Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Plenary 6: Reproductive Issues

DISCUSSANTS

MODERATORS

Mario E. Castellanos, MDM. Jonathon Solnik, MD

Antonio R. Gargiulo, MDSerene Srouji, MD

Motti Goldenberg, MDAnusch Yazdani, MBBS

Brian M. Cohen, MBChB, MD (Postdoctoral)Stephen L. Corson, MD

Cihat Unlu, MD

Miriam Hanstede, MDNeena Malhotra, MD

Emad Mikhail, MD

Arti M. Luthra, MSAdrienne Mandelberger, MD

Chandra C. Shenoy, MD

Professional Education Information   Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology.  Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.  The AAGL designates this live activity for a maximum of 1.0 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  National Trends of Surgical Management of Ectopic Pregnancy. United States 1998‐2011 Emad Mikhail ................................................................................................................................................ 4  Reproductive Outcomes of 10 Years Asherman's Surgery Miriam Hanstede .......................................................................................................................................... 6  Genital Tuberculosis in Female Infertility: An Enigma Arti M. Luthra .............................................................................................................................................. 10  Does the Mode of Surgery for Hydrosalpinges Affect Outcome in In‐Vitro‐Fertilization (IVF) Cycles? – A Randomized Trial Comparing Laparoscopic Salpingectomy and Proximal Tubal Occlusion (PTO) Neena Malhotra .......................................................................................................................................... 12  Laparoscopic Removal of Streak Gonads in Turner Syndrome Adrienne Mandelberger .............................................................................................................................. 15  Treatment of Difficult Ectopic Pregnancies With Needle Aspiration and Local Infusion Chandra C. Shenoy ...................................................................................................................................... 16  Cultural and Linguistics Competency  ......................................................................................................... 17  

 

Plenary  6:  Reproductive  Issues    

Moderators:  Brian  M.  Cohen,  Stephen  L.  Corson,  Cihat  Unlu    

Discussants:  Antonio  R.  Gargiulo,  Motti  Goldenberg,  Mario  E.  Castellanos,    M.  Jonathon  Solnik,  Serene  Srouji,  Anusch  Yazdani  

 Faculty:  Miriam  Hanstede,  Arti  M.  Luthra,  Neena  Malhotra,  Adrienne  Mandelberger,    

Emad  Mikhail,  Chandra  C.  Shenoy    This   section   provides   participants   with   insight   regarding   the   management   of   the   ectopic   pregnancy;  simple  and  complex   surgery  of  hydrosalpinges  before   IVF,  Asherman’s   syndrome,  genital   tuberculosis,  and  the  surgical  removal  of  streak  gonads.    Learning   Objectives:   At   the   conclusion   of   this   course,   the   participant   will   be   able   to:   1)   Discuss  management   of   tubal   pregnancy   whether   simple   or   highly   complex   (including   injection   therapy),   2)  explain  the  manner  in  which  hydrosalpinges  should  be  managed  surgically  prior  to  in  vitro  fertilization;  3)  describe  the  outcomes  of  Asherman’s  syndrome,  endoscopic  assesment  of  genital   tuberculosis,  and  endoscopic  removal  of  streak  gonads.    

Course  Outline    12:05   National  Trends  of  Surgical  Management  of  Ectopic  Pregnancy.    

United  States  1998-­‐2011   E.  Mikhail  

12:11   Discussant   M.  Goldenberg  

12:15   Reproductive  Outcomes  of  10  years  Asherman's  Surgery   M.  Hanstede  

12:21   Discussant   M.J.  Solnik  

12:25   Genital  Tuberculosis  in  Female  Infertility  :  An  Enigma   A.M.  Luthra  

12:31   Discussant   A.R.  Gargiulo  

12:35   Does  the  Mode  of  Surgery  for  Hydrosalpinges  Affect  Outcome  in  In-­‐Vitro  Fertilization  (IVF)  Cycles?  A  Randomized  Trial  Comparing  Laparoscopic    Salpingectomy  and  Proximal  Tubal  Occlusion  (PTO)   N.  Malhotra  

