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Pulsed CO2 Laser and Microsurgery
Vol. 48, No.3, September 1987 Printed in U.S.A.
FERTILITY AND STERILITY Copyright @ 1987 The American Fertility Society
Pulsed CO 2 Laser and Microsurgery
1. Badawy SZA, ElBakry MM, Baggish MS, Choe JK: Pulsed
To the Editor: In their article, "Pulsed CO 2 Laser Versus Conventional Microsurgical Anastomosis of the Rat Uterine Horn," Badawy, Baggish, and Choe concluded that the laser section is more efficient in the healing process. 1 Our group, using the same model and the same pulsed CO 2 laser, has obtained different results. We compared adhesion formation and healing process after microsurgical reanastomosis of the rat uterine horn transsected with, respectively, cold knife, argon, Vag, and CO 2 laser (n = 10 in each group). We found minimal adhesions with all kinds of section except with the Vag laser section, which created extended adhesions. Histologic studies showed the best healing with the knife section, with minimal fibrosis. CO 2 laser scars showed some places with atrophy of the epithelium, a thin mucosa, inflammatory process in the muscularis, and little fibrosis, with some disorganization of the layers. In contrast, Yag laser gave the worst results, with a very thin mucosa that even disappears in some cases; collagen fibrosis and disorganization of the layers are important. With argon laser, the results were intermediate. We concluded that CO2 laser section is superior for reduction of adhesions and fewer histologic lesions compared with argon and Yag lasers, but it is with the knife that we had the best healing process. With the development of surgery via laparoscopy, the laser will become a valuable tool in performing neosalpingostomy or surgery of endometriosis. For endometriosis, regarding the better results we obtained with CO2 laser, it seems to be the best choice if we can use laser via optic fibers. Otherwise, laser is of no use by laparotomy because it does not have any advantage over knife and bipolar coagulation. Perhaps Argon laser with other parameters could be used in the same way as laparoscopy.2,3
Claudie Boutteville, M.D. Denis Querleu, M.D. Centre Hospitalier de Roubaix Paris, France February 24, 1987 512
REFERENCES
Letters-to-the-editor
CO 2 laser versus conventional microsurgical anastomosis of the rat uterine horn. Fertil SteriI46:127, 1986 2. Baggish MS, ElBakry MM: Comparison of electronically superpulsed and continuous-wave CO 2 laser on the rat uterine horn. Fertil Steril 45:120, 1986 3. Tulandi T, Vilos GA: A comparison between laser surgery and electrosurgery for bilateral hydrosalpinx: a 2-year follow-up. Fertil Steril 44:846, 1985
Reply of the Authors: We would like to thank Drs. Boutteville and Querleu for their interest in our article. 1 They concluded that the use of pulsed CO 2 laser for cutting the tube was superior to argon and Vag laser. Tissue healing following the use of pulsed CO 2 laser was associated with thin mucosa, little fibrosis, and disorganization of muscularis. In contrast, the use of the knife to cut the tube was associated with minimal fibrosis and best-quality healing. In our article,1 we demonstrated that tissue healing after both pulsed CO 2 laser and microscissors was associated with intact mucosa. Some fibrosis was present in the muscularis and serosa of the conventional group. In the pulsed CO 2 laser group, we found good healing of muscularis without fibrosis or disruption. This may be due to the specifics of pulsed CO 2 laser in use. In our study, we used a power density of 6 X 104 W /cm 2, duty cycle of 400 pulses/sec, and the pulse width was 0.4 X 1O-3/sec. The energy delivered to tissue was 2.24 J and tissue exposure time was 0.16 seconds. Therefore, the use of intermittent high-laser power with pulse repetition allows for cooling of tissues between pulses and minimizes the thermal effect on tissues. This explains the absence of necrosis or fibrosis in the anastomosed tube in our studies. Furthermore, Baggish and ElBakry2 found that the least amount of thermal damage was achieved by the use of pulsed CO 2 laser with a power density of 100,000 to 450,000 W /cm 2 at rates of 300 to 500 pulses/sec, and pulse width between 0.3 and 0.5 ms. H pulse repetition rate is increased to 600 to 700 pulses per second, then the pulsed beam mimics the CW modes of CO 2 laser. Conversely, the use of 300 pulses/sec results in excessive time on tissue exposure and is not advisable for clinical use. Baggish Fertility and Sterility
