Infertility surgery

The common infertility surgery are conservative surgery for endometriosis (37%), myomectomy (17%), ovarian drilling for polycystic ovarian disease (10%), adhesiolysis (5%), hysteroscopic cannulation for cornual block(4%), cystectomy for ovarian cysts (3%) and tubal anastamosis for tubectomy reversal in our infertility unit .

Endometriosis

This is one of the commonest indication for therapeutic endoscopic surgery in infertility. Endometriosis is present in 15-20 % of laparoscopies performed for infertility. The diagnosis of endometriosis a visual one either by laparoscopy or laparotomy. Early endometriosis appears as red, white or black lesions in the pelvis. The early lesions are excised or coagulated with bipolar diathermy at laparoscopy. In severe endometriosis the ovaries became adherent to the tube, uterus or pelvic sidewall. The ovaries may contain endometriotic cysts of varying size. The rectum can also become adherent to uterus and pouch of Douglas. The aim of the conservative surgery is to the restore the anatomy of pelvis and to destroy the endometrial implants. Endometriotic cyst may be treated by enucleation or coagulation of the cyst lining depending on whether the cyst is intraovarian or extraovarian. There is very little role for medical therapy with danozol or GnRH for patients with infertility.

Our experience in treating 532 patients of endometriosis showed a pregnancy rate of 38% for mild endometriosis, 56% for moderate endometriosis and 56% for severe endometriosis 1.

Myomas

Myoma is one of the commonest benign tumors. 25% of women over the age of 35 have myomas 2. Majority of myoma is asymptomatic. The role of myoma in producing infertility and habitual abortion is not proven. However 40-60 % of women complaining of infertility become pregnant after myomectomy, even if no other causes of infertility can be identified 3. A recent study on 88 women with fibroids versus 249 women undergone IVF showed marked reduction in pregnancy rates when the myomas were intramural or submucous 4. Laparoscopic myomectomy is performed for intramural myomas. Meticulous endoscopic suturing and tissue removal are two difficult steps in laparoscopic myomectomy. Excessively large myomas, myomas very close to fallopian tube or uterine vessels are difficult by laparoscopic route 5.Submucous myomas are best treated by hysteroscopic surgery.

We had published our preliminary results of 222 laparoscopic myomectiomies performed from 1993-97. Indications were infertility in 60% cases. Majority of patients had single myoma (64%). 28% of primary infertility and 33 % of secondary infertility patients conceived after Myomectomy 6. Subsequently, we published our experience of 762 women who underwent laparoscopic surgery for uterine leiomyomas over a 13-year period 7. A total of 1,375 myomas were removed; the most common indication was infertility (50.9%), and the majority of myomas (49.52%) were intramural. The mean duration of surgery was 95 min, and the average blood loss was 250.5 ml. The average hospital stay was 1.3 days. Major complications included an unexplained postoperative death and one laparotomy for postoperative bleeding. The risk of complications is comparable to that with the open procedure, whereas morbidity and length of hospital stay are much lower.

Most ovarian cysts in pre-menopausal women are benign. So in selected patients, management of ovarian cysts via operative laparoscopy is appropriate. The main objection to laparoscopic management of ovarian cyst is fear of spillage of cancer cells into peritoneal cavity if the tumor turns out to be malignant. Various studies have reported the rate of relapse and progress of ovarian cancer was not influenced by intraoperative spillage of tumor 8,9 .

Preoperative evaluation with sonography, color Doppler and tumor markers helps you to evaluate the malignant potential of the tumor. Ovarian cystectomy or oophorectomy is treatment depending on the type of cyst, age and fertility of the patient.

We treated 206 ovarian mass laparoscopically- 54 teratomas, 67 serous tumors, 27 mucinous cysts, 36 paraovarian cysts and 22 miscellaneous type. Majority was treated by cystectomy and rest adnexctomy. We encountered 4 borderline malignancies in this series.

Tubal disease

Tubal factor is responsible in 20% of the women with infertility. The most common predisposing factors are pelvic inflammatory disease, previous pelvic surgery, endometriosis, pelvic tuberculosis and appendicitis. The common presentations are tuboovarian adhesions, proximal tubal block and distal tubal block or hydrosalpinx. Adhesions are treated by adhesiolysis laparoscopically. Proximal tubal block is now treated by hysteroscopic cannulation. Hydrosalpinx can be managed by salpingoneostomy. Major degree tubal damage is now better treated by IVF than surgery.

Approximately 1% of the women who undergo this procedure subsequently request reversal of tubal sterilization. The conventional method for reversal of tubal sterilization is microsurgical tubal anastomosis by laparotomy10. Recent improvements in laparoscopic microsurgical instruments allow tubal anastomosis to be performed by laparoscopy.11

Microsurgical tubal anastomosis is the gold standard for reversal of sterilization. This includes the following principles: proper magnification, use of microsurgical instruments to minimize tissue damage, gentle handling of tissues, proper dissection, excision of damaged and fibrosed tissues, meticulous haemostasis, avoiding overzealous electrodessication, keeping the tissues moist, avoidance of talc from surgical gloves and the use of fine non-absorbable 6/0 to 8/0 sutures.

