The International Council on Infertility Information Dissemination, Inc

MINIMALLY-INVASIVE REPRODUCTIVE AND GYNECOLOGIC SURGICAL TECHNIQUES FOR THE INFERTILITY PATIENT by Donald I. Galen, M.D.

INTRODUCTION

Evidence-based medicine has demonstrated that the incidence and frequency of infertility is increasing.  This is partly due to women deferring pregnancy until a later age (for career, financial or personal reasons), and also from other medical conditions such as pelvic adhesions, endometriosis, tubal occlusion, sexually transmitted infections, sperm abnormalities, genetic and anatomic causes.  Fortunately, the treatment options for infertile couples have also been expanding.  In this article, I will focus on minimally-invasive, or non-invasive surgical options for the fertility challenged couple.

 

LAPAROSCOPY
Initially performed as an in-patient procedure, laparoscopy has evolved and been refined significantly over the past 20 years.  Modern laparoscopes now are available in sizes as small as 1.9 mm diameter.  High intensity Xenon illumination has been developed, and high-resolution digital cameras are now available.  Thus, during the past 15 years, most modern operative laparoscopy employs the use of video monitoring systems, so that the entire operative team can visualize the operative field and assist and be involved in the surgical procedure, in the same fashion that open surgical procedures are done.  This has spawned the development of “endoscopic surgical suites” in most surgical facilities.  The advantage of videolaparoscopy is that only a few very small (1/2 inch) incisions are required, and most women can go home the same day.  Post-operative pain is minimized, scars are minimal, and surgical risks are reduced.  Recovery is faster and detrimental effects of adhesions on future fertility are minimized. 

Laparoscopy allows gynecologists and reproductive surgeons to diagnose causes of infertility and to determine if a woman’s fallopian tubes are open.   Physicians can identify the presence of endometriosis, ovarian cysts, uterine abnormalities such as fibroids, pelvic adhesions and other pelvic pathology. 

For a woman to become pregnant, it is necessary that at least one of her fallopian tubes is open and anatomically normal.  While another radiology test, called a hysterosalpingogram (HSG) can be used to determine if tubes are open, the laparoscope is more accurate and is the “gold standard” for evaluation of a woman’s fertility status.  In addition to visualizing if there is free flow of a blue colored solution through the tube(s), the surgeon can also visualize the quality of the fibria (the end of the tube) and determine, with a high degree of accuracy, if the tubes are likely to function normally to allow for pregnancy.  If the tube has adhesions restricting its motion, or if there are adhesions around the woman’s ovaries, these can be removed.   Both ovaries are also identified, and again, evaluated for evidence of pathology.  Photographs are typically taken for the patient’s records and later reference.  

Another important structure is the uterus.  This is where embryos implant, and where pregnancies develop and are nourished.  The presence of benign uterine tumors called fibroids (myomata uteri), can, depending on their location, number and size, have a significant effect in the ability of the woman to either become or stay pregnant.  Fibroids are one of the most common abnormalities seen, and if a women is not trying to become pregnant, may not require treatment.  However, when pregnancy is desired, it is very important to consider removal of large (>4 cm) fibroids within the uterine wall, and to remove fibroids located within the uterine cavity, usually via a hysteroscopic approach. 

Endometriosis is another commonly seen problem in women during their reproductive years.  In some cases, endometriosis does not seem to have a significant effect on becoming pregnant.  In others, it can prevent pregnancy and/or implantation via mechanisms that are still not completely understood.  Many studies have shown that removal of pelvic endometriosis at the time of laparoscopy may have a beneficial effect on subsequent  fertility.  Like uterine fibroids, endometriosis may recur even after removal, and patients should be aware of this possibility. Thus the best “window” for pregnancy occurs in the first year or so following treatment or removal of endometriosis. 

Ovarian cysts are another common finding in women trying for pregnancy.  If these cysts are from normal ovulation, then simply waiting 1-2 months, or possibly using oral contraceptives for one cycle will cause them to regress.  In other cases, cysts can be from endometriosis within the ovary (called an endometrioma) or from benign or rarely malignant tumors.  Laparoscopy again allows the reproductive surgeon to remove these ovarian cysts, in order to maximize future fertility.

