Laparoscopy 3

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Laparoscopy 3

  1. 1. Infertility David Toub, M.D. Medical Director Newton Interactive
  2. 2. Definitions <ul><li>Infertility </li></ul><ul><ul><li>Inability to conceive after one year of unprotected intercourse (6 months for women over 35?) </li></ul></ul><ul><li>Fertility </li></ul><ul><ul><li>Ability to conceive </li></ul></ul><ul><li>Fecundity </li></ul><ul><ul><li>Ability to carry to delivery </li></ul></ul>
  3. 3. Statistics <ul><li>80% of couples will conceive within 1 year of unprotected intercourse </li></ul><ul><li>~86% will conceive within 2 years </li></ul><ul><li>~14-20% of US couples are infertile by definition (~3 million couples) </li></ul><ul><li>Origin: </li></ul><ul><ul><li>Female factor ~40% </li></ul></ul><ul><ul><li>Male factor ~30% </li></ul></ul><ul><ul><li>Combined ~30% </li></ul></ul>
  4. 4. Etiologies <ul><li>Sperm disorders 30.6% </li></ul><ul><li>Anovulation/oligoovulation 30% </li></ul><ul><li>Tubal disease 16% </li></ul><ul><li>Unexplained 13.4% </li></ul><ul><li>Cx factors 5.2% </li></ul><ul><li>Peritoneal factors 4.8% </li></ul>
  5. 5. Associated Factors <ul><li>PID </li></ul><ul><li>Endometriosis </li></ul><ul><li>Ovarian aging </li></ul><ul><li>Spermatic varicocoele </li></ul><ul><li>Toxins </li></ul><ul><li>Previous abdominal surgery (adhesions) </li></ul><ul><li>Cervical/uterine abnormalities </li></ul><ul><li>Cervical/uterine surgery </li></ul><ul><li>Fibroids </li></ul>
  6. 6. Emotional and Educational Needs <ul><li>Disease of couples, not individuals </li></ul><ul><li>Feelings of guilt </li></ul><ul><li>Where to go for information? </li></ul><ul><li>Options </li></ul><ul><li>Feelings of frustration and anger </li></ul><ul><li>Support groups (e.g. Resolve) </li></ul>
  7. 7. Overview of Evaluation <ul><li>Female </li></ul><ul><ul><li>Ovary </li></ul></ul><ul><ul><li>Tube </li></ul></ul><ul><ul><li>Corpus </li></ul></ul><ul><ul><li>Cervix </li></ul></ul><ul><ul><li>Peritoneum </li></ul></ul><ul><li>Male </li></ul><ul><ul><li>Sperm count and function </li></ul></ul><ul><ul><li>Ejaculate characteristics, immunology </li></ul></ul><ul><ul><li>Anatomic anomalies </li></ul></ul>
  8. 8. The Most Important Factor in the Evaluation of the Infertile Couple Is:
  9. 9. HISTORY
  10. 10. History-General <ul><li>Both couples should be present </li></ul><ul><li>Age </li></ul><ul><li>Previous pregnancies by each partner </li></ul><ul><li>Length of time without pregnancy </li></ul><ul><li>Sexual history </li></ul><ul><ul><li>Frequency and timing of intercourse </li></ul></ul><ul><ul><li>Use of lubricants </li></ul></ul><ul><ul><li>Impotence, anorgasmia, dyspareunia </li></ul></ul><ul><ul><li>Contraceptive history </li></ul></ul>
  11. 11. History-Male <ul><li>History of pelvic infection </li></ul><ul><li>Radiation, toxic exposures (include drugs) </li></ul><ul><li>Mumps </li></ul><ul><li>Testicular surgery/injury </li></ul><ul><li>Excessive heat exposure (spermicidal) </li></ul>
  12. 12. History-Female <ul><li>Previous female pelvic surgery </li></ul><ul><li>PID </li></ul><ul><li>Appendicitis </li></ul><ul><li>IUD use </li></ul><ul><li>Ectopic pregnancy history </li></ul><ul><li>DES (?relation to infertility) </li></ul><ul><li>Endometriosis </li></ul>