The traditional technique involves the use of an operating microscope after gaining access to the abdominal cavity via a laparotomy. Fine scissors or monopolar diathermy is used to dissect the serosa over the area of blockage, resecting the affected area and applying 3 to 4 concentric sutures in the tubal muscularis with the knots placed outside the tubal lumen. The serosa is then approximated over the site of reanastomosis with a further layer of fine sutures, generally 6/0 in size.

Even though this method offers a high success rate with intrauterine pregnancy rates of 60 to 80%; there are a number of drawbacks.11 They are requirement of a laparotomy, prolonged hospitalization and the increased possibility of adhesion formation leading to impaired fertility.

Minimal access techniques using laparoscopy have recently been developed which allow successful reanastomosis without the need for laparotomy or microscopes. Laparoscopy avoids tissue drying, foreign body contamination and tissue abrasion from packs and bleeding from an incision. It also allows for meticulous haemostasis and reduced tissue manipulation. Hospitalization can be reduced considerably and the development of adhesions is uncommon when the open approach is avoided.

A number of different minimal access techniques have been proposed for tubal anastomosis, including sutures11, tissue glues12, clips13, combined hysteroscopic and laparoscopic approaches14 and combined laparoscopy and minilaparotomy15.

Reversal of tubal sterilization by laparoscopy first was attempted by Sedbon et al. with the use of biologic glue as a tissue adhesive material and an intraluminal guide wire 16. In 1992, Koh and Janik presented the world's first laparoscopic tubal anastomosis for reversal of sterilization using microsurgical techniques17. Since then, advances in both instrumentation as well as in surgical technique have led to the acceptance of laparoscopic microtubal anastomosis as an acceptable alternative to the open technique with major advantages and comparable results.

Patient selection and prognostic factors

Multiple factors affect the outcome of microtubal anastomosis. They include the type of prior sterilization, the site of anastomosis, the length of the reconstructed tube, presence of other pelvic disease, the interval between the sterilization and the tubal surgery, the age of the patient, the presence of other factors affecting fertility and the type and quality of surgery.

Pre-operative evaluation includes an ultrasound of the pelvis, a hysterosalpingogram and semen analysis of the male partner. Although a preliminary laparoscopic evaluation prior to surgery may be useful in planning the surgical approach, we perform laparoscopic anastomosis as a single step procedure.

Equipments and instruments

A magnification of 20 to 40 is essential for identifying healthy mucosa and muscularis, before anastomosis can be performed. The quality of the picture depends on both the camera and the monitor. This magnification can be achieved by using a 3-chip CCD camera with zoom facility and a 20-inch high-resolution video monitor.

Micro-instruments are essential for effective laparoscopic suturing. Needle holders and graspers with sandblasted tips to reduce glare, atraumatic terminal serrations, jaw apposition without slippage of fine sutures and a sensitive handle design are essential. A range of instruments are available like 3 mm Koh ultra-microsurgical instruments from Karl Storz.

7-0 or 8-0 polypropylene / nylon sutures with easily penetrable needles are ideal for tubal anastomosis.

Surgical technique

Four types of anastomosis are possible: Isthmo-isthmic, isthmo-ampullary, ampullo-ampullary, and tubo-cornual. The lumen size is very small in isthmo-isthmic anastomosis, but a thick muscularis allows a technically easier anastomosis and good pregnancy outcome. Luminal disparity is a technical problem in isthmo-ampullary anastomosis. In ampullo-ampullary anastomosis, the thin muscularis and prolapse of mucosal folds can be a problem. Tubocornual anastomosis is the most technically difficult tubal surgery.

The surgical procedure involves transection of the tubal stumps and removal of scar tissue, approximation of the mesosalpinx, anastomosis of the muscle and mucosa, and approximation of the serosal layer.

The operative technique is as follows:

The results obtained by laparoscopic microsurgical anastomosis look promising with good intrauterine pregnancy rates of 60-80% and a very low ectopic pregnancy rate of 1-6%. The major published series include:

	YEAR	PATIENTS	INTRAUTERINE PREGNANCIES	LIVE BIRTHS	ECTOPIC PREGNANCIES
Dubuisson et al 18	1998	32	17	13 (40.6 %)	Not stated
Bisonette et al 19	1999	102	64	49 (50.5 %)	5
Yoon et al 20	1999	202	154	98 (48.5 %)	5
Mettler et al 21	2001	28	15	15 (53.6 %)	2
Cha et al 22	2001	37	28	NS	1

We have performed 80 cases of laparoscopic tubal anastomosis since 1996. The technique of anastomosis is similar to the one in open microsurgery. The tubectomy site was prepared in 2 layers and anastomosis was done with four 7-0 prolene sutures. 3 mm Koh instruments were used for the anastomosis. 45 cases were following tubectomy by Pomeroy’s method and 35 cases were of those following sterilization using Fallope’s rings. 70 cases, an anastomosis was done on only one side. 44 patients (55%) became pregnant and the majority conceived within 9 months. 6 patients had ectopic pregnancies (7.5%).

CONCLUSION

The large series of cases mentioned above are evidence that laparoscopic tubal anastomosis is not just feasible but equally effective as open methods with much less postoperative discomfort and morbidity, more rapid return to activity and improved cosmesis. Recent studies using the Zeus and the da Vinci robotic systems for laparoscopic tubal anastomosis have shown good results but are limited by the high costs and the increased operating time 23,24.