Pelvic and abdominal adhesions (scar tissue) is an additional cause for both pelvic pain as well as infertility. These adhesions can obstruct the ends of the fallopian tubes, can interfer with egg transport from the ovary to the tube, and can distort pelvic anatomy.  The impact on fertility can be substantial, and again every effort is made to remove as many of these adhesions as can be safely accomplished.  Experience has demonstrated that there is a risk of new adhesions forming following any type of surgery.  This risk, however, is minimized with the use of laparoscopy, as compared to an open abdominal approach. 

Approximately 2% of pregnancies occur in a woman’s fallopian tube, rather than in her uterine cavity.  These tubal pregnancies are also called ectopic pregnancies. Ectopic pregnancies can be a serious problem for women if they rupture, and in fact ruptured ectopic pregnancies are the leading cause of death in early pregnancy. Fortunately, with current technology, most early ectopics can be identified by measuring a woman’s rise in her hCG hormone level.  This rate of rise has a close correlation with normal versus abnormal pregnancies.  Combined with early ultrasound, most ectopics can be identified before there is a risk of rupture, which allows for these abnormal pregnancies to be either treated by laparoscopy, or by injection of a medication called methotrexate, which dissolves and eliminates the abnormal pregnancy. 

Evidence-based studies have demonstrated that patient outcomes are, in most cases, better with laparoscopy than with open incisional approaches.  Improved technical innovations (such as radial dilating abdominal access systems, ultrasonic surgical instruments, argon beam coagulation, surgical lasers and adhesion prevention products) have all contributed in making these procedures more effective and safer for women.

 

HYSTEROSCOPY

Early hysteroscopy was used only for diagnostic purposes, as a means of seeing inside the woman’s uterus to look for causes of infertility, or to diagnose causes of irregular bleeding such as uterine polyps.  Again, as instrumentation and experience (and patient demand) increased, modern operative hysteroscopy allows the use of very small or flexible hysteroscopes and video monitoring systems.  These procedures do not require any incisions and are performed by using the woman’s cervix for uterine access.  Office hysteroscopy is now a common procedure as it requires little or no anesthesia and allows the fertility specialist to view the uterus as well as the openings to the fallopian tubes.  There is even a smaller flexible scope that can be placed into the fallopian tubes in order to visualize their lining and quality.  

In addition to diagnosis, the operative hysteroscope is used for removal of fibroids within the uterine cavity in order to restore normal intrauterine anatomy prior to pregnancy.  Removal of endometrial polyps, and lysis (removal) of adhesions within the uterine cavity also can be accomplished.  Uterine anomalies causing recurrent pregnancy loss, such as the presence of a uterine septum, can effectively and safely be removed without the need for a large abdominal incision as was required prior to the development of operative hysteroscopy.

To perfom hysteroscopy, the surgeon uses a continuous flow of liquid to separate the walls of the uterus and provide a “working space” for specialized instruments.  Because all hysteroscopic procedures are ambulatory in nature and require no incisions, women can go home either immediately after, or within a few hours of their completion; most women are back to virtually all normal activities later that same day.

 

HYDROSALPINGES

Fallopian tubes can be damaged from prior surgery, scar tissue from either prior surgery, from pelvic infections, or from pelvic endometriosis.  In many women with damaged fallopian tubes, the end of the tube will seal shut and the tube will fill with fluid and not function.  This is called a hydro (water) salpinx (tube).  The presence of a hydrosalpinx will not only make the chance of a future pregnancy very unlikely, it will also reduce the chance of a successful pregnancy even using In Vitro Fertilization (IVF) techniques.  A number of published studies have demonstrated that if a woman undergoes an IVF cycle, her chance of a successful pregnancy outcome will be reduced as much as 50% with the presence of one or two fluid-filled fallopian tubes.  Because of these findings, women interested in pursuing IVF have, in the past, been advised to have their tubes either removed or burned and sealed using a laparoscopic, or in some cases, using an open surgical technique. 

