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H YSTEROCOPIC SURGERY AND SUCCESS OF IVF/ICSI

H YSTEROCOPIC SURGERY AND SUCCESS OF IVF/ICSI . Prof .dr. Tomaž Tomaževič Ljubljana, Slovenia Brioni , 5-8 september 2013. Uncredible p rogress of infertility treatment during last 30 years.

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H YSTEROCOPIC SURGERY AND SUCCESS OF IVF/ICSI

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  1. HYSTEROCOPIC SURGERY AND SUCCESS OF IVF/ICSI Prof .dr. Tomaž Tomaževič Ljubljana, Slovenia Brioni , 5-8 september 2013

  2. Uncredibleprogressofinfertilitytreatmentduring last 30 years • Not onlybecauseoffantasticdevelopmentofendocrinologyand IVF, butalsobecauseofbetterdiagnostics (VUS) andlessinvasivesurgicaltreatment . • Due to theprogress, todaywealsobetterunderstandtheclinicalimportanceofuterineinfertilityfactor.

  3. Today it is clear that the presence of variousintrauterine abnormalities is associatedwith decreased fertility • Therefore it is important to look at the role ofhysteroscopicsurgery in the modern infertilitytreatment .

  4. Hysteroscopicsurgery in naturalconception ? • Thirtyyearsago theuterineinfertilityfactorseemed to berarelypresentand to beratherunimportant. • Becauseofresults in manyobservationalstudies on hysteroscopicsurgery, reportinggoodresults in termsoffertilityandpregnancyoutcomes , the views on clinical importance of uterineinfertilityfactorhave slowlybeen altered. • Theimportanceofuterineabnormalities as infertilityfactors in naturalconceptionhasonlyrecentlybeenprooven in fiveprospectivecontrolstudies: on hysteroscopicmyomectomyandhysteroscopicmetroplasty in unexplainedinfertility . • Studiesclearlyshowed : thatubmucousmyomasanduterineseptaedecreaseandhysteroscopymetroplastyimprovesnaturalfertility ( Casini 2006, Shokeir T 20010, Pabuccu2004, Mollo 2009, Shokeir 2011).

  5. Hysteroscopicsurgeryin IVF/ICSI? • Hysteroscopicsurgery was introducedto improveoutcomes in pregnanciesafter IVF/ICSI. • Withtheuseof IVF/ICSI webypassedallinfertilityfactorsexcept uterus andembryo. • Bystudyingtheresultsof IUI and IVF/ICSI in womenwithtreated , nontreatedand no uterinedisorderswegotnewclinicalinformations on uterinedisordersandinfertility

  6. According to Pavoneetal., based on evidence, uterineevaluationhasbecomeanimportant part of modern simplifiedinfertilitytreatment • In thereviewarticlebyT . Tulandiand Akkour K. • Role of reproductive surgery in the era of assistedreproductivetechnology In theJournal. Clinical Obstetrics andGynaecologyBest Practice & Research26 (2012) 747–755 • Authorssay, thatbased on evidence, hysteroscopiccorrectionofintrauterinedisordersis animportantendoscopic procedure in womenwithinfertility. • Pavone M E etal. Simplificationof modern infertilitytreatmentObstetrial & GynecologicalSurvey 2011

  7. Let us seetheevidences. In the T. Tulandireviewpapers, thefollowing evidence basedpapers on hysteroscopicsurgery, uterinedisordersandinfertility, havebeencited : Thestudyby Perez Medina etal (2005) (polyps) . ThestudybyShokeiretal, (2010) ( submucousmyoma) TheStudybyTomazevicetal. (2010) (hysteroscopicmetroplasty) No study ( hysteroscopicadhaesiolysis)

  8. :Perez Medina etal.. In Hum Reprod 2005;20: 1632–1635publishedaprospectiverandomised-controlled trial : 215 womenwith up to four IUI treatmentcycleswereincluded • Study : Polypectomy(N=107) • Control:Biopsy(N=108). Furthermore, more than one-half of women in the polypectomy groupconceived spontaneously within 3 months after surgery.