and ElBakry also found that wounds following CO2 laser are funnel-shaped, thus sparing the endometrium, and this explains the good healing of the mucosa of the rat uteri in this study.2 Therefore, the outcome of the use of pulsed CO 2 laser depends on power density, pulse width, and repetition rate of pulses per second. Drs. Boutteville and Querleu also alluded to the value of laser laparoscopy using fiber. In this regard, Baggish and ElBakry3 published data to suggest that the use of CO 2 laser fiber increases the option available to the gynecologist for operative laparoscopy. The use of the fiber eliminates the necessity of realigning the beam through the operating laparoscope. In addition, the fiber is brought close to the tissue, thus avoiding injury to surrounding structures. Studies are underway in our department for the use of CO 2 laser fiber in patients with endometriosis and adhesions. It is true that the use of CO 2 laser in infertility surgery has an equal success rate to conventional microsurgery.4 However, the use of CO2 laser with its modalities can achieve lysis ()f adhesions in difficult locations, decreasing operating time, and offers the new easy modality of delivering CO2 laser with a flexible fiber through the laparoscope. S. Z. A. Badawy, M.D. M. S. Baggish, M.D. J. K. Choe, M.D. Department of Obstetrics and Gynecology Health Science Center Syracuse, New York April 7, 1987 REFERENCES 1. Badawy SZA, ElBakry MM, Baggish MS, Choe JK: Pulsed CO 2 laser versus conventional microsurgery anastomosis of the rat uterine horn. Fertil Steril 46:127, 1986 2. Baggish MS, ElBakry MM: Comparison of electronically superpulsed and continuous-wave CO 2 laser on the rat uterine horn. Fertil Steril 45:120, 1986 3. Baggish MS, ElBakry MM: A flexible CO2 laser fiber for operative laparoscopy. Fertil Steril46:16, 1986 4. Daniell JF: The role of lasers in infertility surgery. Fertil Steril 42:815, 1984
FSH Accumulation in hMG-Treated Patients
To the Editor: The recent article by Dr. Ben-Rafael and coworkers! on the differences in ovarian stimulation in gonadotropin-treated women and its relationship to follicle-stimulating hormone (FSH) accuVol. 48, No.3, September 1987
mulation is most interesting. The number of cases in each group was small and likewise there were no corresponding pregnancy rates which, after all, is the main goal of an in vitro fertilization (IVF) program. In our IVF program, 2 we too have been measuring serum luteinizing hormones (LH) immediately preceding the triggering human chorionic gonadotropin (hCG) injection and have correlated this with egg quality and pregnancy rates in a series of 100 laparoscopies, excluding male factors. Human menopausal gonadotropin (hMG), 2 to 5 ampules daily, was used for ovarian stimulation, generally starting on day 2 of the cycle. Monitoring included daily sonograms, estradiols (E 2), LHs, and evaluation of cervical mucus. In these hundred cycles, 60 patients had LH levels ~ 9 mID Iml or decreasing levels of LH ~ 12 mID Iml within 3 hours prior to the hCG. The 60 patients with the lower levels of LH had an average of 5.3 eggs obtained, which developed into 4.3 cleaved embryos and had a pregnancy rate of 27% per laparoscopy and 33% per embryo transfer. The 40 patients with higher LH levels had an average of 5.5 eggs obtained with 3.1 embryos and a pregnancy rate of 8% per laparoscopy and 11% per embryo transfer. Pregnancy rates differed at the 0.5 level. Egg morphology, also differed, with the higher LH levels tending to have ova with more cumulus clumping. In our program, we do not measure serum progesterone or testosterone and, in all probability, these were elevated associated with the higher LH levels. Thus, we strongly agree with Dr. Ben-Rafael on the utility of measuring serum LH and we additionally recommend cancelling laparoscopies in cases of higher LH in order to achieve better pregnancy rates per laparoscopy.
