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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