  9. Shokeiretal. In Fertil. Steril. 2010;94:724–729 published a prospectiverandomisedcontroltrial on hysteroscopicmyomectomyandnaturalconception . • A meta-analysis supported these findings (Pritts 2009). (RR, 0.36%; 95% CI, 0.18–0.74). • The miscarriage rate decreased after surgery • . Submucousmyomasandtheirimplications in thepregnancyratesofpatientswithotherwiseunexplaindinfertilityundergoinghysteroscopicmyomectomy : St N= 101 vs. C N=103 RR 2,1 . 95% CI 1.5-2,9

  10. TheresultsbyShokeiret-al. in naturalconception, agreewithfindingsofEldar_ Geva T etal. in assistedconception (1998) Eldar-Geva T, Meagher S, Healy DL, MacLachlan V, BrehenyWood CFertilSteril. 1998 Oct;70(4):687-91 • Effect of intramural, subserosal, submucosaluterine fibroids and no fibroidon the IVF • A retrospectivecomparativestudy : • 106 studyvs. 318 controlcycles

  11. Tomazevic T, Ban H etalpublished a retrospectivematchedcontrolstudy - Septate, subseptateandarcuate uterus decreasepregnancyandlivebirthratesin IVF/ICSI- RBMO 2010; 21: 700-705 • In a matchedcontrolstudytheyevaluated the effect of uterine septum on IVF outcome among 2481 embryotransfers in IVF and ICSI cycles.

  12. 1) Ban H , Tomaževič T etal. Outcomeofsingletonpregnanciesafter IVF /ICSI in womenbeforeandafterresectionofuterineseptumcompared to normal controls. Matchedcontrolstudy. EJOGRB 2009 ; 146:184-87 . . Study N =31 vs. Control N = 62 411 singleton IVF pregnancies ( FHR +) wereincluded. Uterineseptumincreasesspontaneousabortion in singleton IVF pregnancies • (OR: 12- 15 ) • P<0.001 AFS 6 AFS 5 Aftersurgerythedifferencesdisappeared

  13. 2) Tomaževič T, Ban H etal . : Septate, subseptateandarcuate uterus decreasepregnancyratein IVF/ICSI: matchedcontrolstudy - 2481 ETs. : : OR 7.0 forlargerand OR 2.5 forarcuate uterus (P<0.001) . Aftersurgerythedifferences in pregnancyratedisappeared

  14. 3) Tomaževič T, Ban H etal.Septate, subseptateandarcuate uterus decreaselivebirthrate in IVF/ICSI: - RBMO 2010; 21: 700-705 • OR 30 forlargerand • OR 15 forarcuate uterus – • P<0.001) Aftersurgerythedifferences in livebirthratesdisappeared

  15. Metanalysisof the published resultssupportedthefindingthathysteroscopicmetroplastyimprovesthesucceessin IVF/ET (Valle 2013) Valleetal. HysteroscopicMetroplasty for the Septate Uterus: Reviewand Meta-AnalysisJournal of Minimally Invasive Gynecology, 2013.

  16. Paucityofevidence on theimportanceofhysteroscopicadhesiolysis in ART • Hysteroscopicadhaesiolysisfavourablyinfluencesmenstraulirregularitiesandinfertility . • Theresults in termsofpregnancyratesafterhysteroscopicadaesiolysisdepends on extension, severityofadhesions: • mild 88-100% • moderate 67%-84% • in severe 28% - 57%. • Thesuccessofhysteroscopicoperations. • TulandiT :Although there is paucity of evidence it is logical to create normal uterine environment before IVF /ICSI treatment

  17. Conclusions • Uterineevaluationandhysteroscopicsurgicaltreatmentservesto optimisethesuccessof IVF/ICSI. • Mutatismutandis it servesalso to optimisenaturalconceptionandsuccessofnaturallyconcievedpregnancies. . Twosailors on board ( Adriatic 2012) Thankyoufor yourattention

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