The advancement of new perspectives in assisted reproductive technology (ART) through the use of modern infertility evaluation technique  Stillclinician needs to reassess how infertility should be best treated. Recently the focus of treatment for infertility has shifted from systematic correction of each identified factor.

1. The Role of laparoscopy
in the era of ART
Prof. Rokeya Begum
Laparoscopic & Hysteroscopic Surgeon
DIRECTOR
Surgiscope Fertility Centre

2. The advancement of new perspectives in assisted
reproductive technology (ART) through the use of
modern infertility evaluation technique
Still
clinician needs to reassess how infertility should be
best treated.

3. • Recently the focus of treatment for
infertility has shifted from systematic
correction of each identified factor
• to applying the most efficient therapy like
ART

4. There is debate between
1. Reproductive surgery by endoscope
2. ART

5. Endoscopic ART
Advantages - Restores normal -Time saving
anatomy -excellent result
- Enhances natural
pregnancy
- repeated
pregnancy
- long term result
excellent
Disadvantages - surgical expertise -Expensive
-Procedure related -OHSS
complications. -Per trial result
-Operation risk
- Unpredicted
outcome

6. Debate is complex in
regards to
1.Age of the patient.
2.Ovarian reserve.
3.Previous management whether surgery
or ART

7. Can ART Replace Endoscopy?
Endoscopy and ART are complementary, not
supplementary.
1st IVF Child- Ovum retrieval by Laparoscopy.
Still Laparoscopic egg retrieval is required
whenever ovaries are inaccessible.

8. What is the best approach?
Individualization
1.Case selection.
2.Time.
3.Pathology/Disease.

9. Endometriosis
Benefit of laparoscopic surgery prior to IVF
a) Spontaneous pregnancy in mild to moderate disease
b) Elimination of pelvic pain by destruction of the peritoneal
endometriotic lesions which may be mistaken as OHSS if
patient subjected to IUI.

10. c)Confirm the diagnosis histologically.
d)Reduce the risk of infection.
e)Improves access to follicle.
f)Improves ovarian responses.

11. Risk
1. Decrease ovarian reserve and loss of the
ovarian tissue
2. Premature ovarian failure 2% if bilateral.
3. Decreases oocyte number and quality for
IVF

12. RECOMMENDATION
.
Removal of endometrioma more than 4cm
prior to IVF
Rationale.
1. Improve access of follicle.
2. Reduce risk of inadvertent puncture of cyst.
3. Reduce risk of infection.

13. Uterine Fibroid AND ART
When to remove fibroid before ART
1. All intracavitary or submucos fibroid.
2. Intramural more than 5 cm.
3. Infertility unresponsive to therapy

14. How to remove
Surgical approach depends
1. location
2. Size
3.Equipment
4.Training

15. Endoscopic approach has
definite role
• Hysteroscopic myomectomy – intracavitary and
submucous myoma without damaging the
myometrium.
• Laparoscopic myomectomy does not seems to be
superior to conventional open myomectomy
regarding fertility.

16. Tubal Sterilization and
ART
Tubal anostomosis for reversal of
sterilization has significantly higher
cumulative pregnancy rate than IVF and
is more cost effective even above 40 yrs.

17. The decision between
ART and tubal reversal
is highly complex
And affected by the following factors
* Age of the women
* Ovarian reserve
* Number and quality of sperm/ejaculate
* Site and extent of tubal diseases.
* Presence of other infertility factors.
* The experience of the surgery.
* Patient preference.

18. Distal tubal block
Hydrosalpinges
Blocked tube at the outer end secrets
fluid faster than it is absorbed.
Becomes enlarge sac of secretion.

19. Inflammatory/Toxic fluid leaks
back into uterus
1.Direct mechanical flushing effect on embryo.
2.Direct embryotoxic effect.
3.Effect on endometrial receptivity.

20. Surgery for distal tubal disease and prognosis
1.Limited filmsy adnexal adhesions
2.mildly dilated tubes <3cm with thin pliable
wall.
3.Lush endosalpinx with preservation of the
mucosal folds.