12:41   Discussant   S.  Srouji  

12:45   Video:  Laparoscopic  Removal  of  Streak  Gonads  in  Turner  Syndrome   A.  Mandelberger  

12:51   Discussant   M.E.  Castellanos  

12:55   Video:  Treatment  of  Difficult  Ectopic  Pregnancies  With  Needle  Aspiration    and  Local  Infusion   C.C.  Shenoy  

1:01   Discussant   A.  Yazdani  

1:05   Adjourn  

 

1

PLANNER  DISCLOSURE  The  following  members  of  AAGL  have  been  involved  in  the  educational  planning  of  this  workshop  and  have  no  conflict  of  interest  to  disclose  (in  alphabetical  order  by  last  name).  Art  Arellano,  Professional  Education  Manager,  AAGL*  Amber  Bradshaw  Speakers  Bureau:  Myriad  Genetics  Lab  Other:  Proctor:  Intuitive  Surgical  Erica  Dun*  Frank  D.  Loffer,  Medical  Director,  AAGL*  Linda  Michels,  Executive  Director,  AAGL*  Johnny  Yi*    SCIENTIFIC  PROGRAM  COMMITTEE  Arnold  P.  Advincula  Consultant:  Intuitive  Royalty:  CooperSurgical  Sarah  L.  Cohen*  Jon  I.  Einarsson*  Stuart  Hart  Consultant:  Covidien  Speakers  Bureau:  Boston  Scientific,  Covidien  Kimberly  A.  Kho  Contracted/Research:  Applied  Medical  Other:  Pivotal  Protocol  Advisor:  Actamax  Matthew  T.  Siedhoff  Other:  Payment  for  Training  Sales  Representatives:  Teleflex  M.  Jonathon  Solnik  Consultant:  Z  Microsystems  Other:  Faculty  for  PACE  Surgical  Courses:  Covidien    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).  Mario  E.  Castellanos*  Brian  M.  Cohen*  Stephen  L.  Corson*  Antonio  R.  Gargiulo  Consultant:  Kawasaki  Robotics  USA,  Inc.,  OmniGuide  Motti  Goldenberg*  Miriam  Hanstede*  Arti  Luthra*  Neena  Malhotra*  Adrienne  Mandelberger*  Emad  Mikhail*  Chandra  C.  Shenoy*  M.  Jonathon  Solnik  Consultant:  Z  Microsystems  Other:  Faculty  for  PACE  Surgical  Courses:  Covidien  Serene  Srouji*  Cihat  Unlu*  Anusch  Yazdani*    

2

Asterisk  (*)  denotes  no  financial  relationships  to  disclose.  

3

NATIONAL TRENDS OF SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY. UNITED STATES 1998-2011EMAD MIKHAIL, M.D.

DISCLOSURES

• I have no financial relationships to disclose.

LEARNING OBJECTIVES

• To appraise the prevalence and temporal trends in surgical management of ectopic pregnancy in the U.S.

• To compare those trends based on presence of concomitant IUP.

Background

• Ectopic pregnancies account for approximate to 2% of all pregnancies, with the great majority occurring in the fallopian tube.1

• Surgical options include Salpingectomy or salpingostomy. 2

• The most common complication and the major reason for secondary intervention after conservative management is persistent ectopic pregnancy. 3

STUDY POPULATION

• Setting: All community hospitals in the U.S. participating in HCUP, excluding rehabilitation and long-term acute care hospitals.

• Participants: The study includes all inpatient hospitalizations for women receiving treatment for ectopic pregnancy as identified using ICD-9-CM codes.

