Chairperson: Haryana Chapter Of ISAR ,2011-2015 Executive member ISAR 2016-2017 Associate RCOG Director: LOOMBA HOSPITAL AND IVF CENTRE , Ambala Cantt. HARYANA since 1988 Ex consultant at central hospital ,Arar, Saudi Arabia Ex senior resident Ganga Ram Hospital New Delhi. Graduate from GOMCO ,Patiala.1985.Awards: President’s gold medal at university level.Affiliations: ASRM,RCOG,FOGSI,ISAR,ACOG,,IAGE, ASPIRE,Foetal Medicine Foundation regular attendee at many national and international conferences. Achievements: First IVF/ART centre in haryana in 2003 Trained at CLEVELAND CLINIC U.S.A in IVF/ICSI Trained at HARVARD in advanced ultrasound in fetal medicine Advanced laparoscopy training at Kiel, Germany.Specialised : Infertility/ART, Fertility related Fields Laparoscopic surgeries, Fetal medicine Recurrent pregnancy loss

www.loombahospital.com

Dr.Poonam LoombaM.D.

loombapoonam@gmail.com

www.loombaivf.com

Role of hysteroscopy and laparoscopyin IVF

Poonam Loomba ,M.D. Loomba hospital and IVF Centre Ambala Cantt.

Kurt Semm (1927-2003)As one of the most critically

acclaimed fathers of laparoscopy.

In 1970, after becoming the chairman of Ob/Gyn at the University of Kiel, his co-workers demanded that he undergo a brain scan because, they said, “only a person with brain damage would perform laparoscopic surgery”

German Engineer and Gynecologist.Introduced automatic insufflator,thermocoagulation ,loop knots,irrigation device in 1983, performedendoscopic appendectomy as part ofA gynecologic procedure.

Learning objectives• Utilising the effective tool of hysteroscopy and

selecting appropriately, patients for operative laparoscopy prior to IVF with an evidence based approach.

• Make changes in clinical practice as per expertise and available resources by introducing MAST in infertility management.

Success of IVF depends upon Implantation which further depends upon synchronization of factors:

• Quality of embryos • Optimal culture conditions • Receptivity of the endometrium • Maternal immune system

Three important components of management

Background Check • Majority of pelvic pathology in infertile women is frequently not well

appreciated by routine examinations and the usual diagnostic procedures • Tubal morphology , patency, ovarian morphology, endometriosis, adnexal

adhesions can all be resolved with Laparoscopy which is the gold standard .

• Endometrial polyps, submucous fibroids, uterine septum, or intrauterine adhesions can be found in 10% to 15% of women seeking treatment for subfertility and can be confirmed with hysteroscopy.

• Removal of polyps improves pregnancy rates to 63% vs 28% with biopsy

• Removal of sub mucous myomas improves preg rates to 39% vs 21% with expectant management

Tools to evaluate female pelvic organs

• Hysterosalpingography

• TVUS/3D/4D Technology

• Saline infusion sono hysterography

• Hysteroscopy

• MRI

Hysteroscopy, however, is considered the gold standard for diagnosis of intrauterine lesions

HSG• Defines cavity and fallopian tubes thus can diagnose

developmental /acquired uterine anomalies as well as tubal pathologies.

• Cost effective.

• HSG has relatively low sensitivity (50%) and positive predictive value (PPV; 30%) for diagnosis of endometrial polyps and submucous myomas.

• Can not differentiate between septate and bicornuate uterus

• Low radiation,Painful ,Less patient compliance

TVUS /3D 4D

• TVUS has low sensitivity and specificity for detecting intra cavitary lesions.

• 3D/4D imaging can diagnose developmental anomalies of uterus.

• Non invasive.

• Needs expertise and equipment

• Learning curve

Saline infusion sonohysterography

More image than imagination

May be as effective as hysteroscopy in detecting intra cavitary abnormalities

More cost effective and simple to perform

ASRM Practice guidelines

Hysteroscopy is the definitive method for the diagnosis and treatment of intrauterine pathology.

It is also the most costly and invasive method for uterine cavity evaluation.