Arnold Jacobson, M.D. Donald 1. Galen, M.D. Founders of the John Muir Memorial Hospital In Vitro Fertilization Program Walnut Creek, California March 5, 1987 REFERENCES 1. Ben-Rafael Z, Strauss JF III, Mastroianni L Jr, Flickinger GL: Differences in ovarian stimulation in human menopausal gonadotropin treated women may be related to follicle-stimulating hormone accumulation. Fertil Steril 46:586, 1986 2. Jacobson A, Zorn G, Galen D, Kronick E, Adams C, Hill D, Beernink F, Beernink H: The deleterious effect of LH rises on egg quality and pregnancy rates in an IVF program (Abstr). Presented at the Fifth World Congress on in Vitro
Letters-to-the-editor
513
FERTILITY AND STERILITY Copyright @ 1987 The American Fertility Society
Pulsed CO 2 Laser and Microsurgery
1. Badawy SZA, ElBakry MM, Baggish MS, Choe JK: Pulsed
To the Editor: In their article, "Pulsed CO 2 Laser Versus Conventional Microsurgical Anastomosis of the Rat Uterine Horn," Badawy, Baggish, and Choe concluded that the laser section is more efficient in the healing process. 1 Our group, using the same model and the same pulsed CO 2 laser, has obtained different results. We compared adhesion formation and healing process after microsurgical reanastomosis of the rat uterine horn transsected with, respectively, cold knife, argon, Vag, and CO 2 laser (n = 10 in each group). We found minimal adhesions with all kinds of section except with the Vag laser section, which created extended adhesions. Histologic studies showed the best healing with the knife section, with minimal fibrosis. CO 2 laser scars showed some places with atrophy of the epithelium, a thin mucosa, inflammatory process in the muscularis, and little fibrosis, with some disorganization of the layers. In contrast, Yag laser gave the worst results, with a very thin mucosa that even disappears in some cases; collagen fibrosis and disorganization of the layers are important. With argon laser, the results were intermediate. We concluded that CO2 laser section is superior for reduction of adhesions and fewer histologic lesions compared with argon and Yag lasers, but it is with the knife that we had the best healing process. With the development of surgery via laparoscopy, the laser will become a valuable tool in performing neosalpingostomy or surgery of endometriosis. For endometriosis, regarding the better results we obtained with CO2 laser, it seems to be the best choice if we can use laser via optic fibers. Otherwise, laser is of no use by laparotomy because it does not have any advantage over knife and bipolar coagulation. Perhaps Argon laser with other parameters could be used in the same way as laparoscopy.2,3
Claudie Boutteville, M.D. Denis Querleu, M.D. Centre Hospitalier de Roubaix Paris, France February 24, 1987 512
REFERENCES
Letters-to-the-editor
CO 2 laser versus conventional microsurgical anastomosis of the rat uterine horn. Fertil SteriI46:127, 1986 2. Baggish MS, ElBakry MM: Comparison of electronically superpulsed and continuous-wave CO 2 laser on the rat uterine horn. Fertil Steril 45:120, 1986 3. Tulandi T, Vilos GA: A comparison between laser surgery and electrosurgery for bilateral hydrosalpinx: a 2-year follow-up. Fertil Steril 44:846, 1985
Reply of the Authors: We would like to thank Drs. Boutteville and Querleu for their interest in our article. 1 They concluded that the use of pulsed CO 2 laser for cutting the tube was superior to argon and Vag laser. Tissue healing following the use of pulsed CO 2 laser was associated with thin mucosa, little fibrosis, and disorganization of muscularis. In contrast, the use of the knife to cut the tube was associated with minimal fibrosis and best-quality healing. In our article,1 we demonstrated that tissue healing after both pulsed CO 2 laser and microscissors was associated with intact mucosa. Some fibrosis was present in the muscularis and serosa of the conventional group. In the pulsed CO 2 laser group, we found good healing of muscularis without fibrosis or disruption. This may be due to the specifics of pulsed CO 2 laser in use. In our study, we used a power density of 6 X 104 W /cm 2, duty cycle of 400 pulses/sec, and the pulse width was 0.4 X 1O-3/sec. The energy delivered to tissue was 2.24 J and tissue exposure time was 0.16 seconds. Therefore, the use of intermittent high-laser power with pulse repetition allows for cooling of tissues between pulses and minimizes the thermal effect on tissues. This explains the absence of necrosis or fibrosis in the anastomosed tube in our studies. Furthermore, Baggish and ElBakry2 found that the least amount of thermal damage was achieved by the use of pulsed CO 2 laser with a power density of 100,000 to 450,000 W /cm 2 at rates of 300 to 500 pulses/sec, and pulse width between 0.3 and 0.5 ms. H pulse repetition rate is increased to 600 to 700 pulses per second, then the pulsed beam mimics the CW modes of CO 2 laser. Conversely, the use of 300 pulses/sec results in excessive time on tissue exposure and is not advisable for clinical use. Baggish Fertility and Sterility