Study Design

• A cross-sectional analysis of Nationwide Inpatient Sample (HCUP-NIS) for all patients who underwent surgical management of ectopic pregnancy

• Joinpoint regression was used to estimate temporal trends [APC] in salpingectomy versus salpingostomy during the study period

4

National Trends of surgical management of tubal

ectopic pregnancy

National Trends of surgical managementof tubal ectopic pregnancy based on presence

of concomitant IUP

APCforSalpingectomyversusSalpingostomy

Subgroup

Direct costs of medical care

Per hospitalization

Annual expenditures(in millions)

Mean‡ (95% CI) Total‡ (95% CI)

All ectopic pregnancies6,062 (5,958, 6,165) 165.6 (156.5, 174.7)

Surgical outcome*

Salpingectomy6,393 (6,273, 6,513) 107.1 (100.6, 113.7)

Salpingotomy/salpingostomy5,909 (5,738, 6,080) 13.5 (12.5, 14.5)

Other adnexal procedure7,155 (6,977, 7,332) 11.3 (10.6, 12.0)

No procedure3,699 (3,515, 3,882) 5.3 (4.8, 5.7)

CostofInpatientCareforEctopicPregnancy

REFERENCES

• 1 American College of O, Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstetrics and gynecology2008; 111(6): 1479-85.

• 2 Stock L, Milad M. Surgical management of ectopic pregnancy. Clinical obstetrics and gynecology 2012; 55(2): 448-54.

• 3 Seifer DB. Persistent ectopic pregnancy: an argument for heightened vigilance and patient compliance. Fertility and sterility 1997; 68(3): 402-4.

CONCLUSION

• There is an increasing tendency to perform salpingectomy as oppose to salpingostomy as surgical management approach of ectopic pregnancy.

• There is no significant change in the trends for non-surgical management.

5

Reproductive Outcomes of 10 years Asherman's

SurgeryMiriam Hanstede M.D.

Disclosure slide

2

I have no financial relationships to disclose

Objective

3

Identify the potential problems of a pregnant Asherman’s patientList the risk factors of morbidity in the post partum periode of anAsherman patient

Between Fritsch and Asherman

H.Fritsch

N=1

1894

B.Bass

N=20

1927

S.Stamer

N=61

1946

J.Asherman

N=29

1948

Intra uterine adhesions

IUA

Trauma

to the endometrium

in a

gravid uterus

Trauma to the endometrium in a non

gravid uterus

Trauma to the

endometrium caused by infections

Asherman

Syndroom

Trauma to the endometrium

caused byhypoxia

10 years retrospective cohort

707 patients

707 patients

638 Asherman

638 Asherman

770 procedures

770 procedures

69 excluded

69 excluded

6

Etiology of IUA

7

Classification of IUA

8

Grade ESGE3 n %

1 24 3.8

2 16 2.5

2a 211 33.1

3 226 35.4

4 107 16.8

5 54 8.5

Totaal 638 100

Grade AFS4 n %

Score 1-4 (mild) 240 6.3

Score 5-8 (moderate) 211 33.1

Score 9-12 (severe) 387 60.7

Totaal 638 100

Outcome

Outcome 1-3 attempts n %

Complete 606 95Incomplete 7 1.2

Drop out 25 3.8

Year author n % recovery of uterine anatomy

1986 Fedele et al. 6 31 62.5

1999 Capella-Allouc et al. 7 31 51.6

2003 Pace et al. 8 75 93.3

2006 Fernandez et al. 9 71 43.6

Spontaneous recurrence

n %No recurrence 432 71.3

Recurrence 174 28.7

Total 606 100

Dropouts and incomplete resection

32 5.0

Recurrence and grade of adhesionsGrade ESGE %

1 20.8

2 25.0

2a 22.7

3 29.1

4 38.5

5 41.9

Grade AFS %

Milde 22.9

Moderate 22.7

Servere 36.5

Follow-up (2003-2012)

n %

Complete 389 73.2

In-complete 37 7.0

Dropout 105 19.8

Subtotal 531 100

Not yet contacted 107

Total 638

Response rate: 80.2%

7

Follow-up

13

IRB approvalFollow up on 638 womenResponse rate 80.2%Complete data on 389 women292 (75.1%) women at least got pregnant once97 (24.9%) did not (yet) conceive