More recently, with FDA approval of a transcervical sterilization coil, women now have the option for an “off label” use of this device for sealing their fallopian tube(s) before IVF.  This tubal coil is placed using an office hysteroscope, and requires no major anesthesia or any incision.  After a three-month waiting period for the tube(s) to occlude, the woman can then proceed with her IVF cycle and have the best chance of a successful pregnancy outcome.  Although this coil was developed initially for permanent female sterilization using a no incision approach, this is yet another example of how minimally-invasive surgical techniques can improve the fertility status of women with hydrosalpinges.

  

MICROSURGICAL REVERSAL OF TUBAL STERILIZATION (MTR)

Initially, microsurgery was the domain of eye surgeons, ear surgeons, neurosurgeons and plastic surgeons, all using very small instruments, and aided by an operating microscope for achieving precise and exacting reconstructive surgery.  Microsurgery has now been developed for women with infertility.  One of the first applications of microsurgery was for correction of prior tubal damage, and for women who had been previously sterilized and desired to have their tubes reopened for additional pregnancies.  This new field of microsurgical repair involved not only use of the operating microscope and small instruments, but also required surgeons to learn “microsurgical technique” which is quite different and more exacting than standard gynecologic surgery.  Benefits to patients include better outcomes, higher fertility, and in the case of tubal reversal, high pregnancy rates.  Tubal reversal surgery is now performed in ambulatory surgery centers and office-based surgical centers, with women going home later the same day of their surgery.  Post-operative pain is less than with other techniques, and pregnancy rates in the best tubal reversal centers (published literature) averages 60%. This has continued to evolve, such that all tubal reversal procedures performed in our office-based operating room are discharged home within two hours after completion of their reversal surgery. Current pregnancy rates following microsurgical tubal reversal surgery in women under age 38 average 75-80%. Tubal reversal can now even be accomplished remotely with the introduction in 2000 of computerized laparoscopic robotic surgical systems.

 

ADHESION PREVENTION

One of the known risks of any type of surgery is the subsequent development of scar tissue, more commonly called adhesions.  If a person has a mole removed from her skin, the scar tissue formed is minimal and will not cause any other future medical risks.  In the case of abdominal or pelvic surgery, any procedure carries with it the risk of adhesions forming as a result of the healing process. These intra-abdominal adhesions can produce subsequent pelvic pain, can interfere or damage fallopian tubes, thus increasing future infertility, and can result in bowel obstruction which necessitates further surgery.   Studies have demonstrated that the risk of adhesion formation is higher if an open abdominal incision is used, and if non-microsurgical techniques are employed.  The use of minimally-invasive and/or endoscopic surgery has significantly reduced the chance of adhesions forming.  

However, even in the best of hands and with the best of surgical techniques, there still remains a risk of post-operative adhesion formation.  To address this risk, a number of manufacturers have developed an array of patches, liquids, foams and gels to be applied to the surgical site(s) at the time of surgery in order to minimize or reduce the risk of subsequent post-operative adhesions.  To date, these products are partially effective, but more effective spray adhesion barriers are currently undergoing clinical investigative studies in the United States.  Early, preliminary data suggests that this new generation of adhesion-prevention product will be easier to apply and more effective at reducing the risks of post-operative adhesion formation.

 

ULTRASOUND

Ultrasound, while not a surgical technique, has evolved tremendously since its introduction in the late 1960’s. Today, most gynecologists and infertility specialists have one or more high-resolution ultrasound systems, which can view a woman’s uterus, ovaries, and pelvis in a non-invasive, painless and safe manner.  The presence and size of ovarian cysts, uterine fibroids, and other pelvic abnormalities are easily seen.  Early clinical pregnancies are diagnosed and followed using transvaginal ultrasonography.   Ultrasound is also used to remove eggs from a woman’s ovaries, to measure the thickness and quality of her uterine lining, and to guide placement of embryos during In Vitro Fertilization procedures. 

In addition to the standard black-and-white ultrasound, there is now color Doppler ultrasound and three-dimensional ultrasound available for specific applications. A special type of examination, termed a saline infusion sonohysterogram (SIS) allows real-time ultrasound to be performed in a physician’s office, with the ability to accurately evaluate the interior of a woman’s uterus for the presence of adhesions, polyps, fibroids or uterine anomalies such as a septate uterus.  Since the ability of a woman to achieve and maintain a pregnancy is directly related to the normalcy of her uterus and uterine lining, the presence of these anatomic abnormalities can reduce her fertility.  If abnormalities are detected, then an operative hysteroscopic approach can be used for removal or correction of these abnormal findings.

