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Use of the Essure microinsert to achieve proximal tubal occlusion for hydrosalpinx
August 2004, Vol. 11, No. 3 Supplement TheJournal of the American Association of Gynecologic Laparoscopists
study. The subjects of group A and B were studied for a total of 131 and 136 cycles, respectively. The ovulation rate (68.70% vs 68.38% in group Aand B, respectively) and the pregnancy rate (40.46% vs 38.91% in group A and B, respectively) were not statistically different between both treatment groups. The abortion rate (16.98% vs 27.77% for group A and group B, respectively) and the live-birth rate (83.01% vs 72.22% in group A and B, respectively) was significantly (p <.05) higher in group A than in group B. The metformin treatment was about 10-fold less expensive than LOD. C01/ZC/usio1/Z. Our data show that either LOD or metformin administration are effective to induce ovulation in CCresistant women with PCOS. Mefformin seems to have a significant advantage in reproductive outcomes due to a major improvement of abortion rate with less cost.
133. Surgical Sterilization of Childbearing-Aged Women by Means of Laparoscopic Cholecystectomy JA Akhtamov, B Negmadganov, KH Narzullaev, F Ganiev, S Azimov. Regional Centre of Endosurgery, Samarkand, Uzbekistan. Study Objective. Surgical sterilization of fertile age women by means laparoscopic cholecystectomy. Desigrz. Of 1460 laparoscopic cholecystectomies that had been performed, 991 (67.9%) were performed on women of childbearing age. The average patient age was 38.4 + 6.1 years. Patients with chronic calculous cholecystitis were examined and prepared for outpatient surgery, whereas in acute stages, an emergency procedure was performed. Isolated laparoscopic cholecystectomies were performed in 74 patients at acute calculous cholecystitis and in 517 patients at chronic stage. Settirzg. Regional Centre of Endosurgery, Samarkand, Uzbekistan. Patierzts. Seventy-four patients with acute calculous cholecystitis and 517 patients at chronic stage. Measuremerzts arzd Mairz Results. Laparoscopic cholecystectomy had been added with surgical sterilization in 86 women. In 15 (17.4%) cases had acute catarrhal cholecystitis. Laparoscopic surgical sterilization in isolated form had been performed in 31 cases. Indications for surgical sterilization in calculous cholecystitis in 84 women were having two or more living children of different sexes, written consent, and more than 30 years of age. Twenty-four patients had previous lower abdominal surgery. In only three (12.5%) cases did we fall to carry out simultaneous surgical sterilization because of massive adhesive process in small pelvis. Corzclusiorz. Surgical sterilization during laparoscopic cholecystectomy does not require an additional incision, does not prolong operative time, does not increase blood loss and rehabilitation time, and does not increase demand additional medical care both during the procedure and afterward.
134. Ovarian Recovery after Laparoscopic Removal of Ovarian Cysts: Insights from Short-Term Postsurgical Follow-up M Busacca, M Barbieri, M Vignali, G Oggioni, G Spadaccini, C Bertulessi. Milan, Italy. Study Objective. To assess the hypothetical risk of decreasing the ovarian reserve after surgical excision of benign ovarian cysts. Desigrz. Prospective analysis. Settirzg. University-affiliated hospital, department of obstetrics and gynecology. Patierzts. Between January and July 2003, 31 patients, mean age 33.3 + 4.0 years, with benign mono/bilateral ovarian cyst(s) undergoing laparoscopic excision, were recruited to participate in the study. Measummerzts arzd Mairz Results. All patients underwent laparoscopic excision of ovarian cyst, removing it from the ovarian cortex by traction with grasping forceps. When necessary, hemostasis was achieved with bipolar forceps. No sutures were used for reapproximation of the ovarian edges. All patients were asked to return within the eighth day of the first and the third menstrual cycle after surgery to undergo a basal ultrasonographic evaluation. Ovarian volume, antral follicle count, ovulation and stromal blood flow were recorded. All recruited patients underwent the first postsurgical evaluation. Twenty patients (65%) also were evaluated at the second assessment. Whereas ovarian volume resulted in similar findings in the operated and in the contralateral intact gonad at first ultrasonographic evaluation, a statistically significant (p =.004) reduction (median 33 %, range 18 %-81%) in basal volume was observed at the second assessment. Conversely, total number of follicles resulted similar at both evaluations. No significant differences were recorded in terms of ovarian blood flow between operated and intact gonads. Furthermore a statistically significant decrease in number of ovulations was encountered in operated ovaries at 3-month follow-up (p <.001). Corzclusiorz. According to these preliminary data, surgical excision of ovarian cyst, independently from its nature, could impair ovarian function.
