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Is laparoscopy back?
Is laparoscopy back? Avner Hershlag, M.D., and Jacob Markovitz, M.D. Center for Human Reproduction, Department of Obstetrics/Gynecology, North Shore University Hospital–NYU School of Medicine, Manhasset, New York
Should surgical treatment of presumed endometriosis be advocated for all patients who fail to conceive after multiple IVF cycles? Without appropriately designed clinical studies, there is currently little evidence to support this approach. (Fertil Steril威 2005;84:1585– 6. ©2005 by American Society for Reproductive Medicine.) Key Words: Laparoscopy, endometriosis, IVF
It was after a prolonged courtship, and with many objections of parties involved on both sides, that laparoscopy and human embryology were finally wed, through the prolific collaboration of Patrick Steptoe and Robert Edwards, respectively. It was laparoscopy, during the better part of the first decade of IVF, which allowed us exclusive access to the ovaries and enabled the surgeon to provide the embryologist with oocytes. Although the two disciplines continued to enjoy a cordial relationship, each started to take off on its own. While IVF slowly made the transition from an experimental procedure to an established treatment with pregnancy rates (PR) increasing gradually, laparoscopy developed from a simple diagnostic technique into a sophisticated treatment modality. Operative laparoscopy, with newly developed equipment and high-resolution optics, had largely replaced laparotomy procedures for a multitude of pelvic pathologies, including leiomyomas, tubal disease, and all levels of endometriosis. The emergence of vaginal ultrasound led to a swift break of IVF away from laparoscopy. The vaginal approach proved superior, easier, and more patient friendly. In addition to the simplified access to the ovaries, refinement of controlled ovarian hyperstimulation (COH) along with fine-tuning of laboratory techniques, led to dramatic improvement in implantation as well as live birth rates. Rather than merely a “tubal bypass” procedure, by the mid-90s IVF became an acceptable treatment for the entire gamut of infertility etiologies, including endometriosis. With reproducible success rates, IVF has provided us with a unique model to revisit old, unproven concepts. In the absence of a unifying theory to explain infertility resulting from endometriosis, successful IVF treatment without surgery would have provided evidence against many of the old hypotheses. Three separate centers reported such findings in 1995 (1–3). No difference was found in PRs between pa-
Received March 17, 2005; revised and accepted March 17, 2005. Reprint requests: Avner Hershlag, M.D., Department of Obstetrics/Gynecology, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030 (FAX: 515-562-1710; E-mail: hershlag@ nshs.edu).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2005.03.089
tients with endometriosis and tubal factor in a series of 360 IVF cycles (1). Patients with endometriosis conceived at the same rate as controls (3). In addition, there was no discernible difference in success rates across the various stages of endometriosis (1–3). Such reports provided the rationale for using IVF as a “laparoscopy bypass” in patients with endometriosis. Overall, diagnostic as well as operative laparoscopy has been removed, to a large degree, from the treatment algorithms of most fertility centers in this country as well as around the world. In this issue of Fertility and Sterility, the distinguished group from Stanford University Medical Center attempts to return laparoscopy to the pivotal role it had once played in the treatment of patients with endometriosis (4). We read this study with great interest and much anticipation, given that this center has consistently reported excellent success rates in IVF, while continuing to be a major referral center for operative laparoscopy. In this report, the investigators advocate the nonselective use of laparoscopy in patients with multiple IVF failures. The series is retrospective, and the control group is of similar patients who have chosen not to undergo surgery. Had this study been planned ahead, done prospectively and randomized appropriately, it would have provided much needed information pertinent to our everincreasing subspecialty. However, this particular study suffers from almost all the ailments inherent to retrospective chart reviews. First and foremost, 100% of the patients in the study (surgical) group had endometriosis. Is this a reflection of different diagnostic standards, or of a different patient population than the reported 20%–50% prevalence of endometriosis in infertility patients (5)? In addition, most of these patients had stage III and IV disease. In all likelihood, at least some of them were complaining of pain, and some would have even had sonographic evidence of their disease, including the seven patients with endometriomas. Therefore, the “control” group does not seem to be appropriately matched. Patients with symptoms or signs of endometriosis, for whom surgery was probably encouraged, would have opted in most cases to follow their doctor’s recommendation. Not only are the investigators comparing apples and oranges, the apples too are of different varieties.