Take home babyrate 68.6%14

423 pregnacies

Miscarriage

n=153EUG n=6

Parity n=264

Life birthn=267

(10 twins)

Perinatale deathn=2

Multivariate analysis

Pregnancies Multivariate analysis

Age 0.040Miscarriage 0.067Gravidity 0.007Parity 0.921Causal procedure 0.346Graad adhesions ESGE 0.183Restore of uterine anatomy 0.000Spontaneous recurrence 0.890

Multivariate analyse

Life Birth Multivariate analysis

Age 0.000Miscarriage 0.095Gravidity 0.140Parity 0.484Causal procedure 0.008Graad adhesions ESGE 0.086Restore of uterine anatomy 0.000Spontaneous recurrence 0.476

Pregnancy complications

n % General population (%)

IUGR 10 4 3-10

premature/immature birth 37 14.8 5

Abruptio placentae 1 0.4 0.3-1.6

No complications 202 80.8

Totaal 250 100

Unknown 14

Remarkable

n % General population (%)

Head 210 79.2

Breach 46 17.3 3-4%

Unknown 9 3.5

Total 265 100

8

19

1st trimester procedure

post partum procedure

Placenta implantation problems

Placenta problems n % Generalpopulatie %

Placenta praevia 12 4.9 0.3-1

Placenta acreta 18 7.4 0.004

Placenta increta 5 2.0 0.004

Placenta percreta 3 1.3 0.004

Placenta praevia en accreta, incretaof percreta

8 3.3

No placenta related problems 198 81.1

Total 244 100

Unknown 20

Post partum complications

Post partum complications n %

Hemorragia post partum 26 10.2

Manuel removal of placenta 29 11.3

Combination of the above 41 16.0

Post partum curettage for retained products

5 2.0

No problems related to post partum period

155 60.5

Subtotal 256 100

Unknown 8 3.3

Total 264 100

29.3%Post partumcomplications

Reference

22

1 Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated appraisal. Fertil Steril. 1982;37:593–610 2 Hanstede MMF, van der Meij E, Goedemans L, Emanue MH. Centralized Asherman’s surgery 2003-2013: accepted for publication Ferti Steril 2015 3 K. Wamsteker and S. De Block, “Diagnostic hysteroscopy: technique and documentation,” in Endoscopic Surgery for Gynecologists, C. Sutton and M.

Diamond, Eds., pp. 511–524, Saunders, London, UK, 1998. 4 American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian

anomalies and intrauterine adhesions. Fertil Steril.1988;49:944–955 5 Yu D, Wong Y, Cheong Y, Xia E, Li T. Asherman syndrome: one century later. Fertil Steril, 2008;89. 759–779 6 Fedele L, Vercellini P, Viezzoli T, Ricciardiello O, Zamberletti D. Intrauterine adhaesions: current diagnostic and therapeutic trends. Acta Eur Fertil

1986;17:317. 7 Capella-Allouc S, Morsad F, Rongieres-Bertrand C, Taylor S, Fernandez H. Hysteroscopic treatment of severe Asherman’s syndrome and subsequent fertility.

Hum Reprod 1999;14:1230–3. 8 Pace S, Stentella P, Catania R, Palazzetti PL, Frega A. Endoscopic treatment of intrauterine adheiosn. Clin Exp Obstet Gynecol 2003;30:26-8. 9 Fernandez H, Al Najjar F, Chauvenaud-Lambling et al. (2006). "Fertility after treatment of Asherman's syndrome stage 3 and 4". J Minim Invasive Gynecol 13

(5): 398–402.

9

Genital Tuberculosis In Female Infertility – An

Enigma

Dr Arti Luthra MSDirector, Luthra maternity & Infertility

Centre

I have no financial relationships to disclose.