  13. 13. History-Female <ul><li>Irregular menses, amenorrhea, detailed menstrual history </li></ul><ul><li>Vasomotor symptoms </li></ul><ul><li>Stress </li></ul><ul><li>Weight changes </li></ul><ul><li>Exercise </li></ul><ul><li>Cervical and uterine surgery </li></ul>
  14. 14. When Not to Pursue an Infertility Evaluation <ul><li>Patient not sexually-active </li></ul><ul><li>Patient not in long-term relationship? </li></ul><ul><li>Patient declines treatment at this time </li></ul><ul><li>Couple does not meet the definition of an infertile couple </li></ul>
  15. 15. Physical Exam-Male <ul><li>Size of testicles </li></ul><ul><li>Testicular descent </li></ul><ul><li>Varicocoele </li></ul><ul><li>Outflow abnormalities (hypospadias, etc) </li></ul>
  16. 16. Physical Exam-Female <ul><li>Pelvic masses </li></ul><ul><li>Uterosacral nodularity </li></ul><ul><li>Abdominopelvic tenderness </li></ul><ul><li>Uterine enlargement </li></ul><ul><li>Thyroid exam </li></ul><ul><li>Uterine mobility </li></ul><ul><li>Cervical abnormalities </li></ul>
  17. 17. Overall Guidelines for Work-up <ul><li>Timeliness of testing-w/u can usually be accomplished in 1-2 cycles </li></ul><ul><li>Timing of tests </li></ul><ul><li>Don’t over test </li></ul><ul><li>Cut to the chase, i.e. proceed with laparoscopy if adhesive disease is likely </li></ul>
  18. 18. Work-up by Organ Unit
  19. 19. Ovary
  20. 20. Ovarian Function <ul><li>Document ovulation: </li></ul><ul><ul><li>BBT </li></ul></ul><ul><ul><li>Luteal phase progesterone </li></ul></ul><ul><ul><li>LH surge </li></ul></ul><ul><ul><li>EMBx </li></ul></ul><ul><li>If POF suspected, perform FSH </li></ul><ul><li>TSH, PRL, adrenal functions if indicated </li></ul><ul><li>The only convincing proof of ovulation is pregnancy </li></ul>
  21. 21. Ovarian Function <ul><li>Three main types of dysfunction </li></ul><ul><ul><li>Hypogonadotrophic, hypoestrogenic (central) </li></ul></ul><ul><ul><li>Normogonadotrophic, normoestrogenic (e.g. PCOS) </li></ul></ul><ul><ul><li>Hypergonadotrophic, hypoestrogenic (POF) </li></ul></ul>
  22. 22. BBT <ul><li>Cheap and easy, but… </li></ul><ul><ul><li>Inconsistent results </li></ul></ul><ul><ul><li>Provides evidence after the fact (like the old story about the barn door and the horse) </li></ul></ul><ul><ul><li>May delay timely diagnosis and treatment </li></ul></ul><ul><ul><li>98% of women will ovulate within 3 days of the nadir </li></ul></ul><ul><ul><li>Biphasic profiles can also be seen with LUF syndrome </li></ul></ul>
  23. 23. Luteal Phase Progesterone <ul><li>Pulsatile release, thus single level may not be useful unless elevated </li></ul><ul><li>Performed 7 days after presumptive ovulation </li></ul><ul><li>Done properly, >15 ng/ml consistent with ovulation </li></ul>
  24. 24. Urinary LH Kits <ul><li>Very sensitive and accurate </li></ul><ul><li>Positive test precedes ovulation by ~24 hours, so useful for timing intercourse </li></ul><ul><li>Downside: price, obsession with timing of intercourse </li></ul>
  25. 25. Endometrial Biopsy <ul><li>Invasive, but the only reliable way to diagnose LPD </li></ul><ul><li>??Is LPD a genuine disorder??? </li></ul><ul><li>Pregnancy loss rate <1% </li></ul><ul><li>Perform around 2 days before expected menstruation (= day 28 by definition) </li></ul><ul><li>Lag of >2 days is consistent with LPD </li></ul><ul><li>Must be done in two different cycles to confirm diagnosis of LPD </li></ul>
  26. 26. Fallopian Tubes