Fertility and Sterility姞 Vol. 84, No. 6, December 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
1585
Because of the retrospective nature of this report, they could not have implemented a uniform approach to the patients’ treatment before surgery, making evaluation of the benefit from surgery impossible. There is another aspect of this type of management that the investigators do not relate to at all; the morbidity and mortality associated with operative laparoscopy. Although the term “minimally invasive surgery” may imply a minor surgical procedure, many such procedures are quite extensive, last several hours, and are associated with significant morbidity and even mortality. It is therefore imperative that any argument that supports increasing the extent of surgical intervention in the infertile patient population should be based on sound evidence.
1586
Hershlag and Markovitz
Is laparoscopy back?
REFERENCES 1. Olivennes F, Feldberg D, Liu H, Cohen J, Moy F, Rosenwaks Z. Endometriosis: a stage by stage analysis—the role of in vitro fertilization. Fertil Steril 1995;64:392– 8. 2. Gerber S, Paraschos T, Atkinson G, Margara R, Winston RML. Results of IVF in patients with endometriosis: the severity of the disease does not affect outcome, or the incidence of miscarriage. Hum Reprod 1995;10: 1507–11. 3. Dmowski WP, Rana N, Michalowska J, Friberg J, Papierniak C, El-Roeiy A. The effect of endometriosis, its stage and activity, and of autoantibodies on in vitro fertilization and embryo transfer success rates. Fertil Steril 1995;63:555– 62. 4. Littman E, Giudice L, Lathi R, Berker B, Milki A, Nezhat C. Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization. Fertil Steril 2005;84:1574 – 8. 5. Pritts E, Taylor R. An evidence-based evaluation of endometriosisassociated infertility. Endocrinol Metab Clin N Am 2003;32:653– 67.
Vol. 84, No. 6, December 2005
Should surgical treatment of presumed endometriosis be advocated for all patients who fail to conceive after multiple IVF cycles? Without appropriately designed clinical studies, there is currently little evidence to support this approach. (Fertil Steril威 2005;84:1585– 6. ©2005 by American Society for Reproductive Medicine.) Key Words: Laparoscopy, endometriosis, IVF
It was after a prolonged courtship, and with many objections of parties involved on both sides, that laparoscopy and human embryology were finally wed, through the prolific collaboration of Patrick Steptoe and Robert Edwards, respectively. It was laparoscopy, during the better part of the first decade of IVF, which allowed us exclusive access to the ovaries and enabled the surgeon to provide the embryologist with oocytes. Although the two disciplines continued to enjoy a cordial relationship, each started to take off on its own. While IVF slowly made the transition from an experimental procedure to an established treatment with pregnancy rates (PR) increasing gradually, laparoscopy developed from a simple diagnostic technique into a sophisticated treatment modality. Operative laparoscopy, with newly developed equipment and high-resolution optics, had largely replaced laparotomy procedures for a multitude of pelvic pathologies, including leiomyomas, tubal disease, and all levels of endometriosis. The emergence of vaginal ultrasound led to a swift break of IVF away from laparoscopy. The vaginal approach proved superior, easier, and more patient friendly. In addition to the simplified access to the ovaries, refinement of controlled ovarian hyperstimulation (COH) along with fine-tuning of laboratory techniques, led to dramatic improvement in implantation as well as live birth rates. Rather than merely a “tubal bypass” procedure, by the mid-90s IVF became an acceptable treatment for the entire gamut of infertility etiologies, including endometriosis. With reproducible success rates, IVF has provided us with a unique model to revisit old, unproven concepts. In the absence of a unifying theory to explain infertility resulting from endometriosis, successful IVF treatment without surgery would have provided evidence against many of the old hypotheses. Three separate centers reported such findings in 1995 (1–3). No difference was found in PRs between pa-
Received March 17, 2005; revised and accepted March 17, 2005. Reprint requests: Avner Hershlag, M.D., Department of Obstetrics/Gynecology, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030 (FAX: 515-562-1710; E-mail: hershlag@ nshs.edu).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2005.03.089