It should be reserved for further evaluation and treatment of abnormalities defined by less invasive methods such as HSG and sonohysterography

The inSIGHT study: costs and effects of routine hysteroscopy prior to a first IVF treatment cycle. A randomised controlled trial

Smit JG ,Kasius JC et al 2012

• In (IVF) and (ICSI) treatment a large drop is present between embryo transfer and occurrence of pregnancy.

• The implantation rate per embryo transferred is only 30%. • Studies have shown that minor intrauterine abnormalities can be found in 11-45% of

infertile women with a normal transvaginal sonography or hysterosalpingography.

• Two randomised controlled trials have indicated that detection and treatment of these abnormalities by office hysteroscopy after two failed IVF cycles leads to a 9-13% increase in pregnancy rate.

• Therefore, screening of all infertile women for intracavitary pathology prior to the start of IVF/ICSI is increasingly advocated.

• In absence of a scientific basis for such a policy, this study will assess the effects and costs of screening for and treatment of unsuspected intrauterine abnormalities by routine office hysteroscopy, with or without saline infusion sonography (SIS), prior to a first IVF/ICSI cycle.

Septal resection

• Is surgical management of uterine septum necessary prior to IVF?

Cutter

Keeper

Prevalence of septum

General Infertile RPL

HYSTEROSCOPIC METROPLASTY FOR SEPTATE UTERUS A meta analysis of 16 published series Fertil steril 2000 (Homer,Liand Cooke)

Before After Pregnancy 1062 491

Miscarriage 933 (88%) 67 (14%) Preterm delivery 95 (9%) 29 (6%)

Term delivery 34(3%) 395 (80%)

TRUST

The Randomised Uterine Septum Transection Trial

2014......RCT finally published... Removal of septum produced better outcome. Dutch multicentered study .Septum length 1/4th of cavity

Intra uterine synichae

AAGL Guidelines for Intra uterine Synichae

• Hysteroscopy is the method of choice for diagnosis.• HSG and SISHG can be done in absence of hysteroscopy.• MRI is not fully evaluated.• Hysteroscopic guidance is the method of choice with any tool.• Laparoscopy may be combined in cases of dense and lateral

adhesions.• Antibiotics not a routine practice.• IUD is not advisable after resection.• Foley’s catheter is not recommended.• Estrogens can be used to prevent recurrence.• Hyaluronic acid gel can reduce adhesions .• Since recurrence rate is high :1 in 3 women, reassessment of

cavity after 2 to 3 cycles with HSG or Office hysteroscopy.

Submucous fibroids –grading :to decide the route of surgery

• T0- whole in endometrial cavity

• T1 - >50% in endometrial cavity

• T2- < 50% in endometrial cavity

SISHG

Decisive Factors• Location of myomas• Number of myomas• Size of myomas• Asymptomatic/symptomatic• Associated adenomyosis/endometriosis• Distortion of endometrium• Previous failed ivf cycles• Previous pregnancy losses• Available expertise and resources• Other factors affecting fertility

Optimal management of myomas in an IVF set up

SUB MUCOUS

HYSTEROSCOPIC MYOMECTOMY

SUBSEROUS AND INTRAMURAL

<4CM

OBSERVE

4-7CM >7CM

LM/AM?

Sub-mucous myomas

AAGL Practice guidelines for sub mucous myomas :Evidence A

• Removal improves fertility esp for type 0 and type 1 but it remains low as compared to normal uteri.

• Hysteroscopy/SIS /MRI are highly specific and sensitive for diagnosis.

• HSG is less sensitive and specific• TVUS is less sensitive and specific than SIS/Hysteroscopy and

MRI.• MRI is superior in classification and realtionship of myomas

with serosa .• Cervical preparation can reduce trauma .• Pre op use of GnRHa corrects anaemia

39 yr female sec infertility POR

34 yr Pr Infertility .failed IUI Cycles

Polyps

For the infertile patient with a polyp, surgical removal is recommended to allow natural conception or assisted reproductive technology a greater opportunity to be successful (Level A) AAGL Guidelines

Hysteroscopic tubal catheterization in infertility

Indications-• Obstruction & occlusion of ostium & proximal

tract• Transfer of gametes or embryos

Laparoscopy

Role of diagnostic laproscopy in infertility

1. Tubal block on HSG2. Suspected peri-tubular adhesions3. Suspected endometriosis4. Mullerian anomaly5. Unexplained infertility

J Hum Reprod Sci. 2010 Jan;3(1):20-4.

