Which is better ? Tubal surgery or Assisted Reproductive Technologies (ART) when dealing with cases of infertility. Discussion of IUI, IVF and more treatments options in relation to this topic.

2. DIRECT ART vs. SURGERY
Endometriosis
6 – 10 % of reproductive age women
Ovarian endometriomas -
17 – 44 % of women with
endometriosis
Tubal disease
Accounts for 25 – 35 % of female infertility
> than ½ due to salpingitis
Upto 20 – 30 % of women regret tubal
ligation

3. DIRECT ART vs. SURGERY
CLINICAL DILEMMAS
Uncertainty regarding the decision
- to operate or
- to plan ART directly
(balancing the potential detrimental effect of
surgery on ovarian reserve against the
potential benefit that may be gained)

4. ANU TEST TUBE BABY CENTER
Dr. Anuradha Katragadda

5. CURRENT ISSUES
Guiding factors for chosing management
options
Surgical treatment
Effect of endometriosis on IVF outcome
Surgical treatment prior to IVF

6. Management Options
Factors to be considered –
Woman‟s symptoms
Fertility prognostic factors
- Age
- Ovarian reserve
Previous surgical and treatment
history
Nature of the cyst
Wishes of the woman

7. Endometrioma –
surgical treatment
Controversial
It may not reverse the inflammatory and
biomolecular changes
Concerns regarding safety of surgical
treatment
- Reduction in ovarian reserve and
- Added risk of requiring on
oophorectomy

8. Endometrioma – Surgery
Individualise management based on:
- Clinical factors
- Pain symptoms
- Size of cysts and
- Concerns over potential malignancy

9. Ovarian Endometrioma –
Surgery
ESHRE Guidelines :
Ov. Endometrioma > 3 cm. size
√ - Cystectomy
- Excision of endometrioma capsule
X - Drainage and coagulation
AMH test - to reflect ovarian reserve before
surgery

10. SURGICAL TREATMENT –
PRIOR TO IVF
Benefit uncertain
Available evidence re. concerns for surgery;
- No reduced ov. Responsiveness with COH
- No risk of growth or rupture of endometriomas
with COH
- Needs antibiotic prophylaxis to reduce risk of ov.
Abscess
- ART treatments do not seem to increase
recurrence rate of endometriotic lesions or
symptoms

11. ENDOMETRIOMA - POF
ESHRE Guide-lines:
Clinicians should counsel regarding
- Risks of reduced ovarian function after
surgery &
- Possible loss of ovary
„The decision to proceed with surgery
should be considered carefully
if woman has had previous
ovarian surgery‟

12. ENDOMETRIOMA - POF
2.4 % of POF following Laparoscopic Surgery
Possibility of late onset POF –
from 5-24 months of treatment
Cause of POF
 Direct tissue damage due to surgery & coagulation
 Previous presence of cyst
 Associated Immunological genetic & endocrine factors
Surgery for Bilateral ovarian endometrioma
 Real risk of 2 – 6 % of POF
 counselling important

13. RECURRENT ENDOMETRIOSIS –
SURGERY vs. ART
Medical treatment – contraceptive effect
Surgery –
Major benefit is achieved shortly after the Ist attempt
Severe periovarian adhesions generally recur & limit
tubal-pick up
If initial surgery does not result in pregnancy,
subsequent surgical procedures are not likely to be
effective for increasing fecundability
Halving of preg. Rates after re-op. surgery compared with
first-line surgery (22 % vs 40 %)

14. DECISION FOR RE-OPERATIVE
SURGERY vs. IVF
Must be made on
Symptoms
Presence of complex cysts
(requiring histological diagnosis)
Age
Ovarian reserve
Male factor infertility &
Availability of skilled surgeons

15. RECURRENT ENDOMETRIOSIS –
INFERTILITY
TREATMENT WITH IVF –
AN EFFECTIVE ALTERNATIVE
TO REPEAT SURGERY FOR
MODERATE TO SEVERE
ENDOMETRIOSIS

16. Endometriomas with extraovarian,
intestinal disease and DIE
Reproductive outcomes have „not been
shown to be impracted‟ by the
excision –
except providing symptomatic
relief

17. FERTILITY PRESERVATION IN
WOMEN WITH ENDOMETRIOSIS
At serious risk of future fertility
Young women with endometriosis not
planning to conceive
Prior to laparoscopic surgery

18. ESHRE Guidelines :
“Appropriate Counseling” –
- Risk of reduced ov. Function
- Possible risk of oophorectomy
Surgery considered 1st line;
- Highly symptomatic women
- With an intact ov.reserve
- Unilateral and large cysts
- Cysts with syspicious radiological and clinical features
Direct IVF;
- Asymptomatic women
- Advanced age
- ov. Reserve
- Bilateral endometriomas
- H/o prior ov. surgery

19. Dr. Anuradha Katragadda
ANU TEST TUBE BABY CENTER

20. LAPAROSCOPIC OVARIAN
ELECTRO CAUTERY

21. PREDICTORS – FOR LEOS
RESPONSE
Favourable Responders
 Slim Women
 High LH levels > 10 IU / L
Poor Responders
 BMI > 35 Kg /m2
 Serum Testosterone conc. > 4.5 n
 Free Androgen Index > 15
 Duration of infertility > 3 Yrs.