  27. 27. Tubal Function <ul><li>Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition </li></ul><ul><li>Kartagener’s syndrome can be associated with decreased tubal motility </li></ul><ul><li>Tests </li></ul><ul><ul><li>HSG </li></ul></ul><ul><ul><li>Laparoscopy </li></ul></ul><ul><ul><li>Falloposcopy (not widely available) </li></ul></ul>
  28. 28. Hysterosalpingography (HSG) <ul><li>Radiologic procedure requiring contrast </li></ul><ul><li>Performed optimally in early proliferative phase (avoids pregnancy) </li></ul><ul><li>Low risk of PID except if previous history of PID (give prophylactic doxycycline or consider laparoscopy) </li></ul><ul><li>Oil-based contrast </li></ul><ul><ul><li>Higher risk of anaphylaxis than H 2 O-based </li></ul></ul><ul><ul><li>May be associated with fertility rates </li></ul></ul>
  29. 29. Hysterosalpingography (HSG) <ul><li>Can be uncomfortable </li></ul><ul><li>Pregnancy test is advisable </li></ul><ul><li>Can detect intrauterine and tubal disorders but not always definitive </li></ul>
  30. 30. Laparoscopy <ul><li>Invasive; requires OR or office setting </li></ul><ul><li>Can offer diagnosis and treatment in one sitting </li></ul><ul><li>Not necessary in all patients </li></ul><ul><li>Uses (examples): </li></ul><ul><ul><li>Lysis of adhesions </li></ul></ul><ul><ul><li>Diagnosis and excision of endometriosis </li></ul></ul><ul><ul><li>Myomectomy </li></ul></ul><ul><ul><li>Tubal reconstructive surgery </li></ul></ul>
  31. 31. Falloposcopy <ul><li>Hysteroscopic procedure with cannulation of the Fallopian tubes </li></ul><ul><li>Can be useful for diagnosis of intraluminal pathology </li></ul><ul><li>Promising technique but not yet widespread </li></ul>
  32. 32. Uterine Corpus
  33. 33. Corpus <ul><li>Asherman Syndrome </li></ul><ul><ul><li>Diagnosis by HSG or hysteroscopy </li></ul></ul><ul><ul><li>Usually s/p D+C, myomectomy, other intrauterine surgery </li></ul></ul><ul><ul><li>Associated with hypo/amenorrhea, recurrent miscarriage </li></ul></ul><ul><li>Fibroids, Uterine Anomalies </li></ul><ul><ul><li>Rarely associated with infertility </li></ul></ul><ul><ul><li>Work-up: </li></ul></ul><ul><ul><ul><li>Ultrasound </li></ul></ul></ul><ul><ul><ul><li>Hysteroscopy </li></ul></ul></ul><ul><ul><ul><li>Laparoscopy </li></ul></ul></ul>
  34. 34. Cervix
  35. 35. Cervical Function <ul><li>Infection </li></ul><ul><ul><li>Ureaplasma suspected </li></ul></ul><ul><li>Stenosis </li></ul><ul><ul><li>S/P LEEP, Cryosurgery, Cone biopsy (probably overstated) </li></ul></ul><ul><li>Immunologic Factors </li></ul><ul><ul><li>Sperm-mucus interaction </li></ul></ul>
  36. 36. Cervical Function <ul><li>Tests: </li></ul><ul><ul><li>Culture for suspected pathogens </li></ul></ul><ul><ul><li>Postcoital test (PK tests) </li></ul></ul><ul><ul><ul><li>Scheduled around 1-2d before ovulation (increased estrogen effect) </li></ul></ul></ul><ul><ul><ul><li>48 0 of male abstinence before test </li></ul></ul></ul><ul><ul><ul><li>No lubricants </li></ul></ul></ul><ul><ul><ul><li>Evaluate 8-12h after coitus (overnight is ok!) </li></ul></ul></ul><ul><ul><ul><li>Remove mucus from cervix (forceps, syringe) </li></ul></ul></ul>
