2014 Update on Fertility
Three recent recommendations, on clomiphene, immunization, and postsurgical adhesions, may affect how you practice. These experts get to the heart of the guidelines.
The Societies noted that more severe adnexal adhesions are associated with lower pregnancy rates, and treatment of adnexal adhesions appears to improve pregnancy rates. Investigators found adhesions to cause about three-quarters of postoperative small bowel obstructions; however, the relationship between adhesions and pelvic pain remains unclear. It is thought that adhesions may cause visceral pain by impairing organ mobility, but there is no relationship between the extent of adhesions and the severity of pain. It appears that only dense adhesions involving the bowel are associated with chronic pelvic pain. Predicting the outcome of lysis of adnexal or bowel adhesions is difficult.
Reduction of adhesion formation
Theoretically, adhesions may be reduced by minimizing peritoneal injury during surgery, avoiding intraoperative reactive foreign bodies, reducing local inflammatory response, inhibiting the coagulation cascade and promoting fibrinolysis, or by placing barriers between damaged tissues.
Related Article: Update on Fertility G. David Adamson, MD (February 2008)
Careful surgical technique includes gentle tissue handling, meticulous hemostasis, excision of necrotic tissue, minimizing ischemia and desiccation, using fine and nonreactive suture, and preventing foreign-body reaction and infection, all “microsurgical principles.”
ASRM and SRS reported that the surgical approach (laparoscopy vs laparotomy) is much less important than the extent of tissue injury. However, laparoscopy may result in less tissue and organ handling and trauma, avoid contamination with foreign bodies, enable more precise tissue handling, and result in less postoperative infection. The pneumoperitoneum has a tamponade effect that facilitates hemostasis during laparoscopy, but the process also can be associated with peritoneal desiccation and reduced temperatures that can increase injury.
Laparoscopic myomectomy was found to have a 70% risk of postoperative adhesions, compared with a 90% risk after laparotomy. It is unclear whether peritoneal closure at laparotomy reduces or increases adhesions, but parietal peritoneal closure at primary cesarean delivery results in fewer dense and filmy adhesions.
Related Article: How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy Michael Baggish, MD (Second of a 2-part series on laparoscopic complications, October 2012)
Adjuncts to surgical technique
SRM and SRS reported on three adjuncts to surgical technique that have been proposed to reduce the risk of postoperative adhesions: anti-inflammatory agents, peritoneal instillates, and adhesion barriers.
Dexamethasone, promethazine, and other local and systemic anti-inflammatory drugs and adhesion-reducing substances have not been found effective for reducing postoperative adhesions.
Peritoneal instillates—which create “hydroflotation” and include antibiotic solutions, 32% dextran 70, and crystalloid solutions such as normal saline and Ringer’s lactate with or without heparin or corticosteroids—have not been found effective.8 Icodextrin 4% (Adept Adhesion Reduction Solution, Baxter Healthcare) is FDA approved as an adjunct to good surgical technique for the reduction of postoperative adhesions in patients undergoing gynecologic laparoscopic adhesiolysis. However, a systematic review concluded that there is insufficient evidence for its use as an adhesion-preventing agent.8
Adhesion barriers may help reduce postoperative adhesions but cannot compensate for poor surgical technique. Although the bioresorbable membrane sodium hyaluronic acid and carboxymethyl cellulose (Seprafilm, Genzyme Corp) is FDA-approved, there is limited evidence that it prevents adhesions after myomectomy.9 Because it fragments easily, it is mostly used at laparotomy.
Oxidized regenerated cellulose (Interceed, Ethicon Women’s Health and Urology) is an FDA-approved absorbable adhesion barrier for use at laparotomy that requires no suturing and has been shown to reduce the incidence and extent of new and recurrent adhesions at both laparoscopy and laparotomy by 40% to 50%, although there is little evidence that this improves fertility.9 Complete hemostasis must be achieved to use Interceed, and the addition of heparin confers no benefit.
Another product is expanded polytetrafluoroethylene (ePTFE, Gore-Tex Surgical Membrane, WL Gore and Associates), a nonabsorbable adhesion barrier produced in thin sheets and approved by the FDA for peritoneal repair. ePTFE must be sutured to tissue and helps prevent adhesion formation and reformation regardless of the type of injury or whether complete hemostasis has been achieved. In a small trial, it decreased postmyomectomy adhesions.10 ePTFE also was more effective than oxidized regenerated cellulose in preventing adhesions after adnexal surgery.11 Its use has been limited by the need for suturing and later reoperation for removal, although it probably does not have to be removed if it will not interfere with normal organ function since it has been used as a pericardial graft for many years.12
Hyaluronic acid (HA) solution (Sepracoat, Genzyme) is a natural bioabsorbable component of the extracellular matrix. Women undergoing laparotomy have fewer new adhesions with HA solution, but it is not approved for use in the United States.13 Polyethylene glycol (PEG; SprayGel, Confluent Surgical) was effective in early clinical trials but is not FDA-approved.12 Fibrin sealant (Tisseel VH, Baxter Healthcare) has been reported to decrease the formation of adhesions after salpingostomy, salpingolysis, and ovariolysis. Because it is a biologic product derived from human blood donors, it poses a risk for transmission of infectious agents. It is FDA-approved for use in cardiothoracic surgery, splenic injuries, and colostomy closure for hemostasis.