23. PCOS – SURGERY / IVF
IVF in PCOS –
• Last option
• IVF in PCOS with concomitant diseases
• Ist choice
- Severe endometriosis tubal
obstruction
- Male factor
• IVF in Hyperresponders to Gonadotrophins
- to reduce multiple pregnancy risk

27. Uterine septum: a guideline
RECOMMENDATIONS
• There is no uniform definition of septum configurations
• Most women with a septate uterus have efficient reproductive function
• The data regarding reproductive implications of septate uteri and
treatment effects are limited and comprised primarily of observational,
principally descriptive studies without untreated control groups
• There is insufficient evidence to conclude that uterine septum is
associated with infertility (grade C)
• Several „observational studies‟ indicate that hysteroscopic septum
incision is associated with improved clinical pregnancy rates in women
with infertility (grade C)
• Some limited studies indicate that hysteroscopic septum incision is
associated with an improvement in live birth rate in women with infertility
or prior pregnancy loss (grade C)
• In a patient with infertiltiy or prior pregnancy loss, may be reasonable to
consider septum incision following counselling reg. potential risks and
benefits of the procedure

28. Dr. Anuradha Katragadda
ANU TEST TUBE BABY CENTER

29. HOW SEVERE IS THE
TUBAL PROBLEM
Tubal Disease
• Accounts for 25 -35 % of female factor
infertility
• More than ½ of the cases due to salpingitis
Upto 20 – 30 % of women regret having tubal
ligation

31. Proximal
Mid Segment
Distal
Occlusion
• Obliterative fibrosis
• SIN
• Tubal Polyps
• Cornnual fibroids
• Segmental salpingectomy
• Sterilization
• ectopic
• Congenital segmental absence
i. Non occlusive, preserved fimbriae –
Fimbrial agluttination
ii. Occlusive, absent fimbriae:
• Hydrosalpinx
• Post-distal salpingectomy
• Sterilization
• Ectopic preg.
TUBAL DAMAGE
Proximal
Mid Segment

32. Proximal tubal
occlusion
accounts for 10 – 25 % of tubal
disease
i. Obstruction resulting from
• Plugs of mucus & amorphous
debris
• Spasm of uterotubal junction
ii. True anatomic blockage – from
fibrosis due to
- SIN
- PID or
- endometriosis

33. Proximal tubal
occlusion
to distinguish true from
false occlusion
This will guarantee a
prompt entrance into IVF
for patients with true
occlusion
Fluroscopic or
Hysteroscopic
selective salpingography
and tubal catheterization

34. Cannulation
of proximal
tubal
occlusion
i. Obstruction relieved in 85 %
of tubes and approximately
½ of patients conceive
ii. Approx. 1/3rd of opened
tubes subsequently
reocclude
iii. Incidence of tubal
perforation during
cannulation reported to be
- 3 – 11 % without any clinical
consequence

36. Proximal tubal
occlusion
IVF preferred to
resection and
microsurgical
anastomosis
• In older women and
• Presence of significant
male factor
(True blockage –
obliterative fibrosis

37. Proximal tubal
occlusion
less invasive,
Single IVF
attempt can
equal post-
surgical
pregnancy rates
Tubocornual
anastomosis
„not justified‟

39. Midsegment
tubal
occlusion
Well-executed
microsurgical tubal
reanastomosis –
can equal the
cumulative PR of
3 - IVF attempts

40. Distal tubal
occlusion and
hydrosalpinx
Functional repair of
hydrosalpinx by Laparoscopic
neosalpingostomy is not
recommended
- dismal of PR
- high risk of ectopic
pregnancy
- 70 % risk of
recurrence of
hydrosalpinx

41. For complete
distal tubal
occlusion or
hydrosalpinx -
• salpingectomy &
proximal tubal occlusion
is a „requirement prior
to IVF‟.

42. DISADVANTAGES OF TUBAL
SURGERY
• Generalizable to surgeon with less skill and
experience
• Risks for surgical complications
• Post-op. discomfort during short recovery phase
• Success following tubal surgery may be
significantly lower than for IVF
• The „risk of ectopic pregnancy‟ is increased in
patients having IVF for tubal disease, it is higher
after tubal surgery
All these factors need to be considered when
choosing appropriate treatment strategy

43. TUBAL SURGERY IN ERA OF
ART
Main indications for tubal surgery –
Selective cannulation of proximal occlusion
Reversal of „sterilization in women younger than
35 yrs.

44. ERA OF ART
Impressive PR of 44 % / initiated cycle
- in women < 35 yrs
- decreases with age
but remains higher than
natural fecundity rate of 20 % upto age 40 yrs
With the availability of frozen embryos for later
transfer,
combined PR from a single retrieval cycle
exceeds the cumulative PR
of any surgical repair of fallopian tubes

45. ERA OF ART
„Impatience to conceive‟
Waiting for atleast 1 yr. to realize the post surgical
pregnancy potential
Wastes precious time
Eventual entry into ART delayed and
Chances of conception further reduced particularly
after 35 yrs.

46. ERA OF ART
Careful selection and individualization
Multifactorial infertility,
inoperable tubal damage,
severe endometriosis,
endometriomas < 3 cm.
Recurrent endometriosis
„ART would be the only option‟
Surgery to be regarded as
„complementary not competetive‟
to achieve the desired goal

47. DIRECT ART VS. SURGERY

48. RECURRENT ENDOMETRIOMA :

49. EXPERT OPINION
? Surgery
? GnRH-a /GnRH – IVF
? Combined