  37. 37. Cervical Function <ul><li>PK, continued (normal values in yellow) </li></ul><ul><ul><li>Quantity (very subjective) </li></ul></ul><ul><ul><li>Quality (spinnbarkeit) (>8 cm) </li></ul></ul><ul><ul><li>Clarity (clear) </li></ul></ul><ul><ul><li>Ferning (branched) </li></ul></ul><ul><ul><li>Viscosity (thin) </li></ul></ul><ul><ul><li>WBC’s (~0) </li></ul></ul><ul><ul><li># progressively motile sperm/hpf (5-10/hpf) </li></ul></ul><ul><ul><li>Gross sperm morphology (WNL) </li></ul></ul>Male factors
  38. 38. Problems with the PK test <ul><li>Subjective </li></ul><ul><li>Timing varies; may need to be repeated </li></ul><ul><li>In some studies, “infertile” couples with an abnormal PK conceived successfully during that same cycle </li></ul>
  39. 39. Peritoneum
  40. 40. Peritoneal Factors <ul><li>Endometriosis </li></ul><ul><ul><li>2x relative risk of infertility </li></ul></ul><ul><ul><li>Diagnosis (and best treatment) by laparoscopy </li></ul></ul><ul><ul><li>Can be familial; can occur in adolescents </li></ul></ul><ul><ul><li>Etiology unknown but likely multiple ones </li></ul></ul><ul><ul><ul><li>Retrograde menstruation </li></ul></ul></ul><ul><ul><ul><li>Immunologic factors </li></ul></ul></ul><ul><ul><ul><li>Genetics </li></ul></ul></ul><ul><ul><ul><li>Bad karma </li></ul></ul></ul><ul><ul><li>Medical options remain suboptimal </li></ul></ul>
  41. 41. Male Factors
  42. 42. Male Factors <ul><li>Serum T, FSH, PRL levels </li></ul><ul><li>Semen analysis </li></ul><ul><li>Testicular biopsy </li></ul><ul><li>Sperm penetration assay (SPA) </li></ul>
  43. 43. Male Factors-Semen Analysis <ul><li>Collected after 48 0 of abstinence </li></ul><ul><li>Evaluated within one hour of ejaculation </li></ul><ul><li>If abnormal parameters, repeat twice, 2 weeks apart </li></ul>
  44. 44. Normal Semen Analysis
  45. 45. Sperm Penetration Assay <ul><li>aka “zona-free hamster ova assay” </li></ul><ul><li>Dynamic test of fertilization capacity of sperm </li></ul><ul><li>Failure to penetrate at least 10% of zona-free ova consistent with male factor </li></ul><ul><li>False positives and negatives exist </li></ul>
  46. 46. Treatment Options
  47. 47. Ovarian Disorders <ul><li>Anovulation </li></ul><ul><ul><li>Clomiphene Citrate ± hCG </li></ul></ul><ul><ul><li>hMG </li></ul></ul><ul><ul><li>Induction + IUI (often done but unjustified) </li></ul></ul><ul><li>PRL </li></ul><ul><ul><li>Bromocriptine </li></ul></ul><ul><ul><li>TSS if macroadenoma </li></ul></ul><ul><li>POF </li></ul><ul><ul><li>?high-dose hMG (not very effective) </li></ul></ul>
  48. 48. Ovarian Disorders <ul><li>Central amenorrhea </li></ul><ul><ul><li>CC first, then hMG </li></ul></ul><ul><ul><li>Pulsatile GnRH </li></ul></ul><ul><li>LPD </li></ul><ul><ul><li>Progesterone suppositories during luteal phase </li></ul></ul><ul><ul><li>CC ± hCG </li></ul></ul>
  49. 49. Ovarian Matrix
  50. 50. Ovulation Induction <ul><li>CC </li></ul><ul><ul><li>70% induction rate, ~40% pregnancy rate </li></ul></ul><ul><ul><li>Patients should typically be normoestrogenic </li></ul></ul><ul><ul><li>Induce menses and start on day 5 </li></ul></ul><ul><ul><li>With dosages, antiestrogen effects dominate </li></ul></ul><ul><ul><li>Multifetal rates 5-10% </li></ul></ul><ul><ul><li>Monitor effects with PK, pelvic exam </li></ul></ul>
  51. 51. hMG (Pergonal) <ul><li>LH +FSH (also FSH alone = Metrodin) </li></ul><ul><li>For patients with hypogonadotrophic hypoestrogenism or normal FSH and E 2 levels </li></ul><ul><li>Close monitoring essential, including estradiol levels </li></ul><ul><li>60-80% pregnancy rates overall, lower for PCOS patients </li></ul><ul><li>10-15% multifetal pregnancy rate </li></ul>
