Cochrane review: post-operative procedures for improving fertility following pelvic reproductive surgery

Is laparoscopy necessary before assisted reproductive technology?

PURPOSE OF REVIEW

Laparoscopy is widely used during infertility work-up, although it is sometimes unnecessary. This review highlights when laparoscopic intervention should be used in women undergoing assisted reproductive technology cycles.

RECENT FINDINGS

There is no evidence for an increase in pregnancy rates in assisted reproductive technology cycles following surgical treatment of pelvic adhesions or endometriosis with laparoscopy. If the patient has bilateral visible hydrosalpinges, laparoscopy may be an option for evaluation of the tubes and treatment with salpingectomy in order to enhance the chance of pregnancy before commencing an assisted reproductive technology cycle. Laparoscopic ovarian drilling before assisted reproductive technology may be considered a therapeutic option in polycystic ovary disease patients who previously had severe ovarian hyperstimulation syndrome. Finally, laparoscopy may be useful in replacing the transposed ovaries to their original sites in the pelvic cavity in previously treated cancer patients so that monitoring of the controlled ovarian hyperstimulation and the oocyte aspiration would be much easier during the assisted reproductive technology cycles.

SUMMARY

Laparoscopy should be considered before assisted reproductive technology cycles if the procedure diagnoses and treats a pelvic pathology at the same time and if laparoscopic intervention increases the chance of pregnancy following these cycles.

Chance of adhesion formation after laparoscopic salpingo-ovariolysis: is there a place for second-look laparoscopy?

STUDY OBJECTIVE

To evaluate the chance of adhesion formation after laparoscopic salpingo-ovariolysis and determine the efficacy of early second-look laparoscopy (SLL).

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

Shiraz University hospitals.

SUBJECT

Ninety women with mean duration of infertility of 7.2 years.

INTERVENTIONS

Operative laparoscopy, with early SLL with adhesiolysis in 46 (group 1) and no SLL in 44 women (group 2).

MEASUREMENTS AND MAIN RESULTS

Adnexal adhesions were evaluated according to American Society for Reproductive Medicine adhesion classification. Separation of newly reformed adhesions was performed at the time of SLL. Patients were followed for a year after operation without other infertility treatment. At the time of operation in group 1, adnexal adhesions were graded as severe (class D) in 19 women, moderate (class C) in 31, mild (class B) in 28, and minimal (class A) in 14. Respective figures in group 2 were 10, 30, 34, and 14. After salpingo-ovariolysis these figures were 12, 10, 20, and 50 in group 1 and 6, 14, 17, and 51 in group 2. In group 1 in whom early second-look laparoscopy was performed, at the start of the operation these figures were 17, 20, 21, and 34, and after operation 12, 8, 20, and 52, respectively. There were 11 term pregnancies in group 1 and 15 in group 2. No women with severe adhesions in either group conceived. In group 1, chances of term pregnancy were 18.75% for those with moderate adhesions, 35.71% for women with mild adhesions, and 42.86% in patients with minimal adhesions. Respective figures in group 2 were 26.67%, 41.18%, and 57.14%.

CONCLUSION

The chance of moderate and severe adhesion reformation after laparoscopic salpingo-ovariolysis was 40.2%. Although separation of these adhesions could be performed more easily at the time of early SLL, the chance of pregnancy did not increase compared with that in patients who did not undergo SLL.

An unusual complication of tubal anastomosis

OBJECTIVE

To report an unusual complication associated with the use of a long-term intrafallopian stent during microsurgical tubal anastomosis.

DESIGN

Case report.

SETTING

Tertiary academic center.

PATIENT(S)

A 36-year-old woman in whom an intrafallopian stent used during a sterilization reversal procedure could not be transcervically retrieved in the office.

INTERVENTION(S)

Hysteroscopic evaluation for removal of intrafallopian stent, followed by operative laparoscopy for postoperative abdominal pain.

MAIN OUTCOME MEASURE(S)

Patient symptoms, potential for morbidity, and review of the literature.

RESULT(S)

Hysteroscopic view of the uterine cavity failed to identify the intrafallopian stent. Laporoscopic evaluation of postoperative abdominal pain revealed significant formation of pelvic and abdominal adhesions. The 2-0 nylon suture used as an intrafallopian stent was seen sitting freely on top of the liver serosa. Adhesiolysis and successful retrieval of the stent resolved the patient's symptoms.

CONCLUSION(S)

To our knowledge, this is the first report describing complete dislodgment and cephalad migration of an intrafallopian stent. Patient morbidity and health care costs may increase when long-term stents are used for sterilization reversal.