135. Use of the Essure Microinsert to Achieve Proximal Tubal Occlusion for Hydrosalpinx RB Rosenfield. Portland, Oregon.
Study Objective. Provide a nonincisional treatment alternative for hydrosalpinx to achieve proximal tubal occlusion before in vitro fertilization (IVF). Desigrz. Case report of an obese patient with infertility and hydrosalpinx. Settirzg. Urban general obstetrics and gynecology group practice, IVF with urban private practice. Patierzt. A 31-year-old woman, body mass index 50, anovulatory infertility of 5 years and hydrosalpinx. lrzterverztiorzs/Results. Initial evaluation in December 2001 for a 5 cm suspected corpus luteum cyst. Interval growth from 5 cm to 6 cm in maximum diameter with a newly formed mural nodule led to laparoscopic evaluation in Febmary 2002. A densely adherent 8 cm complex mass with
$47
Oral Presentations
tubo-ovarian adhesions was noted, and oophorectomy was performed, pathology revealing a mixed endometrioid and serous tumor of low malignant potential. Intraoperative management was complicated by persistent hypoxia and hypotension related to body habitus, Trendelenburg, and a class 3 airway. Postoperatively, aggressive pursuit of fertility to be followed by removal of the contra lateral ovary was recommended. In preparation for IVF, hysterosalpingography (HSG) revealed a left-sided hydrosalpinx, which can decrease successful IVF pregnancy by up to 50%. To avoid risks of general anesthesia and laparoscopy, a unilateral Essure microinsert was placed in July 2003, with 6 coils trailing into the endometrial cavity (3-8 coils are recommended). Interval HSG confirmed uterotubal occlusion in October 2003. An IVF cycle was initiated in December 2003 with successful implantation of twins. Conclusion. The Essure microinsert may be an alternative to salpingectomy and laparoscopic tubal occlusion as a means to achieve proximal tubal occlusion in select patients. This may decrease the known risk of interstitial and cornual ectopic seen in alternate methods of tubal occlusion. Essure is approved for sterilization and has not been approved by FDA as a treatment for hydrosalpinx. A case series is needed to assess the safety and efficacy of this technique adequately.
136. Fertility Outcome Comparing Salpingostomy and Fibroplasty with IVF/ICSI/ET L Mettler. University of Kiel, Kiel, Germany.
Study Objective. To assess the effect of tubal surgery on fertility outcome.
Design. Retrospective analysis of 150 patients with tubal infertility. Setting. One hundred fifty patients treated for primary infertility in the outpatient unit of a university department. Patients and Interventions. One hundred fifty women with fertile husbands, normal endocrine parameters, no psychological alterations but tubal, peripheral stenosis or occlusions in both tubes were treated by fimbrioplasty or salpingostomy or by IVF/ICSI and embryo transfer. Only women with bilateral, tubal stenosis or occlusions at laparoscopy were included in the study. Measurements and Main Results. Of those patients who underwent tubal surgery, 28 fimbrioplasties with a blunt dilation of the fimbria on both sides and 72 peripheral salpingostomies were performed. Thirty-eight eversions of the tubes were carried out by sutures and 40 eversions by drawing a bipolar coagulation line around the fimbria. Of the 150 patients in the IVF/ICSI group, 92 underwent IVF treatment with a maximum transfer of three embryos. In 58 patients ICSI and embryo transfer (maximum transfer of three embryos) were performed. No frozen cycles were included. In the surgical follow-up after fimbrioplasties 32% and after salpingostomies 35% of patients became pregnant within 6 months. In the IVF/ICSI group 26% and in the ICSI/ET group 30% of patients became pregnant in one IFV/ICSI/ET trial. As pregnancy rates increase with 3 IVF/ICSI/ET trials, the final evaluation could be difl'erent.
Discussion. As similar rates of pregnancy occur after surgical correction of tubal stenosis and occlusion as after IVF/ICSI/ET, tubal surgery should be performed to allow patients the opportunity to become pregnant by physiological conception without the need of IVF/ICSI/ET. Conclusion. Laparoscopic, peripheral tubal corrective surgery is as equally important as IVF/ICSI/ET.