 

SUMMARY

Contemporary medicine allows physicians to provide minimally-invasive surgery, or in some cases, non-invasive techniques for their fertility patients.   These methods are used initially for the accurate diagnosis and evaluation of a woman’s fertility status, and to identify probable causes for her reduced fertility.  Along with tests to measure sperm function and egg quality, an endoscopic approach for treatment allows the woman to avoid or have minimal incisions, and to reduce the recovery period and discomfort of conventional surgical treatments.  In addition, patients have reduced costs, reduced risks of developing post-operative adhesions, reduced pain and recovery times, and a better chance of achieving a successful pregnancy. Ongoing clinical research continues to develop new and better methods for patient care, and less invasive, safer and more effective surgical techniques for the treatment of abnormal findings.  Fertility treatment thus remains a dynamic and rapidly evolving field, and an exciting and rewarding specialty in which to practice.

 

Donald I. Galen, M.D., FACOG is the Endoscopic and Surgical Director, Reproductive Science Center of the San Francisco Bay Area and Assistant Clinical Professor of Ob/Gyn, University of California, Davis

 

 

Heather Bruce Thiermann Online Angel Award

Heather Bruce Thiermann Online Angel Award

By Linda F. Davey

 

It's nearly impossible to open a newspaper or watch an evening news broadcast without hearing something about the Internet. All too often, accompanying words like "smut," "pornography," "pedophiles" and "scams" perpetuate the myth that nothing but danger lurks in Cyberspace. It's refreshing, then, when a story illustrating the very best the Internet has to offer is broadcast for all to see. Such is the story of Heather Bruce Thiermann.

Heather's story is a triumphant example of how going on-line can not only change lives, but enhance them. Her story shows that friendships made via computers can be as rewarding as any, even if participants never meet face-to-face. But most of all, it demonstrates how experiences in Cyberspace can be exhilarating and sorrowful, and just as in "real life," love, support, encouragement and shoulders to lean on can be found.

Heather was a popular participant on the Infertility Bulletin Board on America Online (AOL). She and her husband, Steven Dempsey, were in the IVF program at The New York Hospital-Cornell Medical Center in New York City. Heather struggled with massive uterine fibroids that prevented her from conceiving, but she was positive and hopeful despite eight years of infertility. After five surgeries, she finally became pregnant following her second in vitro fertilization attempt.

At this time, Heather moved on to the "Pregnant After Infertility" bulletin board on AOL, a subject created by INCIID cofounder, Nancy Hemenway. She shared all the fear and excitement of finally being pregnant with others on the board. As time neared for her planned C-section (previous surgeries made this necessary), her posts on the bulletin board became increasingly excited, and nervous. Then, just hours before the long-awaited time on January 8, Heather's C-section was canceled because of intense snow storms on the East Coast. Her doctor couldn't get to the hospital.

Two days later, on Wednesday, January 10, Heather and Steven became the proud parents of a beautiful and healthy baby girl they named Tara. Steven said he had never seen such a beautiful look of complete happiness in those brief moments when Heather laid eyes on the fruit of her labor. Heather saw Steven holding Tara, then she fell into a coma. She never regained consciousness, and thirteen days later, Heather died.

This terrible loss has been retold throughout Cyberspace and people on all the on-line services and the Internet have reacted with shock and sorrow. Heather's family and her husband have been inundated with e-mails expressing sympathy. You didn't have to know Heather to love her for all that she did to support others on-line.

Many on-line have come together to support the family and show their love and appreciation for Heather. The founders of INCIID established an annual award to recognize the contributions of an individual or group whose participation on-line has served to support, encourage and educate others about infertility. It is named the "Heather Bruce Thiermann Online Angel Award," and the first recipient, posthumously honored, is the special woman for whom it is named. We are so honored to be entrusted with carrying on a part of Heather's spirit.

