Laparoscopie en infertiliteit Koen Clasen CRG-UZA VWRG postgraduaatcursus “Reproductieve geneeskunde in de praktijk”

Inleiding Basisartikel: The position of diagnostic laparoscopy in current fertility practice Bosteels J., Van Herendael B., Weyers S. & D’Hooghe T. Human Reproduction Update Vol.13, No 5: pp. 477-485, 2007

Inleiding Jaren 1990: Diagnostische laparoscopie = eindpunt diagnostiek AFS 1992 WHO manual 1993 +/- overbodig in 40-70% Mogelijkheid tot: Behandeling (‘See & treat’-princiepe) Combinatie met hysteroscopie Complicaties Forman R.G., et al; Hum. Reprod. 1993

Inleiding Laatste jaren: Diagnostische laparoscopie = onder vuur Te weinig nut Te duur Te veel risico’s …

Na/tijdens behandeling Diagnostisch vs Therapeutisch  Ja Iedereen vs  Laparoscopie  vs Neen Selectie  Voor start Na/tijdens behandeling

Selectiecriteria Anamnese (Screenings) Onderzoek HSG CAT Voor/tijdens/na behandeling

Anamnese Voorgeschiedenis van: PID Gecompliceerde appendicitis Pelviene heelkunde Buitenbaarmoederlijke zwangerschap Endometriose (SOA) Luttjeboer F.Y., et al; BJOG 2009

Screening HSG Screening tubaire doorgankelijkheid Specificiteit 83% Sensitiviteit 65% Swart P., et al; Fertil. Steril. 1995

Screening HSG vs LSC Adjusted Fecundity Rate Ratio HSG LSC Unilaterale occlusie 0,80 0,51 Bilaterale occlusie 0,49 0,15 Swart P., et al; Fertil. Steril. 1995

Screening HSG vs LSC HSG bilateraal doorgankelijk + LSC bilaterale occlusie = 5% “95% predictie voor normaal” Swart P., et al; Fertil. Steril. 1995

Screening HSG vs LSC HSG bilaterale occlusie + LSC bilateraal doorgankelijk = 42% “LSC very useful to prevent overtreatment with IVF” Swart P., et al.; Fertil. Steril. 1995; Tanahatoe S. et al.,Reprod. Biomed. Online 2008

Screening HSG vs LSC HSG LSC FRR Bilaterale occlusie Unilaterale occlusie 0,38 0,19 Swart P., et al; Fertil. Steril. 1995

Screening CAT vs HSG “Discriminative capacity of CAT in the diagnosis of any tubal pathology is comparable to that of HSG” Mol B.W.L., et al.; Fertil. Steril. 1997

Screening CAT vs LSC Chlamydiatiter niet belangrijk indien tubae nl doorgankelijk op LSC “LSC is key to prognosis” El Hakim E.A., et al;. Reprod. Biomed. Online 2009

Screening Kosten/baten analyse: “Good prognosis”: CAT “Poor prognosis”: HSG Gevolgd door LSC Mol B.W.L., et al.; Fertil. Steril. 2003

Flow chart CAT       LSC    HSG        LSC    HSG  Tanahatoe S., et al.; Reprod. Biomed. Online 2008; Den Hartog J.E., et al.; Hum. Reprod. 2008

Timing Onverklaarde infertiliteit: Wijziging behandelplan na LSC “Early” LSC aanbevolen Primair 43% Secundair 49% Kahyaoglu S., et al.; J. Obstet. Gynaecol. Res. 2009

Timing Cijfers (uiteraard) afhankelijk van prevalentie pathologie: Onverklaarde infertiliteit: 14% wijziging behandelplan Naar ART (= IVF) Wegens ernstige tubaire problematiek Tsuji I., et al.; Tohoku J. Exp. Med.. 2009