Role of laparohysteroscopy in women with normal pelvic imaging and failed ovulation stimulation with intrauterine insemination.Jayakrishnan K, Koshy AK, Raju R.

• CONCLUSION: One in four women had significant pelvic pathology where treatment could possibly improve future fertility. Diagnostic laparoscopy has a role in infertile women with no obvious abnormality before they proceed to more aggressive treatments.

Hydrosalpinges

Hydrosalpinx

Can be diag by• TVS- sensitivity of 34%• HSG –sensitivity of 65% Hydrosalpinges visible on USG benefit most

from surg in terms of preg after IVF

Hydrosalpinx

Effect on IVF Success• Numerous studies have shown that

hydrosalpinges have a detrimental effect on IVF success rates.

• This finding may be due to mechanical flushing of the embryos from the uterine cavity, decreased endometrial receptivity, or a direct embryotoxic effect Patients with hydrosalpinges visible on ultrasound may be more significantly affected (33, 34).

Fertility and SterilityVolume 90, Issue 5, Supplement , Pages S66-S68, November 2008

Salpingectomy for hydrosalpinx prior to in vitro fertilizationPractice Committee of the American Society for Reproductive Medicine in collaboration with The Society of Reproductive Surgeons

Summary and conclusions 1.The live birth rate achieved with IVF among women with hydrosalpinges is

approximately one half that observed in women without hydrosalpinges.

2.In women with hydrosalpinges, preliminary laparoscopic salpingectomy or proximal tubal occlusion improves subsequent pregnancy and live birth rates achieved with IVF. For every six women with hydrosalpinges, one more ongoing pregnancy will be achieved if salpingectomy or tubal occlusion is performed before IVF.

3.Data are insufficient to permit recommendations regarding the effectiveness of alternative treatments such as laparoscopic neosalpingostomy, transvaginal aspiration of hydrosalpingeal fluid, hysteroscopic tubal occlusion, or antibiotic treatment.

Fertility and SterilityVolume 95, Issue 8 , Pages 2474-2476, 30 June 2011

Effects of salpingectomy on ovarian response in controlled ovarian hyperstimulation for in vitro fertilization: a reappraisal

We conclude that salpingectomy does not influence ovarian response in COH. However, it is important to excise the hydrosalpinx close to the tube to avoid compromising the blood supply to the ovary and this could be achieved without a laparotomy incision. Instead of using electrocautery, one can use other modalities including an ultrasound scalpel or scissors and ligature. Whether hysteroscopy proximal tubal occlusion will improve the IVF PR in women with hydrosalpinx remains to be seen (9).

Endometriosis : ESHRE 2014 It is found in 10%-15% of the general population and in up to one third of the

infertile population

Gold standard to establish the diagnosis is histologic analysis of tissue samples obtained at the time of surgery

Ovarian endometriomas should be removed by cystectomy, rather than drainage and coagulation, to avoid recurrence.

Deep infiltrating endometriosis should be managed by experienced surgeons, because complication rates are high.

There is no proven benefit of hormonal treatment as adjuvant therapy to surgery, but nor is there proven harm with this approach. After cystectomy, hormonal therapy may be offered to reduce the risk for recurrence

Medical therapy alone does not improve one’s chance of achieving a pregnancy and should not be offered for this reason.

Surgical treatment of early-stage endometriosis improves fertility outcome

For advanced stage surgery may be considered but most of them require IVF .

Suppression of endometriosis with a GnRH agonist or extended OCP use improves IVF outcome.

ESHRE 2014

Endometrioma

Endometriotic Cysts

Interfere with successful oocyte collecting during IVF

May be associated with pain.

They may increase the risk for adnexal torsion during pregnancy

Surgery could negatively affect ovarian reserve ,thus not recommended in POR

The removal of larger endometriomas (> 3 cm) has not been shown to improve IVF outcome, although surgery is recommended to those with painful symptoms.

Thank you