In addition to naming the INCIID Online Angel award for Heather, more than 60 on-line friends are making a patchwork quilt for baby Tara. A memorial fund in Heather's name has been established at Cornell MedicalCenter with the funds earmarked for infertility research. A separate fund has been established for Steven and Tara. One AOL participant called for volunteers who live in theNew York area to join a group called "The Aunties," whose members will help take care of Tara, run errands, and generally help Steven when possible.

At INCIID, we have come to know and love Steven. We are amazed at the strength and grace with which he has managed the terrible hand fate has dealt him. We very much enjoyed meeting him face-to-face at the INCIID conference this past March [1996], at which he accepted the first "Heather Bruce Thiermann Online Angel Award."

At INCIID, we continue our quest to educate people about infertility. Heather worked very hard to educate others, especially about their options regarding IVF vs. hysterectomy. Heather was part of a very special on-line family, and she is missed by everyone.

Please contact INCIID if you are interested in serving on or organizing a committee for the Annual INCIID Online Angel Award

 

INCIID Insights Publication Information

INCIID Insights Publication Information

 

INCIID Insights is distributed approximately 9 to 10 times a year with a very large “resource edition” in October. It is full of up-to-date and cutting-edge information from some of the world’s most renowned reproductive specialists. The INCIID Newsletter has more than 20,000 subscribers. If your organization would like write an article, become a sponsor, or advertise please Contact INCIID:

 

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All content included in this newsletter, such as text, graphics, cartoon characters, logos, button icons, images, audio clips, digital downloads, data compilations, and software, is the property of International Council on Infertility Information Dissemination, Inc. (INCIID), or its content suppliers and is protected by United States and international copyright laws.

 

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INCIID, INCIID Insights, marks, cartoon characters, graphics, logos, page headers, button icons, scripts, and service names are trademarks or trade dress of International Council on Infertility Information Dissemination, Inc., in the United States and other countries. INCIID’s trademarks and trade dress may not be used in connection with any product or service that is not INCIID’s, in any manner that is likely to cause confusionamong customers, or in any manner that disparages or discredits INCIID. All othertrademarks not owned by INCIID that appear in this publication (both in print and electronic versions) are the property of their respective owners, who may or may not be affiliated with, connected to, or sponsored by INCIID.

These components may not be copied, reproduced, republished, uploaded, posted,transmitted, or distributed in any way, including by e-mail or other electronic means. Without the prior written consent of the owner, modification of the materials, use of the materials on any other web site or networked computer environment, or use of the materials for any purpose other than personal, non-commercial use is a violation of thecopyrights, trademarks, and other proprietary rights, and is prohibited.

 

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© 2006 International Council on Infertility Information Dissemination, Inc.

 

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A Baby at Last

Buy it on Amazon

 

The following article is an excerpt from the new book A Baby at Last!, written by Zev Rosenwaks, MD, Director and Physician-in-Chief of the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine at the Weill Cornell Medical Center, Marc Goldstein, MD, Director of the Center for Male Reproductive Medicine and Microsurgery and Surgeon-in-Chief of Male Reproductive Medicine and Surgery at Weill Cornell Medical Center, and health and medical writer Mark L. Fuerst.

 

When to Do In Vitro Fertilization

Almost a quarter of a million babies are born each year through assisted reproductive technology (ART) procedures, and nearly 4 million babies have been born worldwide using a remarkable technique that combines sperm and eggs outside the body, known as in vitro fertilization (IVF). This ART procedure retrieves multiple eggs, mixes them with sperm in the laboratory, and the embryos that grow in a special culture media are then implanted into the uterus.

More than 115,000 IVF treatment cycles are performed in the United States each year, and this figure continues to grow at a steady pace. An IVF cycle costs between $10,000 and $15,000 and, on average, a woman requires more than one cycle to achieve a pregnancy. For each cycle, a woman undergoes hormone injections to stimulate her ovaries, the eggs are fertilized outside the body, and the resulting embryos are then transferred back into the uterus with the hope that an implantation will occur several days later.

About half of all women under age 35, 40% of all women who are 35 and 36, and one third of women who are 37 through 40 will have a baby after a single IVF transfer at Weill Cornell.