Plenary 18--Endometriosis II 137. Complications and Long-Term Follow-up after Laparoscopic Treatment of Deep Infiltrating Endometriosis: A Series of 121 Cases M Canis, N Sterkers, R Botchorishvili, B Rabishong, K Jardon, J Pouly, G Mage. Polyclinique De L'HoteI-Dieu, Clermont-Ferrand, Cedex, France. Study Objective. The incidence of intra and postoperative complications and assessing the incidence of reoperation after an aggressive surgical management in this pathology. Setting. Large tertiary care hospital with university affiliation. Design. A retrospective study of a prospectively used surgical management. Patients. Between January 1998 and December 2002, all patients with deep endometriosis were managed by laparoscopy. This period was chosen, as we considered that our initial learning curve in the management of deep disease was completed at the beginning of 1998. Measurements and Main Results. Two hundred one patients were operated for deep infiltrating endometriosis, 80% had moderate or severe disease according to the ASRM classification. Sixty-one percent underwent a full thickness vaginal excision. A bowel procedure was performed in 13%, a rectal resection with end-to-end anastomosis in 4%. The incidence of rectovaginal and ureteral fistulae were respectively 4% and 0.5%. All cases were repaired successfully. The follow-up ranged from 24 to 73 months. One hundred five of these patients were reoperated for endometriosis. Among these patients, 20% had recurrent or persistent deep endometriosis, 80% had superficial peritoneal disease or ovarian endometriosis. Conclusion. Deep infiltrating endometriosis can be managed with an acceptable complication rate. Complication occurred in large nodules and in repeat procedures emphasizing the importance of a complete treatment during the first surgical procedure and of an earlier diagnosis of deep endometriosis.
138. Correlation Between Pain Symptoms and Deeply Infiltrating Endometriosis Location C Chapron, A Fauconnier, N Chopin, M Vieira, H Foulot, B Dousset, G Breart. Groupe Hospitalier Cochin, Paris, Cedex, France. Study Objective. To evaluate if pelvic pain symptoms are correlated with anatomic location of deeply infiltrating endometriosis (DIE). Design. Retrospective study. Setting. University tertiary referral center.
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study. The subjects of group A and B were studied for a total of 131 and 136 cycles, respectively. The ovulation rate (68.70% vs 68.38% in group Aand B, respectively) and the pregnancy rate (40.46% vs 38.91% in group A and B, respectively) were not statistically different between both treatment groups. The abortion rate (16.98% vs 27.77% for group A and group B, respectively) and the live-birth rate (83.01% vs 72.22% in group A and B, respectively) was significantly (p <.05) higher in group A than in group B. The metformin treatment was about 10-fold less expensive than LOD. C01/ZC/usio1/Z. Our data show that either LOD or metformin administration are effective to induce ovulation in CCresistant women with PCOS. Mefformin seems to have a significant advantage in reproductive outcomes due to a major improvement of abortion rate with less cost.
133. Surgical Sterilization of Childbearing-Aged Women by Means of Laparoscopic Cholecystectomy JA Akhtamov, B Negmadganov, KH Narzullaev, F Ganiev, S Azimov. Regional Centre of Endosurgery, Samarkand, Uzbekistan. Study Objective. Surgical sterilization of fertile age women by means laparoscopic cholecystectomy. Desigrz. Of 1460 laparoscopic cholecystectomies that had been performed, 991 (67.9%) were performed on women of childbearing age. The average patient age was 38.4 + 6.1 years. Patients with chronic calculous cholecystitis were examined and prepared for outpatient surgery, whereas in acute stages, an emergency procedure was performed. Isolated laparoscopic cholecystectomies were performed in 74 patients at acute calculous cholecystitis and in 517 patients at chronic stage. Settirzg. Regional Centre of Endosurgery, Samarkand, Uzbekistan. Patierzts. Seventy-four patients with acute calculous cholecystitis and 517 patients at chronic stage. Measuremerzts arzd Mairz Results. Laparoscopic cholecystectomy had been added with surgical sterilization in 86 women. In 15 (17.4%) cases had acute catarrhal cholecystitis. Laparoscopic surgical sterilization in isolated form had been performed in 31 cases. Indications for surgical sterilization in calculous cholecystitis in 84 women were having two or more living children of different sexes, written consent, and more than 30 years of age. Twenty-four patients had previous lower abdominal surgery. In only three (12.5%) cases did we fall to carry out simultaneous surgical sterilization because of massive adhesive process in small pelvis. Corzclusiorz. Surgical sterilization during laparoscopic cholecystectomy does not require an additional incision, does not prolong operative time, does not increase blood loss and rehabilitation time, and does not increase demand additional medical care both during the procedure and afterward.