21. Fimbrioplasty and neosalpingostomy women less
than 35 years
Pregnancy rates depend on
- Degree of tubal diseases
- More favorable with good prognosis patient.
Hydrosalpinx Mild Severe
IUP 58-77% 0-22%

22. Indications for proximal
tubal block or
salpingectomy
1. Extensive, dense peritubal adhesion.
2. Massive dilated tubes
3. Thick fibrotic walls and /or
4. Sparse or absent luminal mucosa.

23. Surgical treatment should be considered for all
women with hydrosalpinx prior to IVF
Surgical treatment are
1. Salpingectomy
2.Tubal occlusion by diathermy
3. USG guided aspiration.
4. Laparoscopic neosalpingostomy
5.Hysteroscopic approach for cornual block

24. Even patient with unilateral hydrosalpinx have
been shown to have lower pregnancy rate with
IVF.
Unilateral salpingectomy resulted in a significant
improvement in IVF pregnancy rate.
Effect of unilateral
hydrosalpinx on IVF
pregnancy rate

25. Salpingectomy for bilateral hydrosalpinx
have higher
IVF pregnancy rates than for unilateral
hydrosalpinx.

26. Technical aspects of
salpingectomy
1. Coagulation and divide tube close to cornu of uterus.
2. Serial coagulation and cut mesosalpinx.
3. Stay close to the tube to avoid –
* Thermal injury to the ovary
* Vascular injury to ovarian blood supply
* Ovarian insufficiency.

27.  Tubal dysfunction
 Encapasulated fimbriae prevent oocyte
capture.
 Interrupt blood supply to ovaries
- impaired goadotrophin access
target organ.
- affect follicular development
 Impaired access to ovary during pickup.
Peritubal Adhesion

28. Adhesiolysis improve pregnancy rate
Improved pregnancy rates following
adhesiolysis.
12 months 24 months
Not treated 11% 16%
Treated 32% 45%

29. Proximal tubal occlusion
Usually diagnosed by HSG and confirm by
laparoscopic chromopertubation .
Laparoscopic guided Hysteroscopic tubal
cannulation is successful in selective cases.

30. Contraindication of tubal
cannulations by hysteroscopy
1. Genital TB
2. Obliterative fibrosis and long tubal obliteration that are difficult to
bypass with the catheter.
3. Severe tubal damage.
4. Previously performed tubal surgery.
5. Salplingitis isthmica nodosa.
6. combined distal and proximal tubal occlusion.

31. Eftekhar et al conduct retrospective study –
LOD before IVF/ICSI with PCOD reduce risk
of OHSS. Despite the same pregnancy rate
in both groups but more oocytes and
embryo were seen in women without
ovarian drilling group than with LOD.
Ovarian drilling prior to ART
in PCOD

32. Int J Fertil steril 2016 Aprojun : 10(I) : 42-47
This surgical procedure may be considered as
useful technique in the management of patient
who have previously develop OHSS.
There are ongoing concerns about long term
effect of LOD on ovarian function.

33. Laparoscopy after failed ART
treatment
With the advancement of ART
Clinicians are preferentially selecting a new
controlled ovarian stimulation/IVF-ICSI cycle after
failed ART.

34. • 50% patient – show undetected endometriosis or
adhesion if laparoscopy is performed after failed IVF.
No RCTS have confirmed this rates.

35. Hysteroscopy after repeated IVF
failures
Hysteroscopy increase pregnancy rates even in
the absence of intra uterine pathology in women
with recurrent failure.

38. Asherman’s syndrome and
ART
Hysteroscopic adhesiolysis has promising
reproductive outcome for infertile women.

41. Conclusion
Optimal and prudent use of this minimally invasive
procedure may avoid
Costly treatment like IVF
Increase the success of IVF outcome

42. The future…
On-going randomised trials
will shed more light on the role
of routine out-patient
hysteroscopy before IVF

43. Prof. Syeda Nurjahan Bhuiyan

44. Thank You