 

Candidates for IVF

Couples who require IVF treatment fall into many categories. No matter what the cause for their infertility, if conventional treatment has not resulted in a pregnancy, they become candidates for IVF.

Candidates for IVF include couples with tubal factor infertility; couples where the male partner has severely compromised semen parameters (decreased sperm density, motility and/or morphology); when the man has no sperm in the ejaculate, due to either an obstruction or poor or no sperm production; women of advanced maternal age and diminished ovarian reserve; women with untreatable endometriosis; couples with unexplained infertility or antisperm antibodies; and even couples who carry genetic abnormalities and do not want to pass this on to their children.

IVF was originally devised to bypass the need for a healthy fallopian tube, where the sperm and egg normally meet for fertilization. Currently, when a woman has obstructed tubes or scaring around her fallopian tubes, her options are surgery or IVF. If a woman is older than 35 or if she has had unsuccessful tubal surgery, Dr. Rosenwaks generally recommends IVF as the best treatment. However, a sterilization reversal using microsurgery to reconnect the fallopian tubes may be the best choice for a woman under age 35 who has had a sterilization procedure, who has a normal ovarian reserve, wishes to have more than one child, and has an adequate amount of tube left to repair. For all other women with tubal infertility, IVF may be a better option because it doesn’t require general anesthesia or major surgery.

The severity of a man’s infertility dictates the best treatment. If he has at least 5 million active sperm, Dr. Rosenwaks generally recommends intrauterine insemination (IUI) either in a natural cycle or with ovarian stimulation (superovulation) of his female partner. If the couple doesn’t achieve a pregnancy with IUI or the man has less than 500,000 active sperm, then Dr. Rosenwaks recommends IVF with intracytoplasmic sperm injection (ICSI).

As noted above, a woman’s age, as well as her ovarian reserve, which reflects the biologic age of her ovaries, is critical to determining her fertility potential. To get a sense of a woman’s ovarian reserve, Dr. Rosenwaks measures her blood levels of follicle-stimulating hormone (FSH), estradiol, and anti-mullerian hormone (AMH) levels on day 3 of her cycle. A high FSH level indicates a woman has a diminishing ovarian reserve and suggests she may need more aggressive treatment. AMH levels can be used to confirm the diagnosis; low levels denote poor ovarian reserve. A clomiphene challenge test can help confirm a diminished ovarian reserve. No test result should absolutely eliminate or preclude treatment. Dr. Rosenwaks encourages women of any age with diminishing ovarian reserve as well as women age 36 and older to have an IVF procedure sooner rather than later.

When endometriosis does not respond to medical or surgical treatments or a woman is age 35 or older, then IVF should be the couple’s treatment of choice.

Couples with unexplained infertility who do not get pregnant during several cycles of superovulation plus IUI are often quite successful with an IVF procedure. The IVF procedure allows Dr. Rosenwaks to evaluate sperm and egg interaction directly and also to evaluate the quality of the embryos. In fact, couples with unexplained infertility have higher pregnancy rates with IVF than couples in which the woman has a tubal problem.

Antisperm antibodies can be managed with IUI, IVF, or ICSI. IUI plus superovulation is the least expensive option but does not work as well as IVF or ICSI. IUI may be successful when levels of antisperm antibodies are low. Dr. Rosenwaks recommends IVF when the woman has antisperm antibodies in her blood or her cervix or when a man has more than 50% of his sperm bound with antibodies. Couples with antisperm antibodies who undergo IVF have the same success rate as those without antibodies. ICSI is the most expensive of these procedures, but it has the highest success rate because the direct injection of sperm into the egg completely bypasses any antibody problems either in the female or male.

Fertility specialists now have the ability to examine embryos in the laboratory before they are implanted. This has expanded the uses of IVF technology to help avoid the transmission of some genetic disorders. Preimplantation genetic diagnosis (PGD) can identify chromosomal abnormalities related to a woman’s advancing age from a single cell removed from a three-day-old embryo, as well as detect specific genetic defects such as cystic fibrosis and sickle cell anemia.

Technological advances such as these, along with ever-improving IVF techniques, make it possible for more women than ever before to have babies at last.

Buy the book on Amazon!