134. Ovarian Recovery after Laparoscopic Removal of Ovarian Cysts: Insights from Short-Term Postsurgical Follow-up M Busacca, M Barbieri, M Vignali, G Oggioni, G Spadaccini, C Bertulessi. Milan, Italy. Study Objective. To assess the hypothetical risk of decreasing the ovarian reserve after surgical excision of benign ovarian cysts. Desigrz. Prospective analysis. Settirzg. University-affiliated hospital, department of obstetrics and gynecology. Patierzts. Between January and July 2003, 31 patients, mean age 33.3 + 4.0 years, with benign mono/bilateral ovarian cyst(s) undergoing laparoscopic excision, were recruited to participate in the study. Measummerzts arzd Mairz Results. All patients underwent laparoscopic excision of ovarian cyst, removing it from the ovarian cortex by traction with grasping forceps. When necessary, hemostasis was achieved with bipolar forceps. No sutures were used for reapproximation of the ovarian edges. All patients were asked to return within the eighth day of the first and the third menstrual cycle after surgery to undergo a basal ultrasonographic evaluation. Ovarian volume, antral follicle count, ovulation and stromal blood flow were recorded. All recruited patients underwent the first postsurgical evaluation. Twenty patients (65%) also were evaluated at the second assessment. Whereas ovarian volume resulted in similar findings in the operated and in the contralateral intact gonad at first ultrasonographic evaluation, a statistically significant (p =.004) reduction (median 33 %, range 18 %-81%) in basal volume was observed at the second assessment. Conversely, total number of follicles resulted similar at both evaluations. No significant differences were recorded in terms of ovarian blood flow between operated and intact gonads. Furthermore a statistically significant decrease in number of ovulations was encountered in operated ovaries at 3-month follow-up (p <.001). Corzclusiorz. According to these preliminary data, surgical excision of ovarian cyst, independently from its nature, could impair ovarian function.
135. Use of the Essure Microinsert to Achieve Proximal Tubal Occlusion for Hydrosalpinx RB Rosenfield. Portland, Oregon.
Study Objective. Provide a nonincisional treatment alternative for hydrosalpinx to achieve proximal tubal occlusion before in vitro fertilization (IVF). Desigrz. Case report of an obese patient with infertility and hydrosalpinx. Settirzg. Urban general obstetrics and gynecology group practice, IVF with urban private practice. Patierzt. A 31-year-old woman, body mass index 50, anovulatory infertility of 5 years and hydrosalpinx. lrzterverztiorzs/Results. Initial evaluation in December 2001 for a 5 cm suspected corpus luteum cyst. Interval growth from 5 cm to 6 cm in maximum diameter with a newly formed mural nodule led to laparoscopic evaluation in Febmary 2002. A densely adherent 8 cm complex mass with
$47
Oral Presentations
tubo-ovarian adhesions was noted, and oophorectomy was performed, pathology revealing a mixed endometrioid and serous tumor of low malignant potential. Intraoperative management was complicated by persistent hypoxia and hypotension related to body habitus, Trendelenburg, and a class 3 airway. Postoperatively, aggressive pursuit of fertility to be followed by removal of the contra lateral ovary was recommended. In preparation for IVF, hysterosalpingography (HSG) revealed a left-sided hydrosalpinx, which can decrease successful IVF pregnancy by up to 50%. To avoid risks of general anesthesia and laparoscopy, a unilateral Essure microinsert was placed in July 2003, with 6 coils trailing into the endometrial cavity (3-8 coils are recommended). Interval HSG confirmed uterotubal occlusion in October 2003. An IVF cycle was initiated in December 2003 with successful implantation of twins. Conclusion. The Essure microinsert may be an alternative to salpingectomy and laparoscopic tubal occlusion as a means to achieve proximal tubal occlusion in select patients. This may decrease the known risk of interstitial and cornual ectopic seen in alternate methods of tubal occlusion. Essure is approved for sterilization and has not been approved by FDA as a treatment for hydrosalpinx. A case series is needed to assess the safety and efficacy of this technique adequately.
