Presentation is loading. Please wait.

Presentation is loading. Please wait.

Update on Reproductive Surgery Prof T C LI Professor of Reproductive Medicine & Surgery Sheffield, England Shenzhen, May 2013.

Similar presentations


Presentation on theme: "Update on Reproductive Surgery Prof T C LI Professor of Reproductive Medicine & Surgery Sheffield, England Shenzhen, May 2013."— Presentation transcript:

1

2 Update on Reproductive Surgery Prof T C LI Professor of Reproductive Medicine & Surgery Sheffield, England Shenzhen, May 2013

3 Areas to be covered Management of distal tubal disease Ovarian surgery revisited Haemostatic agent

4 Management of distal tubal disease Salpingostomy Salpingectomy IVF ?

5 Management of distal tubal disease Salpingostomy Salpingectomy IVF ? Answer: it depends

6 MICROSURGICAL SALPINGOSTOMY: JESSOP SERIES

7 MICROSURGICAL SALPINGOSTOMY

8 SALPINGOSTOMY: GOOD PROGNOSTIC FEATURES small hydrosalpinx no/minimal peri-tubal adhesions normal mucosa normal/thin wall partial occlusion

9 Sapingostomy 1. mobilise fimbriael end

10

11

12 Sapingostomy 2.locate blocked ostium

13 Sapingostomy 3. incise blocked ostium

14 Sapingostomy 4. inspect lumen

15 Sapingostomy 4. inspect lumen - salpingoscopy

16 Sapingostomy 5. eversion of fimbrial mucosa

17 Sapingostomy 6. suture

18

19 MICROSURGICAL SALPINGOSTOMY

20 Salpingoscopy Abnormal Mucosa

21 Management of distal tubal disease Salpingostomy Salpingectomy IVF ?

22 Hydrosalpinges and IVF The live birth rate of patients with hydrosalpinges undergoing IVF is only one-half that of women who do not have hydrosalpinges

23 Hydrosalpinx and IVF outcome : a prospective randomized multicentre trial in Scandinavia on salpingectomy prior to IVF Strandell et al 1999 Human Reprod 14:2762 GroupPatientPRmiscarriage Live birth Salpingectomy %16.2%28.6% No salpingectomy %26.3%16.3% First IVF cycle, regardless of whether or not hydrosalpinges demonstrable by USS PR, p=0.067 LB, p=0.045

24 Hydrosalpinges and IVF Salpingectomy prior to IVF in women with hydrosalpinges improves pregnancy, implantation and live birth rates

25 1. Is it to routinely remove all hydrosalpinges prior to IVF ? 1. Is it cost-effective to routinely remove all hydrosalpinges prior to IVF ?

26 Cost-effectiveness of salpingectomy prior to IVF, based on a RCT Strandell et al 2005 Human Reprod 20:3284 GroupPatient Cost per LB Salpingectomy51 Euro No salpingectomy 44 Euro Up to three IVF cycles, in women with hydrosalpinges demonstrable by USS

27 Cost-effectiveness of salpingectomy prior to IVF, based on a RCT Strandell et al 2005 Human Reprod 20:3284 GroupPatient Cost per LB Salpingectomy51 Euro No salpingectomy 44 Euro Up to three IVF cycles, in women with hydrosalpinges demonstrable by USS More cost-effective

28 1. Is it to routinely remove all hydrosalpinges prior to IVF ? 1. Is it cost-effective to routinely remove all hydrosalpinges prior to IVF ? Yes

29 2. Should proximal tubal occlusion replace salpingectomy?

30 Complications of salpingectomy Impairment of ovarian blood supply, leading to reduced ovarian response to ovarian stimulation in IVF Bowel injury

31 A case of salpingectomy Large hydrosalpinx visible on ultrasound One failed IVF treatment Laparoscopic surgery Dense adhesions between L tube and bowel and pelvic side wall 2 hour operation, salpingectomy Day 3, sepsis, bowel leak Colostomy, ITU for 1 weeks

32 Complications of salpingectomy Impairment of ovarian blood supply, leading to reduced ovarian response to ovarian stimulation in IVF Bowel injury More likely if there were severe adhesions

33

34 Disadvantages of proximal tubal occlusion Pain may get worse Risk of recurrent infection and pyosalpinx May require further surgery to remove the diseased tube at a later date The data on possible benefit is not as robust as that of salpingectomy

35 2. Should proximal tubal occlusion replace salpingectomy? Only if there are severe adhesions

36 3. Should hysteroscopic tubal occlusion replace salpingectomy?