and ElBakry also found that wounds following CO2 laser are funnel-shaped, thus sparing the endometrium, and this explains the good healing of the mucosa of the rat uteri in this study.2 Therefore, the outcome of the use of pulsed CO 2 laser depends on power density, pulse width, and repetition rate of pulses per second. Drs. Boutteville and Querleu also alluded to the value of laser laparoscopy using fiber. In this regard, Baggish and ElBakry3 published data to suggest that the use of CO 2 laser fiber increases the option available to the gynecologist for operative laparoscopy. The use of the fiber eliminates the necessity of realigning the beam through the operating laparoscope. In addition, the fiber is brought close to the tissue, thus avoiding injury to surrounding structures. Studies are underway in our department for the use of CO 2 laser fiber in patients with endometriosis and adhesions. It is true that the use of CO 2 laser in infertility surgery has an equal success rate to conventional microsurgery.4 However, the use of CO2 laser with its modalities can achieve lysis ()f adhesions in difficult locations, decreasing operating time, and offers the new easy modality of delivering CO2 laser with a flexible fiber through the laparoscope. S. Z. A. Badawy, M.D. M. S. Baggish, M.D. J. K. Choe, M.D. Department of Obstetrics and Gynecology Health Science Center Syracuse, New York April 7, 1987 REFERENCES 1. Badawy SZA, ElBakry MM, Baggish MS, Choe JK: Pulsed CO 2 laser versus conventional microsurgery anastomosis of the rat uterine horn. Fertil Steril 46:127, 1986 2. Baggish MS, ElBakry MM: Comparison of electronically superpulsed and continuous-wave CO 2 laser on the rat uterine horn. Fertil Steril 45:120, 1986 3. Baggish MS, ElBakry MM: A flexible CO2 laser fiber for operative laparoscopy. Fertil Steril46:16, 1986 4. Daniell JF: The role of lasers in infertility surgery. Fertil Steril 42:815, 1984
FSH Accumulation in hMG-Treated Patients
To the Editor: The recent article by Dr. Ben-Rafael and coworkers! on the differences in ovarian stimulation in gonadotropin-treated women and its relationship to follicle-stimulating hormone (FSH) accuVol. 48, No.3, September 1987
mulation is most interesting. The number of cases in each group was small and likewise there were no corresponding pregnancy rates which, after all, is the main goal of an in vitro fertilization (IVF) program. In our IVF program, 2 we too have been measuring serum luteinizing hormones (LH) immediately preceding the triggering human chorionic gonadotropin (hCG) injection and have correlated this with egg quality and pregnancy rates in a series of 100 laparoscopies, excluding male factors. Human menopausal gonadotropin (hMG), 2 to 5 ampules daily, was used for ovarian stimulation, generally starting on day 2 of the cycle. Monitoring included daily sonograms, estradiols (E 2), LHs, and evaluation of cervical mucus. In these hundred cycles, 60 patients had LH levels ~ 9 mID Iml or decreasing levels of LH ~ 12 mID Iml within 3 hours prior to the hCG. The 60 patients with the lower levels of LH had an average of 5.3 eggs obtained, which developed into 4.3 cleaved embryos and had a pregnancy rate of 27% per laparoscopy and 33% per embryo transfer. The 40 patients with higher LH levels had an average of 5.5 eggs obtained with 3.1 embryos and a pregnancy rate of 8% per laparoscopy and 11% per embryo transfer. Pregnancy rates differed at the 0.5 level. Egg morphology, also differed, with the higher LH levels tending to have ova with more cumulus clumping. In our program, we do not measure serum progesterone or testosterone and, in all probability, these were elevated associated with the higher LH levels. Thus, we strongly agree with Dr. Ben-Rafael on the utility of measuring serum LH and we additionally recommend cancelling laparoscopies in cases of higher LH in order to achieve better pregnancy rates per laparoscopy.
Arnold Jacobson, M.D. Donald 1. Galen, M.D. Founders of the John Muir Memorial Hospital In Vitro Fertilization Program Walnut Creek, California March 5, 1987 REFERENCES 1. Ben-Rafael Z, Strauss JF III, Mastroianni L Jr, Flickinger GL: Differences in ovarian stimulation in human menopausal gonadotropin treated women may be related to follicle-stimulating hormone accumulation. Fertil Steril 46:586, 1986 2. Jacobson A, Zorn G, Galen D, Kronick E, Adams C, Hill D, Beernink F, Beernink H: The deleterious effect of LH rises on egg quality and pregnancy rates in an IVF program (Abstr). Presented at the Fifth World Congress on in Vitro
Letters-to-the-editor
513