Timing Cijfers (uiteraard) afhankelijk van prevalentie pathologie: Onverklaarde infertiliteit: Standaard LSC bij beëindigen OFO 47% endometriose 40% (21%) “fertility reducing nonendometriotic pelvic pathology” Meuleman C., et al. Fertil. Steril. 2009

Behandeling Van gevonden pathologie: Beperkte gegevens: CPR  Geen  12m 32% 11% 24m 45% 16% Tulandi T., et al. Am. J. Obstet. Gynecol. 1990

Behandeling Van gevonden pathologie: Nuttig, indien: < 37 jaar “Niet te lange duur” Mogelijk via LSC Anders: IVF Niet bevestigd in Cochrane meta-analyse Zarei A., et al. Clin. Obstet. Gynecol. 2009

Surgery for tubal infertility - 2008 Objectives: To determine wether surgery improves the probability of livebirth compared with expectant management or IVF in the context of tubal infertility (regardless of grade of severity). Main results: 0 RCT’s No evidence. Pandian Z., et al, Cochrane Database of Systematic Reviews 2008, Issue 3

Surgery for tubal infertility - 2008 Authors’ conclusions: Any effect of tubal surgery relative to expectant management and IVF in terms of livebirth rates for women with tubal infertility remains unknown. Large trials with adequate power are warranted to establish the effectiveness of surgery in these women. Pandian Z., et al, Cochrane Database of Systematic Reviews 2008, Issue 3

Techniques for pelvic surgery in subfertility - 2006 Objectives: To evaluate The role of tubal surgery in the management of tubal infertility Surgical techniques for the treatment of tubal infertility Main results: 7 RCT’s No evidence of benefit or disadvantage for the use of CO2 laser for: Adhesiolysis: OR pregnancy 1,07; 95%CI 0,40-2,87 Salpingostomy: OR pregnancy 1,38; 95%CI 0,47-4,05 No evidence of benefit or disavantage when laparoscopy was compared to laparotomy No evidence of benefit or disadvantage for the use of thermocoagulation or electrocoagulation at adhesiolysis: OR pregnancy 0,87; 95%CI 0,51-1,46 Ahmad G., et al, Cochrane Database of Systematic Reviews 2006, Issue 2

Techniques for pelvic surgery in subfertility - 2006 Authors’ conclusions: Limited data No evidence: Of benefit or disadvantage of tubal surgery versus no treatment or alternative treatments Of advantage or disadvantage of: using microsurgery over standard techniques laparoscopic approach over laparotomy the use of CO2 laser electrocoagulation over thermocoagulation Randomised controlled trials should be undertaken to: Determine the role of tubal surgery versus no treatment alternative treatments at tubal surgery of: magnification laparosopic approach the use of lasers or electrocoagulation Ahmad G., et al, Cochrane Database of Systematic Reviews 2006, Issue 2

Behandelplan en/of pathologie In functie van behandelplan: Voor/tijdens/na: Ovulatie-inductie IUI IVF/ICSI In functie van gevonden pathologie: PCO zie deel P. De Sutter Endometriose zie deel T. D’Hooghe Hydrosalpinx

Behandelplan Voor Ovulatie-Inductie: Traject HSG + LSC = traject LSC Geen gegevens over HSG + LSC vs HSG Perquin D.A.M., et al. Hum. Reprod. 2006

Behandelplan Tijdens/na Ovulatie-Inductie: LSC na 4 (gefaalde) cycli: 36% volledig normaal 33% (belangrijke) pelviene adhesies 31-67% overbodig? Ochoa Capelo F., et al. Fertil. Steril. 2003

Behandelplan Voor IUI: Mannelijk/Cervicaal/Idiopatisch HSG normaal 21/495 (4%) severe abnormalities 124/495 (40%) wijziginging behandelplan 103/495 (21%) LSC mogelijk therapeutisch nut (40/495 (8%) nonendometriotic) Tanahatoe S., et al. Fertil. Steril. 2003

