panel session 4: role of the mig surgeon in infertility · treatment by laparoscopy of pelvic...
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Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Panel Session 4: Role of the MIG Surgeon in Infertility
PROGRAM CHAIR
G. David Adamson, MD
Leila V. Adamyan, MD Tommaso Falcone, MD Antonio R. Gargiulo, MD
Professional Education Information Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Management of Endometriomas, Endometriosis and Infiltrating Disease T. Falcone ..................................................................................................................................................... 4 Laparoscopic Treatment of Pelvic Adhesions and Distal Tubal Injury/Occlusion and Hysteroscopic Treatment of Proximal Tubal Occlusion A.R. Gargiulo ................................................................................................................................................ 6 Laparoscopic and/or Hysteroscopic Management of Myomas, Adenomyosis, Septum, Intrauterine Adhesions and Polyps L.V. Adamyan ............................................................................................................................................... 8 Cultural and Linguistics Competency ......................................................................................................... 10
Panel Session 4: Role of the MIG Surgeon in Infertility
G. David Adamson, Chair Faculty: Leila V. Adamyan, Tommaso Falcone, Antonio R. Gargiulo
This session provides a comprehensive overview of the MIG surgeon’s role in Infertility. While infertility
applications led early innovation of operative endoscopy, subsequent expansion to other surgical
specialties and increasing utilization of ART resulted in a perceived decrease in the need for MIG
infertility surgery. However, this is not true. Four expert, experienced international MIG surgeons will
describe principles and principal applications of MIG surgery in today’s changed infertility world.
Discussion will include management of endometriomas, endometriosis, and infiltrating disease;
treatment by laparoscopy of pelvic adhesions; distal tubal injury/occlusion, and proximal tubal occlusion
by hysteroscopy. Laparoscopic and/or hysteroscopic management of myomas, adenomyosis, septum,
intrauterine adhesions and polyps will be debated. The panel will focus on situations that gynecological
surgeons encounter frequently in daily practice, with emphasis on practical application and optimal
patient care.
Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Make evidence-
based decisions regarding patient selection and MIG surgical procedures on infertility patients.
Course Outline
3:25 Welcome, Introductions and Course Overview G.D. Adamson
3:30 Management of Endometriomas, Endometriosis and Infiltrating Disease T. Falcone
3:40 Laparoscopic Treatment of Pelvic Adhesions and Distal Tubal Injury/Occlusion
and Hysteroscopic Treatment of Proximal Tubal Occlusion A.R. Gargiulo
3:50 Laparoscopic and/or Hysteroscopic Management of Myomas,
Adenomyosis, Septum, Intrauterine Adhesions and Polyps L.V. Adamyan
4:00 Summary of Presentations and Questions for Panel G.D. Adamson
4:10 Panel Discussion All Faculty
5:05 Adjourn
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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). G. David Adamson Consultant: AbbVie, Bayer Healthcare Corp. Stock Ownership: Ziva Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). G. David Adamson Consultant: AbbVie, Bayer Healthcare Corp. Stock Ownership: Ziva Leila V. Adamyan* Tommaso Falcone*
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Antonio R. Gargiulo Consultant: OmniGuide, Medicaroid Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.
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Management of the Infertile Patient with Advanced
Endometriosis
Management of the Infertile Patient with Advanced
Endometriosis
Tommaso Falcone,M.D.
Professor & Chair
Obstetrics &Gynecology
Cleveland Clinic
Financial DisclosureFinancial Disclosure
• I have no financial relationships to disclose
Learning objectives Learning objectives At the conclusion of this presentation,
participants should be able to:
- Discuss the impact of surgery on fertility outcome
- Assess the pain outcome of medical or surgical treatment of endometriosis.
- Discuss the recurrence risk after medical or surgical management of women with chronic pelvic pain & endometriosis
Spontaneous Pregnancy after Endometrioma Removal
Spontaneous Pregnancy after Endometrioma Removal
• Cochrane database 2008 Hart R et al.- 2 RCTs:
- Excision of cyst associated with a reduced rate of recurrence; reduced symptom recurrence and increased spontaneous pregnancy rates ( OR 5.1) compared with ablative surgery.
RCT = randomized controlled trial
Impact of Excision on Ovarian Reserve: Cleveland Clinic AJOG 2016
Impact of Excision on Ovarian Reserve: Cleveland Clinic AJOG 2016
• The pool of oocytes available=ovarian reserve
• At baseline, patients with endometriomas had significantly lower anti-Müllerian hormone values compared with women without endometriosis.
• Surgical excision of endometriomas appears to have temporary detrimental effects on ovarian reserve.