DISCLOSURE

Objective

To diagnose Genital Tuberculosis, a frequent cause of infertility in developing countries

To evaluate the Laparoscopic and Hysteroscopic appearances in Genital Tuberculosis

Correlation of these endoscopic features with Endometrial polymerase chain reaction and BACTEC culture

Patients

100 infertile women in the reproductive age group (25-38 years) were studied between January 2010 - Jan 2014

Patients with HSG positive findings like tubal block, Intra-uterine synechiae were enrolled in the study and underwent diagnostic laparoscopy and hysteroscopy.

The endometrial sample obtained by curettage were sent for analysis of PCR for mycobacterium complex and BactecCulture.

The PCR and Bactec culture results obtained were retrospectively correlated with the endoscopic features of the individual patient.

Laparoscopic appearance

Perihepatic adhesions

Miliary TuberclesHydrosalpinx

Periovarian adhesions

Observations on Laparoscopy

Signs No. of Patients

PCR Positive Bactec culture positive

Normal findings 42 5 2

Peritubal adhesions 40 3 1

Peri-ovarian adhesions

34 9 3

Bilateral T.O. masses

15 1 None

Beading of tubes 8 0 None

10

Signs No. of Patients

PCR Positive Bactec culture positive

Cornualblock

14 8 3

Delayed spill 8 3 1

Perihepaticadhesions

18 2 1

MiliaryTubercles

6 4 1

Rigid tubes 10 4 None

Hydrosalpinx 14 8 4

Fimbrialphimosis

9 1 1

Bowel and omental

adhesions

17 None None

Hysteroscopic appearance

Intrauterine Synechiae

Periosteal Fibrosis Small uterine cavity

Signs No. of Patients PCR Positive Bactec culture positive

Fibrosed ostia 4 1 None

Intrauterine synechiae-mildModerateSevere –Asherman’ssyndrome

221183

4

624

1

024

Small uterine cavity 14 2 1

Hysteroscopic Findings Results

Endoscopic evaluation is 85% sensitive, and 33% specific. In 48 cases with positive endoscopic findings, endometrial PCR was positive in 20% of cases, Bactec culture was positive in 15% of cases suspected of endometrial Tuberculosis.

A negative evaluation of the endometrium does not rule out Genital tuberculosis because the disease can be present in fallopian tubes without Tubercular endometritis in 30-40% of cases.

Endometrial bacteriological PCR assay plus bactec culture with clinical and endoscopic evaluation are the Gold standards in diagnosis of GTB.

References1. Kohli MD, Nambam B, Trivedi SS, Sherwal BL, Arora S, Jain A. PCR based evaluation of tubercular endometritis in

infertile women of North India. J Reprod Infertil 2011;12:9-14.

2. Mani R, Nayak S, Kagal A, Deshpande S, Dandge N, Bharadwaj R. Tubercular endometritis in infertility: A bacteriologicaland histopathological study. Indian J Tuberc 2003;50:161.

3. Kumar P, Shah NP, Singhal A, Chauhan DS, Katoch VM, Mittal S, et al. Association of tuberculous endometritis with infertility and other gynecological complaints of women in India. J Clin Microbiol 2008;46:4068-70.

4. Khanna A, Agrawal A. Markers of genital tuberculosis in infertility. Singapore Med J 2011;52:864-7.

5. Gupta N, Sharma JB, Mittal S, Singh N, Misra R, Kukreja M. Genital tuberculosis in Indian infertility patients. Int J Gynaecol Obstet 2007;97:135-8.

6. Baxi A, Hansali N, Manila K, Priti S, Dhawal B. Genital tuberculosis in infertile women: Assessment of endometrial TB PCR results with laparoscopic and hysteroscopic features. J Obstet Gynaecol India 2011;61:301-6.

7. Bhanu NV, Singh UB, Chakraborty M, Suresh N, Arora J, Rana T, et al. Improved diagnostic value of PCR in the diagnosis of female genital tuberculosis leading to infertility. J Med Microbiol 2005;54:927-31.

8. Jindal UN, Verma S, Bala Y. Favorable infertility outcomes following anti-tubercular treatment prescribed on the sole basis of a positive polymerase chain reaction test for endometrial tuberculosis. Hum Reprod 2012;27:1368-74.