Behandelplan Voor IUI: LSC f IUI f Randomizatie 77 Drop out 10 3 Zwanger 13 Trial gestart 64 61 IUI 54 Trial voltooid (niet zwanger) 22 23 Tanahatoe S., et al. Hum. Reprod. 2005

Behandelplan Voor IUI: LSC f IUI f OR 95% CI LSC 64 23 Pathologie “We seriously question the value of routinely performing a diagnostic and/or therapeutic LSC prior to IUI.” LSC f IUI f OR 95% CI LSC 64 23 Pathologie 31 (48%) 13 (56%) 1,4 0,5-3,6 Zwanger 34 (44%) 38 (49%) 1,2 0,7-2,3 Tanahatoe S., et al. Hum. Reprod. 2005

Behandelplan Voor/tijdens/na IVF/ICSI Enkel gegevens in functie van gevonden pathologie: PCO zie deel P. De Sutter Endometriose zie deel T. D’Hooghe Hydrosalpinx

Pathologie PCO Ovariële drilling zinvol bij CC resistentie Bevestigd in Cochrane meta-analyse Zie deel P. De Sutter

Laparoscopic ‘drilling’ by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome - 2006 Objectives: To determine the effectiveness and safety of laparoscopic ovarian drilling compared with ovulation induction for subfertile women with clomiphene-resistant PCOS. Main results: 9 RCT’s No evidence of a difference in life birth rate between: LOD: OR 1,04; 95% CI 0,59-1,85 Gonadotrophins: OR 1,08; 95 CI 0,69-1,71 Multiple pregnancy rates: LOD 1% vs Gonadotrophins 16% OR 0,13; 95% CI 0,03-0,52 No evidence of difference in miscarriage rates: OR 0,81; 95%CI 0,36-1,86 Farquhar C., et al, Cochrane Database of Systematic Reviews 2007, Issue 3

Laparoscopic ‘drilling’ by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome - 2006 Authors’ conclusions: No evidence of a difference in: Live birth rate Miscarriage rate Reduction in multiple pregnancy rate makes this option attractive. Ongoing concerns about long-term effects of LOD on ovarian function. Farquhar C., et al, Cochrane Database of Systematic Reviews 2007, Issue 3

Pathologie Hydrosalpinx Hogere zwangerschapspercentages als: Verwijderd Voor IVF Vooral als: Bilateraal Echografisch zichtbaar Zwangerschap 55% vs 16% OR 3,48 95% CI 1,11-10,59 Bevestigd in Cochrane meta-analyse Strandell A., et al. Hum. Reprod. 1999

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation - 2010 Objectives: To assess and compare the value of surgical treatments for tubal disease prior to IVF. Main results: 5 RCT’s No trials reported on life birth rates. Ongoing and clinical pregnancy rates increased with: Laparoscopic salpingectomy For hydrosalpinges Prior to IVF Ongoing: OR 2,14; 95% CI 1,23-3,73 Clinical: OR 2,31; 95% CI 1,48-3,62 No significant advantage of either tubal occlusion or salpingectomy: Ongoing: 1,65; 95%CI 0,74-3,71 Clinical: 1,28; 95% CI 0,76-2,14 Johnson N., et al, Cochrane Database of Systematic Reviews 2010, Issue 1

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation - 2010 Authors’ conclusions: Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. Previous evidence supported unilateral salpingectomy for a unilateral hydrosalpinx and bilateral salpingectomy for bilateral hydrosalpinges. This review now provides evidence that laparoscopic tubal occlusion is an alternative to laparoscopic salpingectomy. Johnson N., et al, Cochrane Database of Systematic Reviews 2010, Issue 1

Take home message Diagnostische laparoscopie is geen routine onderzoek Klinische selectie is nodig, oa op basis van: Anamnese Screening (HSG/CAT) Behandelplan Bewezen therapeutische interventies beperkt: LOD bij cc resistente PCO Salpingectomie of tubaire occlusie bij hydrosalpinx voor start IVF

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