Systematic Reviews, Meta-analysis & Cochrane review: Intervention for
Women with endometrioma prior to ART
Systematic Reviews, Meta-analysis & Cochrane review: Intervention for
Women with endometrioma prior to ART• Meta-analysis: Tsoumpou et al. Fertil Steril 2009
- 5 studies: No treatment versus surgery before IVF
• No difference in clinical pregnancy rate
• No significant difference in outcome (PR/oocytes retrieved/
embryos/gonadotropins/estradiol)• Cochrane database Syst Rev 2010: Benschop et al
- 4 trials-
- Ovarian cystectomy or aspiration does not yield improved clinical PR
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How do you decide: Chance of spontaneous pregnancy vs. need for IVF
How do you decide: Chance of spontaneous pregnancy vs. need for IVF Deeply Infiltrating Endometriosis: (DIE)Deeply Infiltrating Endometriosis: (DIE)
• Bianchi et al JMIG 2009
- Improved outcomes with IVF after removal of DIE
- N=105- IVF no resection of DIE- PR- 24%
- N=64- extensive resection then IVF-41%
• Mathieu d’Argent et al F&S 2010- IVF outcome the same with untreated colorectal
endometriosis as controls (N=29 vs. N=157 tubal factor vs. N= 340 male factor)
• The effectiveness of surgical excision of deep nodular lesions before treatment with assisted reproductive technologies in women with endometriosis-associated infertility is not well established with regard to reproductive outcome
ReferencesReferences
• Goodman LR, Goldberg JM, Flyckt RL, Gupta M, Harwalker J, Falcone T. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls.Am J Obstet Gynecol. 2016 May 27. pii: S0002-9378(16)30243-5
• Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004992. doi: 10.1002/14651858.CD004992.pub3. Review.
• Bianchi PH, Pereira RM, Zanatta A, Alegretti JR, Motta EL, Serafini PC. Extensive excision of deep infiltrative endometriosis before in vitro fertilization significantly improves pregnancy rates.J Minim Invasive Gynecol. 2009 Mar-Apr;16(2):174-80. doi:
• Mathieu d'Argent E, Coutant C, Ballester M, Dessolle L, Bazot M, Antoine JM, DaraïE.Results of first in vitro fertilization cycle in women with colorectal endometriosis compared with those with tubal or male factor infertility Fertil Steril. 2010 Nov;94(6):2441-3. doi: 10.1016/j
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BRIGHAM ANDWOMEN’S HOSPITAL
Consultant: OmniGuide, Inc., Medacaroid
Gargiulo 2016
Gargiulo 2016
COUNSEL INFERTILE PATIENTS ON:
• ROLE OF LAPAROSCOPY IN ADHESIOLYSIS
• ROLE OF LAPAROSCOPY IN DTO
• ROLE OF HYSTEROSCOPY IN PTO
• ROLE OF ART IN TUBAL INFERTILITY
Gargiulo 2016
• Adhesions interfere with gamete and embryo transport
• A small retrospective study shows positive effect of adhesiolysis in infertility
• Effect is dependent on ASRM Adhesion Score
Gargiulo 2016
• Adhesions interfere with gamete and embryo transport
• Surgery can restore anatomic integrity, not functional integrity (case selection!)
• Salpingo‐ovariolysis: PR 50‐60%
• Fimbrioplasty: PR 40‐50%
• Neosalpingostomy: PR 20‐30%
• Neosalpingostomy before IVF: consider in mild hydrosalpinges, no male factor, young
Gargiulo 2016
• Debris, adhesions, polyps may occlude tube
• Hysteroscopic cath has diagnostic and therapeutic value
• Hysteroscopic cath more effective than fluoroscopic (PR: 49% vs 21%)
• Hysteroscopic cath is safer than cornualmicrosurgery (Ectopic: 0% vs 29%)
• Contraindications: infections, inflammation, male factor, prior tubal surgery
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Gargiulo 2016
• Current USA cumulative delivery rate after 3 ART cycles is 54% (higher for tubal factor)
• Not covered by most health plans
• Results highly variable (by center/nation)
• Current risk of multiples is limited by blastocyst culture, PGS, vitrification
• Current risk of OHSS are negligible
• ART is first line for male factor, advanced maternal age
• Randomized trials are non‐existent
• Adhesiolysis is mildly effective
• Distal tubal surgery can be effective in select cases
• Hysteroscopic catheterization can be effective in select cases
• Surgeons must be knowledgeable ART alternative and assist patient‐centered choice
Gargiulo 2016
Gargiulo 2016
Treatment‐dependent and treatment‐independent pregnancy among women with periadnexal adhesions. Tulandi et al. Am J Obstet Gynecol, 1990; 162: 354‐7
Correlation between the American Fertility Society classification of adnexal adhesions and distal tubal occlusion, salpingoscopy, and reproductive outcome in tubal surgery. Marana et al. Fertil Steril, 1995: 64:924‐9Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion. ASRM Practice Committee with SRS. Fertil Steril, 2013: 99:1550‐5Reconstructive tubal microsurgery and assisted reproductive technology. Gomel. Fertil Steril, 2016; 105:887‐890ASRM 2012 committee opinion: role of tubal surgery in the era of assisted reproductive technology. American Society for Reproductive Medicine. Fertil Steril, 2012; 97:539–545Fallopian tube recanalization: lessons learnt and future challenges. Allahbadia and Gautam. Women’s Health, 2010: 531‐48
Pathophysiology and management of proximal tubal blockage. Honoré et al. Fertil Steril, 1999 (71): 531‐48
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LAPAROSCOPIC AND/OR HYSTEROSCOPIC MANAGEMENT
OF MYOMAS, ADENOMYOSIS, UTERINE ADHESIONS, SEPTA, AND POLYPS
Russian Scientific Center for Obstetrics, Gynecology, and Perinatology
Moscow, Russia
Adamyan L.V.