136. Fertility Outcome Comparing Salpingostomy and Fibroplasty with IVF/ICSI/ET L Mettler. University of Kiel, Kiel, Germany.
Study Objective. To assess the effect of tubal surgery on fertility outcome.
Design. Retrospective analysis of 150 patients with tubal infertility. Setting. One hundred fifty patients treated for primary infertility in the outpatient unit of a university department. Patients and Interventions. One hundred fifty women with fertile husbands, normal endocrine parameters, no psychological alterations but tubal, peripheral stenosis or occlusions in both tubes were treated by fimbrioplasty or salpingostomy or by IVF/ICSI and embryo transfer. Only women with bilateral, tubal stenosis or occlusions at laparoscopy were included in the study. Measurements and Main Results. Of those patients who underwent tubal surgery, 28 fimbrioplasties with a blunt dilation of the fimbria on both sides and 72 peripheral salpingostomies were performed. Thirty-eight eversions of the tubes were carried out by sutures and 40 eversions by drawing a bipolar coagulation line around the fimbria. Of the 150 patients in the IVF/ICSI group, 92 underwent IVF treatment with a maximum transfer of three embryos. In 58 patients ICSI and embryo transfer (maximum transfer of three embryos) were performed. No frozen cycles were included. In the surgical follow-up after fimbrioplasties 32% and after salpingostomies 35% of patients became pregnant within 6 months. In the IVF/ICSI group 26% and in the ICSI/ET group 30% of patients became pregnant in one IFV/ICSI/ET trial. As pregnancy rates increase with 3 IVF/ICSI/ET trials, the final evaluation could be difl'erent.
Discussion. As similar rates of pregnancy occur after surgical correction of tubal stenosis and occlusion as after IVF/ICSI/ET, tubal surgery should be performed to allow patients the opportunity to become pregnant by physiological conception without the need of IVF/ICSI/ET. Conclusion. Laparoscopic, peripheral tubal corrective surgery is as equally important as IVF/ICSI/ET.
Plenary 18--Endometriosis II 137. Complications and Long-Term Follow-up after Laparoscopic Treatment of Deep Infiltrating Endometriosis: A Series of 121 Cases M Canis, N Sterkers, R Botchorishvili, B Rabishong, K Jardon, J Pouly, G Mage. Polyclinique De L'HoteI-Dieu, Clermont-Ferrand, Cedex, France. Study Objective. The incidence of intra and postoperative complications and assessing the incidence of reoperation after an aggressive surgical management in this pathology. Setting. Large tertiary care hospital with university affiliation. Design. A retrospective study of a prospectively used surgical management. Patients. Between January 1998 and December 2002, all patients with deep endometriosis were managed by laparoscopy. This period was chosen, as we considered that our initial learning curve in the management of deep disease was completed at the beginning of 1998. Measurements and Main Results. Two hundred one patients were operated for deep infiltrating endometriosis, 80% had moderate or severe disease according to the ASRM classification. Sixty-one percent underwent a full thickness vaginal excision. A bowel procedure was performed in 13%, a rectal resection with end-to-end anastomosis in 4%. The incidence of rectovaginal and ureteral fistulae were respectively 4% and 0.5%. All cases were repaired successfully. The follow-up ranged from 24 to 73 months. One hundred five of these patients were reoperated for endometriosis. Among these patients, 20% had recurrent or persistent deep endometriosis, 80% had superficial peritoneal disease or ovarian endometriosis. Conclusion. Deep infiltrating endometriosis can be managed with an acceptable complication rate. Complication occurred in large nodules and in repeat procedures emphasizing the importance of a complete treatment during the first surgical procedure and of an earlier diagnosis of deep endometriosis.
138. Correlation Between Pain Symptoms and Deeply Infiltrating Endometriosis Location C Chapron, A Fauconnier, N Chopin, M Vieira, H Foulot, B Dousset, G Breart. Groupe Hospitalier Cochin, Paris, Cedex, France. Study Objective. To evaluate if pelvic pain symptoms are correlated with anatomic location of deeply infiltrating endometriosis (DIE). Design. Retrospective study. Setting. University tertiary referral center.
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