1. Should you operate? Surgery in the fertility patient. Kevin Doody MD

2. Conflict of interest Owner, administrator – Center for Assisted Reproduction Ambulatory Surgical Center Surgeon

3. Objectives When to perform surgery prior to IVF / IUI When to avoid surgery prior to IVF / IUI When to offer surgery as an alternative to IVF

4. Major causes of infertility Sperm / male infertility – Obstructive – Non-obstructive Varicocoele Egg / hormonal Female anatomical – Peritoneal – Ovarian – Tubal – Uterine

5. Infertility treatment - strategy Correct identifiable contributing factors IUI or IVF when cause is not identified IUI or ART when identified cause(s) remain uncorrected

6. Surgically treatable male factor Ejaculatory duct obstruction Vasectomy Varicocoele

7. Ejaculatory Duct Obstruction Diagnosis – Low semen volume, low concentration or azoospermia, low or absent semen fructose – Trans-rectal sonography demonstrates dilation of seminal vesicles Treatment options – Transurethral resection of obstruction – ICSI +/- TESE

8. Varicocoele Diagnosis – Visual – Palpation Valsalva – Ultrasound Treatment options – Surgical – Radiological – IUI

9. Peritoneal Disease Endometriosis Peritoneal adhesions Diagnosis – Screening tests Pelvic exam Ultrasound HSG – Diagnostic test Laparoscopy (gold standard)

10. Diagnostic laparoscopy –when to consider Pelvic pain Abnormal HSG Abnormal pelvic exam Abnormal sonogram Prior pelvic surgery Undiagnosed infertility (weak indication)

11. Diagnostic hysteroscopy – when to consider Abnormal bleeding Progressive dysmenorrhea Abnormal sonogram Filling defect on HSG Undiagnosed infertility Incidental to laparoscopy Checklist item prior to IUI or ART

12. Hysteroscopy –office versus O.R. Low suspicion or high suspicion of lesion Insurance / financial issues

13. Endometriosis Stage I, II Stage III, IV

15. EFI surgery form and a simplified figure for patient education showing the estimated pregnancy chance per EFI score. Tomassetti C et al. Hum. Reprod. 2013;28:1280-1288 © The Author 2013. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com

16. Adnexal adhesions Diagnosis – Screening tests Sonography HSG – Diagnostic tests Laparoscopy

17. Ovarian Cysts Endometrioma Dermoid Undiagnosed – Hyperechoic – Echogenic – Sonolucent – Mixed echogenicity – Present or absence of septations, nodules, internal color flow

18. Endometrioma – when to consider surgery Unconfirmed diagnosis Pain High AMH Desire to avoid IVF Concern about possibility of ovarian access following retrieval

19. Endometrioma – surgical options Cystectomy Drainage +/- ablation

20. Laparoscopic removal of endometriomas: Sonographic evaluation of residual functioning ovarian tissue Caterina Exacoustos, MD, Errico Zupi, MD, Annalisa Amadio, MD, Beata Szabolcs, MD, Bonaventura De Vivo, MD, Daniela Marconi, MD, Maria Elisabeyya Romanini, MD, Domenico Arduini, MD Conclusion: Ovarian stripping of endometriomas, but not of ovarian dermoids, is associated with a significant decrease in residual ovarian volume which may result in diminished ovarian reserve and function. American Journal of Obstetrics and Gynecology (2004) 191, 68-72

21. Dermond / teratoma Should almost always be surgically handled (cystectomy) Very low risk of diminishing ovarian reserve unless done by oncologist Important to have firm diagnosis of hyperechoic lesions

22. Tubal factor Proximal obstruction – S.I.N. – Surgical sterilization Essure Post-partum Laparoscopic – Clips / rings – Cautery – Distal occlusion Hydrosalpinx

23. S.I.N. Surgical management involves ischemic / cornual resection + re-implantation Should be discouraged due to high rate of re- occlusion and possibility of ectopic pregnancy IVF should be primary approach

24. Reversal of surgical sterilization Allows natural conception No increased risk of twins Multiple (monthly) opportunities for pregnancy Most appropriate for women with favorable sterilization technique Should be strongly considered in patients with diminished ovarian reserve – Poor prognosis with IVF Should be avoided with partners with poor semen parameters Counseling regarding treatment options is best done by someone proficient in both IVF and tubal surgery

25. Proximal occlusion of unknown etiology Laparoscopy + hysteroscopic tubal cannulation should be primary approach Selective salpingography might be considered if laparoscopy has been previously performed IVF if unable to achieve patency or no pregnancy in 6 – 12 months

26. Distal tubal occlusion / hydrosalpinx Options are salpingectomy + IVF versus neosalpingostomy Decision to perform tubal reconstruction or salpingectomy is best done intra-operatively

27. Fibroids – Surgical management Outpatient Hysteroscopic Laparoscopic Mini-laparotomy Inpatient Laparotomy Severe anemia

28. Leiomyoma – decision to operate Size Location Abnormal menses / bleeding Prior myomectomy Presence of extensive adenomyosis Invasiveness of procedure – Inpatient vs outpatient – Recovery time – Skill of surgical team

29. Fibroids - Location Pedunculated Subserosal Intramural Submucosal Intracavitary Difficult to classify

30. Fibroids -Size Small Intermediate Large

31. Laparoscopic myomectomy Advantages Outpatient Good visualization of entire pelvis Small incisions Can be done with Da Vinci Disadvantages Difficult to detect small intramural myomas Several incisions Can be done with Da Vinci Liability with morcellation Longer OR times

33. Myomectomy by laparoscopy with mini-laparotomy Advantages Outpatient Good visualization of entire pelvis Ability to palpate small intramural leiomyomata No power morcellation required Cosmetically desirable Fast operating times Disadvantages Not state of the art sounding No ability to use “robot”

35. Hysteroscopic myomectomy-technique Morcellator Versapoint Resectoscope

36. Summary Anatomical issues are commonly encountered in patients seeking treatment for infertility In cases a surgical approach to the treatment of infertility is warranted IVF should be encouraged as the primary treatment modality in many (but not all) patients with peritoneal and tubal disease. Salpingectomy is warranted in patients with hydrosalpinx prior to IVF Uterine factors and ovarian cysts should be surgically corrected in many patients as a primary treatment for infertility or to optimize ART outcomes