I HAVE NO FINANCIAL RELATIONSHIPS
TO DISCLOSE.
Learning Objectives
• Explain the impact of myoma, adenomyosis, uterine septa, uterine adhesions, and polyps on fertility
• Discuss the influence of reproductive surgery on IVF results
81%
15%
4%
7,2577,257
LS
HRS
LT
516 myomectomies
during pregnancy and CS
Myomectomy, Russian Scientific Center for Obstetrics, Gynecology and Perinatology, 1991‐2015
Endoscopic technologies improves pregnancy rate up to 15-20%Endoscopic technologies improves pregnancy rate up to 15-20%
IN OUR SERIES: NO CASES OF UTERINE RUPTURE1 CASE OF SARCOMA
7093
0
20
40
60
80
100
LS HRS
rate of pregnancy
MYOMAPerform myomectomy before IVF if: • Submucosal myoma• Myoma >4 cm• Multiple myomaUse of proper suture material/ anti-adhesive materialsSarcoma suspected (endobags)
GnRH agonist UPA (control of bleedingand anemia treatment)
1. reconstruction of the uterine wall using absorbable suture layer by layer
1370 op – retrocervical endometriosis3990
2640
1370
endometriotic cystexternal genital endometiosis +adenomyosisretrocervical endometriosis
3990 op – endometriotic cyst
2640 op – external genital endometriosis & adenomyosis
92 nodular adenomyosis
II st - 750 III st - 370 IV st - 250
75% of patients with previous surgery
35-40% of patients with combined forms
8000 operations
Adenomyosis
Adenomyosisclassification Adamyan L., 1993
Surgery for endometriosis, the Russian Scientific Center, 1991‐2015
• HS and HRS in the treatment of adenomyosis
• Laparoscopic excision of nodular/cystic adenomyosis (original experience 92 cases)
• High rate of infertility and miscarriage • Uterus-preserving surgery in patients who seek to
become pregnant is possible in nodular form of the disease (high risk of recurrence)
• Reconstruction of the uterine wall using absorbable suture layer by layer
ADENOMYOSIS
24%
16%
11%13%
13%
4%19%intrauterine septum
uterus duplex
bicornuate uterus
unicornuate uterus
vaginal aplasia
cervico‐vaginal aplasia
uterus and vaginal aplasia
Urinary tract pathology/malformation – 43%
Surgical treatment of genital malformations, Russian Scientific Center for Obstetrics, Gynecology and Perinatology, 1991-2015
2023
in 74% of cases are associated with extragenital anomalies
27.6%21.2%
9.4%
2.3%2.2%
1.4%
UTERINE SEPTUM • High rate of miscarriage• High rate of infertility • Use of various energy sources• Concomitant gynecological pathology • Cyclic hormonal therapy• Prophylactic resection before IVF ?
8
216
127
103
74
3626
11 7
normal endometrium polypchronic endometritis adenomyosishyperplasia synechiasubmucosal myoma septum
Hysteroscopy in patients with infertilityVarious intrauterine pathology is observed in 25% of patients with infertility Fatemi H.M., Hum Reprod 2011
Currently, there is evidence that performing hysteroscopy before IVF could increase the chance of pregnancy in the subsequent IVF cycle in women who have had one or more failed IVF cycles
600
37.7% had 2 or more unsuccessful attempts of IVF and ET
ADHESIONS/POLYP• Diagnostic hysteroscopy should be performed
after 2 or more IVF failures• Damaged uterine receptivity• Histological investigation• Use of mechanical instruments• Use of cyclic hormonal/antibacterial therapy
after synechiae resection
Stem cells therapy ?
• Adamyan L. Additional internatinal perspectives/ in Nichols D.H. Gynecologic, Obstetric Surgery and related Surgery, 1993, 1167-1182
• Grimbizis GF, Mikos T, Tarlatzis B. Uterus-sparing operative treatment for adenomyosis. Fertil Steril 2014; 101:
• Gordts S. , Campo R. , Brosens I. Hysteroscopic diagnosis and excision of myometrial cystic adenomyosis Gynecol Surg 2014
• Wright JD et al. Trends in Use and Outcomes of Women Undergoing Hysterectomy With Electric Power Morcellation JAMA Oncol 2015
• Rackow BW, Taylor HS. Submucosal uterine leiomyomas have a global effect on molecular determinants of endometrial receptivity Fertil Steril. 2012
• Fatemi H.M, Prevalence of unsuspected uterine cavity abnormalities diagnosed by office hysteroscopy prior to in vitro fertilization. Hum Reprod 2011
• Rackow BW, Taylor HS Endometrial polyps affect uterine receptivity Fertil Steril. 2011
References
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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsian
Indo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
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