9. Malpani A, Malpani A. Anti-tubercular treatment, genital TB and infertility. Hum Reprod 2012;27:3120.

10. Thangappah RB, Paramasivan CN, Narayanan S. Evaluating PCR, culture and histopathology in the diagnosis of female genital tuberculosis. Indian J Med Res 2011;134:40-6.

11

DOES THE MODE OF SURGERY FOR HYDROSALPINGES AFFECT OUTCOME IN IN-VITRO-FERTILIZATION (IVF)

CYCLES? - A RANDOMIZED TRIAL COMPARING LAPAROSCOPIC SALPINGECTOMY AND PROXIMAL TUBAL

OCCLUSION (PTO)

Neena MalhotraMD, DNB, MRCOG 

ART Centre, Department of Obstetrics and Gynecology,All India Institute of Medical Sciences, New Delhi, India

DISCLOSURES

I HAVE NO FINANCIAL RELATIONSHIPS TO DISCLOSE

LEARNING OBJECTIVES

• Examine the mechanism of poor outcome at IVF

in women with hydrosalpinx

• Discuss surgical options prior to in-vitro-

fertilization (IVF) cycles

• Compare two surgical techniques-salpingectomy

and proximal tubal occlusion (PTO) as regards

outcome in women undergoing IVF cycle

• Manifestation of severe disease, associated with deleterious outcome at IVF 

• 10‐30% of IVF‐ET  indicated for hydrosalpinx

(Andersen AH, 1996 )

• Genital TB is the leading cause of tubal damage and hydrosalpinx ( 46.5%) in India 

(Kulshreshta.V, 2011)

• Lower implantation and pregnancy rate in association with hydrosalpinx (Parikh.F, 1996)

Tubal disease‐Hydrosalpinx

– Embryo‐toxic

– Mechanical effect‐ affects receptivity

• Interference to apposition by bathing the endometrial lining

• Fluid rich in PG, IL,TNF‐α, Leukotriene

– Altered Expression 

• Integrins (αvβ3), LIF                   

• HOXA‐10, HOXA‐11   

Impact of Hydrosalpinx

• Surgery  prior to IVF improves outcome                                   (Johnson .N, Cochrane Review, 2010)

• Salpingectomy more invasive 

• Reassuring ovarian function after salpingectomy                   ( Strandell 1999, 2001; Gelbaya 2006)

• Tubal occlusion less invasive, minimal  compromise in ovarian functions 

• Limited studies that compare  salpingectomy  to less invasive methods as tubal occlusion  

)

Why this study?

12

• To compare effects laparoscopic proximaltubal occlusion (PTO) or salpingectomy on ARToutcome in women with hydrosalpinxundergoing IVF‐ET

Aims and Objectives

Study design: Prospective randomized controlled

trial

Place of study: ARU, AIIMS , N. Delhi, India

Subjects: Tubal factor with hydrosalpinx for

intervention prior to IVF

IRB approval

Informed consent

Materials and Methods

Materials and Methods

Pre-IVF evaluation-History, examination and infertility

workup including

Ovarian reserve - FSH, E2, AMH and AFC

Endometrial assessment with 2D/ 3D imaging in luteal

phase

Hysteroscopy and Mock ET

Screened for Genital TB

TVS to screen for hydrosalpinx

INCLUSION

Tubal factor  with bilateral hydrosalpinx

<40 years 

EXCLUSION

>40 years 

Endometriosis

Prior surgery on the ovaries

PCOS

Poor ovarian reserves 

Abnormal uterine cavity 

Contraindication for laparoscopy

Materials and Methods

Exclusion of biasWomen undergoing first IVF cycle Salpingectomy converted to PTO for severe adhesions 

Materials and Methods

Sample size• Seventy five subjects (From May, 2012 to June 2014)

• Randomized prior to IVF

– Group I- Salpingectomy (n=38)

– Group II-Proximal Tubal Occlusion (n=37)

• All surgeries by single surgeon (NM)