  52. 52. Risks <ul><li>CC </li></ul><ul><li>Vasomotor symptoms </li></ul><ul><li>H/A </li></ul><ul><li>Ovarian enlargement </li></ul><ul><li>Multiple gestation </li></ul><ul><li>NO risk of SAb or malformations </li></ul><ul><li>hMG </li></ul><ul><li>Multiple gestation </li></ul><ul><li>OHSS (~1%) </li></ul><ul><ul><li>Can often be managed as outpatient </li></ul></ul><ul><ul><li>Diuresis </li></ul></ul><ul><ul><li>Severe cases fatal if untreated in ICU setting </li></ul></ul>
  53. 53. Fallopian Tubes <ul><li>Tuboplasty </li></ul><ul><li>IVF </li></ul><ul><li>GIFT, ZIFT not options </li></ul>
  54. 54. Corpus <ul><li>Asherman syndrome </li></ul><ul><ul><li>Hysteroscopic lysis of adhesions (scissor) </li></ul></ul><ul><ul><li>Postop Abx, E 2 </li></ul></ul><ul><li>Fibroids (rarely need treatment) </li></ul><ul><ul><li>Myomectomy(hysteroscopic, laparoscopic, open) </li></ul></ul><ul><ul><li>??UAE </li></ul></ul><ul><li>Uterine anomalies (rarely need treatment) </li></ul><ul><ul><li>metroplasty </li></ul></ul>
  55. 55. Cervix <ul><li>Repeat PK test to rule out inaccurate timing of test </li></ul><ul><li>If cervicitis Abx </li></ul><ul><li>If scant mucus low-dose estrogen </li></ul><ul><li>Sperm motility issues (? Antisperm AB’s) </li></ul><ul><ul><li>Steroids? </li></ul></ul><ul><ul><li>IUI </li></ul></ul>
  56. 56. Peritoneum (Endometriosis) <ul><li>From a fertility standpoint, excision beats medical management </li></ul><ul><li>Lysis of adhesions </li></ul><ul><li>GnRH-a (not a cure and has side effects, expense) </li></ul><ul><li>Danazol (side effects, cost) </li></ul><ul><li>Continuous OCP’s (poor fertility rates) </li></ul><ul><li>Chances of pregnancy highest within 6 mos-1 year after treatment </li></ul>
  57. 57. Male Factor <ul><li>Hypogonadotrophism </li></ul><ul><ul><li>hMG </li></ul></ul><ul><ul><li>GnRH </li></ul></ul><ul><ul><li>CC, hCG results poor </li></ul></ul><ul><li>Varicocoele </li></ul><ul><ul><li>Ligation? (no definitive data yet) </li></ul></ul><ul><li>Retrograde ejaculation </li></ul><ul><ul><li>Ephedrine, imipramine </li></ul></ul><ul><ul><li>AIH with recovered sperm </li></ul></ul>
  58. 58. Male Factor <ul><li>Idiopathic oligospermia </li></ul><ul><ul><li>No effective treatment </li></ul></ul><ul><ul><li>?IVF </li></ul></ul><ul><ul><li>donor insemination </li></ul></ul>
  59. 59. Unexplained Infertility <ul><li>5-10% of couples </li></ul><ul><li>Consider PRL, laparoscopy, other hormonal tests, cultures, ASA testing, SPA if not done </li></ul><ul><li>Review previous tests for validity </li></ul><ul><li>Empiric treatment: </li></ul><ul><ul><li>Ovulation induction </li></ul></ul><ul><ul><li>Abx </li></ul></ul><ul><ul><li>IUI </li></ul></ul><ul><ul><li>Consider IVF and its variants </li></ul></ul><ul><li>Adoption </li></ul>
  60. 60. Summary <ul><li>Infertility is a common problem </li></ul><ul><li>Infertility is a disease of couples </li></ul><ul><li>Evaluation must be thorough, but individualized </li></ul><ul><li>Treatment is available, including IVF, but can be expensive, invasive, and of limited efficacy in some cases </li></ul><ul><li>Consultation with a BC/BE reproductive endocrinologist is advisable </li></ul>
  61. 61. Thank you!

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