tients with endometriosis and tubal factor in a series of 360 IVF cycles (1). Patients with endometriosis conceived at the same rate as controls (3). In addition, there was no discernible difference in success rates across the various stages of endometriosis (1–3). Such reports provided the rationale for using IVF as a “laparoscopy bypass” in patients with endometriosis. Overall, diagnostic as well as operative laparoscopy has been removed, to a large degree, from the treatment algorithms of most fertility centers in this country as well as around the world. In this issue of Fertility and Sterility, the distinguished group from Stanford University Medical Center attempts to return laparoscopy to the pivotal role it had once played in the treatment of patients with endometriosis (4). We read this study with great interest and much anticipation, given that this center has consistently reported excellent success rates in IVF, while continuing to be a major referral center for operative laparoscopy. In this report, the investigators advocate the nonselective use of laparoscopy in patients with multiple IVF failures. The series is retrospective, and the control group is of similar patients who have chosen not to undergo surgery. Had this study been planned ahead, done prospectively and randomized appropriately, it would have provided much needed information pertinent to our everincreasing subspecialty. However, this particular study suffers from almost all the ailments inherent to retrospective chart reviews. First and foremost, 100% of the patients in the study (surgical) group had endometriosis. Is this a reflection of different diagnostic standards, or of a different patient population than the reported 20%–50% prevalence of endometriosis in infertility patients (5)? In addition, most of these patients had stage III and IV disease. In all likelihood, at least some of them were complaining of pain, and some would have even had sonographic evidence of their disease, including the seven patients with endometriomas. Therefore, the “control” group does not seem to be appropriately matched. Patients with symptoms or signs of endometriosis, for whom surgery was probably encouraged, would have opted in most cases to follow their doctor’s recommendation. Not only are the investigators comparing apples and oranges, the apples too are of different varieties.
Fertility and Sterility姞 Vol. 84, No. 6, December 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
1585
Because of the retrospective nature of this report, they could not have implemented a uniform approach to the patients’ treatment before surgery, making evaluation of the benefit from surgery impossible. There is another aspect of this type of management that the investigators do not relate to at all; the morbidity and mortality associated with operative laparoscopy. Although the term “minimally invasive surgery” may imply a minor surgical procedure, many such procedures are quite extensive, last several hours, and are associated with significant morbidity and even mortality. It is therefore imperative that any argument that supports increasing the extent of surgical intervention in the infertile patient population should be based on sound evidence.
1586
Hershlag and Markovitz
Is laparoscopy back?
REFERENCES 1. Olivennes F, Feldberg D, Liu H, Cohen J, Moy F, Rosenwaks Z. Endometriosis: a stage by stage analysis—the role of in vitro fertilization. Fertil Steril 1995;64:392– 8. 2. Gerber S, Paraschos T, Atkinson G, Margara R, Winston RML. Results of IVF in patients with endometriosis: the severity of the disease does not affect outcome, or the incidence of miscarriage. Hum Reprod 1995;10: 1507–11. 3. Dmowski WP, Rana N, Michalowska J, Friberg J, Papierniak C, El-Roeiy A. The effect of endometriosis, its stage and activity, and of autoantibodies on in vitro fertilization and embryo transfer success rates. Fertil Steril 1995;63:555– 62. 4. Littman E, Giudice L, Lathi R, Berker B, Milki A, Nezhat C. Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization. Fertil Steril 2005;84:1574 – 8. 5. Pritts E, Taylor R. An evidence-based evaluation of endometriosisassociated infertility. Endocrinol Metab Clin N Am 2003;32:653– 67.
Vol. 84, No. 6, December 2005