• Laparoscopy with three ports

– Salpingectomy -bi-polar electro cautery and scissors

– PTO - bi-polar electro cautery only

Consort Diagram

95 patients assessed for eligibility

75 patients randomized

37 allocated to Proximal Tubal Occlusion (group II)

38 allocated  to salpingectomy (group I)

37 treated38 treated

37analyzed38 analyzed

20  excluded• 8 – AMH <1.5ng/ml• 4 – endometriosis• 3 – previous ovarian surgery• 2 – FSH >12 mIU/mL• 1 – Unwilling• 2 – converted to PTO

13

Primary outcomes

Clinical pregnancy rate

Ongoing pregnancy rate

Live birth rate

Secondary outcomes

Response to COH• Dose  and duration of 

Gonadotropins

• Serum E2 on day of hCGinjection

• Number of oocytes retrieved 

Fertilization rate

Cleavage rate

Number of good quality embryos transferred

Implantation rate

Outcome measures

Group ISalpingectomy

(n=38)

Group IIPTO

(n=37)

P value

Age (years) 30.7±3.5 32.0±4.0 0.17

BMI (kg/m2) 24.2±2.8 25.1±3.2 0.28

Duration of infertility (years)

7.0±3.2 8.2±3.6 0.19

Type- Primary (%)- Secondary (%)

31 (88.5%)4 (11.5%)

32 (86.4%)5 (13.6%)

1.0

Genital TB (%) 14 (40%) 15 (40.5%) 0.43

Protocol- Agonist (%)- Antagonist (%)

26 (74.2%)9 (25.8%)

27 (72.9%)10 (27.1%)

0.71

Results‐ Demographic profile

Group ISalpingectomy

(n=38)

Group IIPTO

(n=37)

P value

Dose of Gn 3607.9±1219.7 3314.7±864.8 0.28

Days of stimulation 11.1±1.6 10.5±1.6 0.13

E2 on day of hCG 3040±1821 3210±1908 072

Follicles (15-20 mm) 10.0±3.6 10.8±4.9 0.49

Oocyte retrieved* 8.4 (2-18) 5.6 (2-21) 0.97

Fertilization rate 0.8±0.2 0.8±0.2 0.46

Cleavage rate 0.9±0.1 0.9±0.1 0.94

Implantation rate(%) 4.4% 7.2% 0.52

*values expressed as median

Response to COH and IVF outcome

Group ISalpingectomy

(n=38)

Group IIPTO (n=37)

P value

Clinical pregnancy rate7 (18.4%) 9 (24.3%) 0.25

Ongoing pregnancy rate7 (18.4%) 8 (21.6%) 0.50

Miscarriage rate0 (0%) 1 (2.7%) 0.55

LBR7 (18.4%) 8 (21.6%) 0.56

Pregnancy outcome in both groups

Conclusions 

• Response to COH and pregnancy outcome similar withboth surgical interventions

• Fertilization, cleavage and implantation rate werecomparable in both groups

• Tubal occlusion is a preferred surgical intervention not justin terms of invasiveness but for little compromise in ovarianreserves

• Women with borderline reserves should be offered tubalocclusion over salpingectomy

• Further RCT with larger size are needed to confirm

• Andersen AN, Lindhard A, Loft A, Ziebe S, Andersen CY. The infertile patient with hydrosalpinges.IVF with or without salpingectomy? Hum Reprod 1996; 11:2081–4.

• Kulshrestha V, Kriplani A, Agarwal N, Singh UB, Rana T. Genital tuberculosis among infertile women and fertility outcome after antitubercular therapy. Int J Gynaecol Obstet. 2011 ; 113(3):229-34.

• Parikh FR, Nadkarni SG, Kamat SA, Naik N,Soonawala SB, Parikh RM: Genital tuberculosis:amajor pelvic factor causing infertility in Indian women. Fertil Steril 1997; 67: 497-500..

