follicular
development
IVF
• Evaluation of oocyte quality
• Evaluation of embryo
quality
• Bypasses subtle tubal
dysfunction
• IVF Itself can be diagnostic
(Nandi and Homburg, 2016).

46. Treatment as per age and duration
of infertility
(Nandi and Homburg, 2016)

47. Why laparoscopy for unexplained
subfertility?
• Endometriosis
• Adhesion
• Anatomical distortion- Tubo-Ovarian
relationship

48. • Meta-Analysis
• Success rate of IVF - ∼25% (NNT- 4)
Jacobson et al., 2010 Duffy et al., 2014
OR for ongoing pregnancy (95% CI) 1.64 (1.05– 2.57) 1.94 (1.20–3.16)
The number of infertile women that
should undergo destruction of
superficial peritoneal endometriosis
12 8
The prevalence of grade I/ II
endometriosis among women with
unexplained infertility
≤50%
NNT 24 16

49. Canadian Fertility and Andrology
Society , 2019

50. Before surgery
Planned procedure
• Diagnostic only
• Additional procedure
Consent
• Consent for additional
unexpected pathology-
ovarian cyst,
hydrosalpinx, adhesion?

51. Mrs BG wants to do laparoscopy

52. Undiagnosed B/L hydrosalpinx
• Perform B/L
salpingectomy taking
consent from the
husband
• Leave it as it is- for
second time surgery
• In an emergency even
where a patient lacks
capacity to consent→
act in the best interests
of the patient, although
the treatment given
must be limited to that
which is a necessity in
the best interests of the
patient (RCOG Clinical
Governance Advice, 2015)

54. Bilateral hydrosalpinx
• After B/L salpingectomy, the women will be
rendered totally dependent on IVF for conception
(Suresh and Narvekar, 2014).
• Paucity of data on long term psychological and
fertility outcomes (Suresh and Narvekar, 2014; Fritz and
Speroff, 2011).
• “Interval salpingectomy”- If refuses surgery prior
to the first IVF, offer surgery if the first cycle IVF
fails (Suresh and Narvekar, 2013).
• “Interval salpingectomy” - cumulative live birth
rates were similar between after 3 cycles of IVF
(Strandell et al., 2001).

55. Surgical aspects of hydrosalpinx
management
• Techniques
• Energy sources
• Complications

56. Alternative to salpingectomy
Laparoscopic salpingectomy is
the “standard”
1. reduces the risk of
2. improves the associated pain
(Suresh and Narvekar, 2013;
Strandell, 2018).
1. Laparoscopic tubal occlusion
2. Laparoscopic salpingostomy
3. Hysteroscopic proximal tubal
occlusion (Suresh and Narvekar,
2013).
• Need large RCT - should be
reserved for complex surgical
cases (Suresh and Narvekar, 2013;
Bhandari et al., 2018)
• If surgery is absolutely
contraindicated, ultrasound-
guided aspiration of
hydrosalpinx at the time of
oocyte retrieval → Increased risk
of recurrence (Suresh and Narvekar,
2013; Strandell, 2018).
Reconstructive tubal surgery-
if >50% retention of normal tubal
mucosa (Suresh and Narvekar, 201;
Strandell, 2018).
1. Limited success for natural
conception
2. Risk of ectopic pregnancy (Suresh
and Narvekar, 2014; Fritz and Speroff,
2011).

57. Salpingectomy in hydrosalpinx
• 2-fold improvement in
implantation rate, pregnancy
rate and live birth rate
1. RCT (Strandell et al., 2001)
2. Cochrane (Johnson et al., 2010)
3. Guideline (NICE, 2013).
• Can theoretically affect the
ovarian reserve and ovarian
response to gonadotropin
stimulation (Suresh and
Narvekar, 2014; Fritz and Speroff,
2011; Strandell, 2018).
• Evidence- similar ovarian
response between treated
and non-treated sides (Surrey
and Schoolcraft, 2001; Kamal,
2013; Strandell et al., 2001; Kotlyar
et al., 2017; Mohamed et al., 2017;
Zhang et al., 2015; Noventa et al.,
2016).

58. Ovaries looking like

59. Is LOD indicated here?

60. Indications of LOD
• PCOS resistant to oral ovulogens
• LH >10 IU/L
• BMI <30 kg/m2
• Needing laparoscopic assessment of the pelvis
• Live too far away from the hospital for the intensive
monitoring required during gonadotropin therapy
(ESHRE, 2018; NICE, 2013; Mitra et al., 2015; Fritz and Speroff, 2011)

61. LOD
• Post-op spontaneous
ovulation rate 40-90% and
50% of them conceive
• Less incidence of multiple
pregnancy and OHSS
• Does not require extensive
monitoring (ESHRE, 2018; Mitra
et al., 2015; Fritz and Speroff, 2011).
• Risk of adhesion
formation → worsens
infertility
• Risk of POF (Lepine et al.,
2017; ESHRE, 2018).

62. • LOD with and without medical ovulation induction may decrease
the live birth rate in women with anovulatory PCOS and CC
resistance compared with medical ovulation induction alone.
• Low-quality evidence suggests that there may be little or no
difference between the treatments for the likelihood of a clinical
pregnancy
• There is uncertainty about the effect of LOD compared with
ovulation induction alone on miscarriage.
• Moderate-quality evidence shows that LOD probably reduces the
number of multiple pregnancy.
• LOD may result in less OHSS.
• The quality of evidence is insufficient to justify a conclusion on live
birth, clinical pregnancy or miscarriage rate for the analysis of
unilateral LOD versus bilateral LOD.

63. Aspects of surgery

64. Technical aspects of LOD- when
indicated
• Number of punctures
• Instruments
• Current settings
• Adhesion prevention