37 Essure 3-8 expanded outer coils visible in uterine cavity expanded outer coils

38 3. Should hysteroscopic tubal occlusion replace salpingectomy? No, there are concerns about implantation and premature labour

39 4. Is aspiration of hydrosalpinges fluid as effective as salpingectomy?

40 Hammadien et al, Human Reprod 2008 Ultrasound-guided hydrosalpinx aspiration, RCT Hammadien et al, Human Reprod 2008 AspirationNo aspiration P value Biochemical pregnancy 14/32 (43.8%) 7/34 (20.6%) 0.04 Clinical pregnancy 10/32 (31.3%) 6/34 (17.6%) 0.2

41 4. Is aspiration of hydrosalpinges fluid as effective as salpingectomy? No

42 5. If the hydrosalpinx is small and not visible on ultrasound, is it still necessary to perform salpingectomy? 5. If the hydrosalpinx is small and not visible on ultrasound, is it still necessary to perform salpingectomy?

43 Hydrosalpinx and IVF outcome : a prospective randomized multicentre trial in Scandinavia on salpingectomy prior to IVF Strandell et al 1999 Human Reprod 14:2762 GroupPatientPRmiscarriage Live birth Salpingectomy %16.2%28.6% No salpingectomy %26.3%16.3% First IVF cycle, regardless of whether or not hydrosalpinges demonstrable by USS PR, p=0.067 LB, p=0.045

44 5. If the hydrosalpinx is small and not visible on ultrasound, is it still necessary to perform salpingectomy? 5. If the hydrosalpinx is small and not visible on ultrasound, is it still necessary to perform salpingectomy? Yes

45 Ultrasound may fail to diagnose hydrosalpinx

46 6. UNILATERAL TUBAL DISEASE Is surgery still worthwhile? 6. UNILATERAL TUBAL DISEASE Is surgery still worthwhile?

47 McComb & Taylor 2001 Fertil Steril 76:1279 Unilateral Hydrosalpinx with a Contra-lateral Patent Tube McComb & Taylor 2001 Fertil Steril 76: women with unilateral hydrosalpinx underwent salpingostomy IU pregnancy rate 43.5% Conclusion – unilateral salpingostomy in women with a contra-lateral patent tube improves fertility

48 Case History 33 year old woman one miscarriage at 7 weeks Infertility for 15 months Conceived spontaneously, but miscarried again at 8 week gestation Investigation – L tube normal. R hydrosalpinx, grossly dilated, intraluminal adhesions, salpingectomy. Three months later, spontaneously conception, term delivery

49 6. UNILATERAL TUBAL DISEASE Is surgery still worthwhile? 6. UNILATERAL TUBAL DISEASE Is surgery still worthwhile? Yes

50 7. How to do salpingectomy properly? 7. How to do salpingectomy properly?

51 Salpingectomy : Surgical tips 1 Main Risk: devascularization of the ovary Operate close to the tube, away from ovarian vessels and suspensory ligament

52

53 Salpingectomy : surgical tips 2 Other Risk: incomplete removal, with development of ectopic pregnancy following ART Do a complete salpingectomy !

54 Areas to be covered Management of distal tubal disease Ovarian diathermy for PCOS Haemostatic agent

55 PCOS & Ovarian Diathermy Why bother doing laparoscopic diathermy or drilling of the ovaries? How should it be done?

56 LOD vs GONADOTROPHIN COCHRANE DATABASE 3 RCTS Vegetti et al 1998 Farquhar et al 2002 Bayram et al 2004 CCR 6-12 month after LOD is similar to 3- 6 cycles of gonadotrophin therapy

57 LOD versus FSH Bayram et al, 2004 Treatment Regimen No of women Pregnant(%)MiscarryMultipleLB(%) LOD strategy LOD LOD 83 (100) 31 (37) (34) LOD + CC LOD + CC 45 (54) 14 (31) (29) LOD + CC + FSH LOD + CC + FSH 23 (28) 18 (78) (52) LOD strategy total (76) (64) FSH85 64 (75) (60)

