Clinical Review

FERTILITY

Author and Disclosure Information

Here is new information on reducing adhesions, the stress and cost of fertility treatment, unhelpful testing, and “long-shot” oocyte cryopreservation


 

References

The author receives grant or research support from IBSA, Serono, and Viacell.

The field of reproductive endocrinology and infertility is anything but stagnant. New technologies continue to enter the market at a brisk pace, and a greater emphasis on evidence has produced better-designed randomized controlled trials, meta-analyses, and practice guidelines. This means greater availability of standardized protocols that reflect best practice and can be tailored to a patient’s condition and needs.

Highlighted here are notable studies and guidelines from the past year, including advice on:

  • preventing peritoneal adhesions
  • expediting in vitro fertilization (IVF) for unexplained infertility
  • counseling the patient about the real limitations of preimplantation genetic screening for aneuploidy
  • informing patients that oocyte cryopreservation is unlikely to lead to live birth.

Guideline urges good surgical technique in battle against adhesions

Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society of Re-productive Surgeons. Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery. Fertil Steril. 2007;88:21–26.

This newly released practice guideline from the American Society of Reproductive Medicine (ASRM) focuses on adhesions and their impact on fertility. The guideline reiterates that peritoneal adhesions are a common and serious complication of gynecologic surgery and emphasizes key principles to reduce their likelihood and extent. These principles include the need to:

  • Perform surgery only when the benefits of doing so clearly outweigh the risks
  • Handle tissue gently (this is the most important preventive technique)
  • Don’t assume laparoscopy is superior to laparotomy—it will be only if less tissue injury occurs
  • Be especially careful when operating on or near ovaries, which form adhesions easily.

Ovarian surgery often necessitates additional operations

Studies have demonstrated that approximately 33% of patients who undergo open abdominal or pelvic surgery are readmitted, on average, two times over the subsequent 10 years for conditions directly or possibly related to adhesions or for further surgery that could be complicated by adhesions. The highest readmission rate directly related to adhesions—7.5 for every 100 initial operations—was associated with ovarian surgery performed via laparotomy.

Adhesion-related complications of gynecologic surgery include small-bowel obstruction, which occurs in approximately 1.5% of women who have undergone abdominal hysterectomy.

The relationship between adhesions and pelvic pain is unclear, although severe bowel adhesions can cause visceral pain. The ASRM guideline notes that “the impact that lysis of bowel or adnexal adhesions may have on abdominal and pelvic pain cannot be predicted confidently.” Postoperative adhesions increase subsequent operating times and risk of bowel injury.

How adhesions affect fertility

Adhesions may impair fertility by distorting adnexal anatomy and interfering with gamete and embryo transport. Among infertile women who have adnexal adhesions, adhesiolysis is associated with pregnancy rates of 32% at 12 months and 45% at 24 months, compared with 11% and 16%, respectively, for untreated women.1 Pregnancy rates are inversely correlated with adhesion scores on the ASRM classification system for adnexal adhesions.2

Some, but not all, adhesion-reducing measures work

According to the ASRM guideline, adhesions may be prevented, at least theoretically, by:

  • minimizing peritoneal injury during surgery
  • avoiding the introduction of reactive foreign bodies
  • reducing the local inflammatory response
  • inhibiting the coagulation cascade and promoting fibrinolysis
  • placing barriers between damaged tissues.

Pharmacotherapeutic and fluid agents. ASRM found no evidence of improved pregnancy outcomes for pharmacologic and fluid agents used as an adjunct during pelvic surgery. For example, anti-inflammatory agents that have been evaluated, both locally and systemically, including dexamethasone and promethazine, have not reduced postoperative adhesions. Antibiotic solutions, 32% Dextran 70, and crystalloid solutions such as normal saline and Ringer’s lactate with or without heparin or corticosteroids have been used to separate adjacent peritoneal surfaces via “hydroflotation,” but none have reduced adhesion formation.

Surgical barriers may help decrease postoperative adhesion formation but cannot compensate for poor surgical technique. I rarely use adhesion barriers because I feel that careful tissue handling, excellent hemostasis, avoiding trauma to healthy tissue, and removal of all diseased tissue are the key ways to obtain good postsurgical results and reduce adhesions.

Hyaluronic acid agents may decrease the prevalence of adhesions and prevent the deterioration of preexisting adhesions, but because of the limited number of studies available, these data should be interpreted with caution.3 However, ASRM found no substantial evidence that they improve fertility, decrease pain, or reduce the incidence of postoperative bowel obstruction.

Averting adhesions: Surgical techniques and tools

By Togas Tulandi, MD, MHCM, and Mohammed Al-Sunaidi, MD It’s available in our archive at www.obgmanagement.com

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