• Johnson N, van Voorst S, Sowter MC, Strandell A, Mol BWJ. Surgical treatment for tubal disease

in women due to undergo in vitro fertilisation. Cochrane Database of Systematic Reviews 2010,

Issue 1.

• Strandell A, Lindhard A, Waldenstro¨mU, et al. Hydrosalpinx and IVF outcome: a prospective,

randomized multicentre trial in Scandinavia on salpingectomy prior to IVF. Hum Reprod 1999;

14:2762–2769.• Strandell A, Lindhard A, Waldenstrom U, Thorburn J, Janson PO, Hamberger L. Hydrosalpinx and

IVF outcome: cumulative results after salpingectomy in a randomized controlled trial. HumanReproduction 2001; 16:2403–10.

• Gelbaya TA, Nardo LG, Fitzgerald CT, Horne G, Brison DR, Lieberman BA. Ovarian response to gonadotrophins after laparoscopic salpingectomy or the division of fallopian tubes for hydrosalpinges. Fertility and Sterility 2006; 85(5):1464–8.

References

14

Laparoscopic Removal of Streak Gonads in Turner Syndrome

Adrienne Mandelberger, MD Icahn School of Medicine at Mount Sinai, New York, New York

Objective: To demonstrate the skills necessary for complete resection of bilateral streak gonads in Turner Syndrome.

Design: Video case presentation with narration highlighting the key techniques utilized.

Setting: Turner syndrome is a form of gonadal dysgenesis that affects 1/2500 live births. Patients often have streak gonads and may present with primary amenorrhea or premature ovarian failure. Patients with a mosaic karyotype that includes a Y chromosome are at increased risk for gonadoblastoma and subsequent transformation into malignancy. Gonadectomy is recommended for these patients, typically at adolescence. Streak gonads can be difficult to identify and tissue margins are often in close proximity to critical retroperitoneal structures. Resection can be technically challenging and requires a thorough understanding of retroperitoneal anatomy and precise dissection techniques to ensure complete removal.

Interventions: Laparoscopic approach to bilateral salpingo-oopherectomy of streak gonads. Retroperitoneal dissection and ureterolysis are performed, with the aid of the Ethicon Harmonic Ace, to ensure complete gonadectomy.

Conclusion: Careful and complete resection of gonadal tissue in the hands of a skilled laparoscopic surgeon is key for effective cancer risk reduction surgery in Turner syndrome mosaics.

15

Treatment of Difficult Ectopic Pregnancies with Needle Aspiration and Local Infusion

Chandra C. Shenoy, MD Mayo Clinic, Rochester, Minnesota

Objective: To show how ectopic and heterotopic pregnancies can be treated with ultrasound guided needle aspiration and local infusion.

Design: Demonstration of technique with narrated video footage and two case presentations.

Setting: Ectopic pregnancies occurs when a pregnancy implants outside of the uterus. Although the most common extrauterine location for implantation is the fallopian tube, other types of ectopic pregnancies can occur. Additionally, the incidence of heterotopic pregnancies—an ectopic pregnancy concurrent with an intrauterine pregnancy—is rising due to assisted reproductive technology.

Case 1 is a patient with an unstable cervical ectopic pregnancy. Surgical resection and systemic methotrexate were not viable options. She is successfully treated with needle aspiration and intergestational infusion of methotrexate.

Case 2 is a patient with a heterotopic pregnancy: an intrauterine pregnancy and an interstitial ectopic. The interstitial pregnancy is successfully treated with needle aspiration and intergestational infusion of hyperosmolar dextrose.

Interventions: Needle aspiration and local infusion can be accomplished using a transvaginal ultrasound, needle guide, 16-gauge single lumen Chiba needle, empty syringe, and syringe with local infusion agent. The technique is similar to oocyte retrieval or an ultrasound guided cyst aspiration.

Conclusion: When an alternative to expectant management, surgical resection, and systemic methotrexate is necessary for treatment of an ectopic pregnancy, needle aspiration and local infusion of methotrexate, potassium chloride, or hyperosmolar dextrose should be considered.

16

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%

17