58 Conclusions of study An electrocautery strategy and ovulation induction with recombinant follicle stimulating hormone are similarly effective in inducing ovulation Multiple pregnancies can largely be avoided by electrocautery and clomifene citrate before rFSH

59 LOD vs GONADOTROPHIN ECONOMIC CONSIDERATIONS Li et al 1998, BJOG

60 LOD vs GONADOTROPHIN ECONOMIC CONSIDERATIONS LODgonadotrophins Cost per live birth Farquhar et al, 2004 US $21095 US $28744 Cost per live birth + delivery Wely et al, 2004 Euro Euro Cost of term pregnancy : LOD 22-33% lower

61 NICE Guidelines Ovarian drilling Women with PCOS who have not responded to CC should be offered laparoscopic ovarian drilling because it is as effective as gonadotrophin treatment and is not associated with an increased risk of multiple pregnancy

62 ADVANTAGES OF LOD 1. Avoids risk of multiple pregnancy 2. Less costly 3. Long term beneficial effects including menstrual regularity, sustained reduction of FAI, sustained restoration of ovulation and further chances spontaneous conception in over 50% of subjects compared with subjects who did not undergo LOD (Amer et al, Human Reprod 2002, 17:2035; Amer et al, Human Reprod 2002, 17:2851)

63 PCOS & Ovarian Diathermy Why bother doing laparoscopic diathermy or drilling of the ovaries? How should it be done?

64 How many punctures should one make?

65 The number of puncture is only one of several variables which determines the amount of electrical energy delivered to the ovary The amount of energy (J) used is calculated as: power (w) x duration (sec) x No of punctures

66 Laparoscopic Ovarian Diathermy How much electrical energy is required to produce optimal results?

67 The amount thermal energy used in LOD Gjonnaess (1984): 250 w x 3 sec x > 5 = > 3750 joules Armar et al (1990): 40 w x 4 sec x 4 = 640 joules Dabirashrafi (1989): Severe ovarian atrophy with 8 holes x 400w x 5 sec = 16,000 Joules

68 The Sheffield Prospective Dose Finding Study Amer, Li & Cooke, women divided into ten groups, each group with 3 women Dose in each group to be determined by the response of previous group Energy utilised for each puncture is standardised The modified Monte Carlo Up-and-Down design

69 Conception rates after LOD Sheffield Prospective Study 1 puncture 234

70 OVARIAN DIATHERMY

71 ELECTRICAL ENERGY Rockett of London diathermy needle needle 8 mm long, 2 mm diameter monopolar coagulation power - 30 W puncture –number 4 –duration 5 seconds

72 With the use of proper techniques, laparoscopic ovarian diathermy is very safe Sheffield series : Adhesions – often minimal ovarian failure – 0/250cases

73 Management of distal tubal disease Ovarian surgery revisited Haemostatic Agent

74

75

76 Floseal Haemostatic Matrix (Baxter) FLOSEAL is indicated in surgical procedures (other than ophthalmic) as an adjunct to haemostasis when control of bleeding by ligature or conventional procedures is ineffective or impractical.

77 What is Floseal?

78 FLOSEAL provides a combination of two independent hemostasis promoting agents. –The gelatin granules swell to produce a tamponade effect –High concentrations of human thrombin convert fibrinogen into fibrin monomers accelerating clot formation

79 Identify the source of bleeding at the tissue surface. Apply FLOSEAL Hemostatic Matrix FAST to the deepest part of the wound or lesion - the source of bleeding at the tissue surface.

80 FLOSEAL granules allow high concentrations of thrombin to react rapidly with the patient's fibrinogen and form a mechanically stable clot.

81 FLOSEAL can be reapplied, if necessary. Once haemostasis is achieved, gentle irrigation should always occur to remove excess product that has not been incorporated into the clot. Do not disrupt the clot by physical manipulation or suction.

82 When is it useful? Pelvic side wall Rectovaginal space Ovarian cyst wall

83 THANK YOU


Download ppt "Update on Reproductive Surgery Prof T C LI Professor of Reproductive Medicine & Surgery Sheffield, England Shenzhen, May 2013."

Similar presentations


Ads by Google