When to try surgical treatment for tubal disease.(Gynecologic Surgery)

PASADENA, CALIF. -- The conundrum of whether tubal disease should be treated before moving on to assisted reproductive technologies has persisted for nearly three decades--since in vitro fertilization was first developed to compensate for tubal dysfunction.

During a recent talk at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California, Dr. Michael P. Diamond weighed the evidence and offered his own recommendations concerning three common forms of tuboperitoneal disease.

"In this day and age, when in vitro fertilization (IVF) success is in the range of 30%-35%, under what conditions do we advocate [surgical] treatment of ... diseases affecting tubes?" asked Dr. Diamond, associate chair of obstetrics and gynecology and director of reproductive endocrinology and infertility at Detroit Medical Center and Wayne State University in Michigan.

Endometriosis

Many theoretical explanations have been posed for how endometriosis interferes with fertility. These explanations include mechanical disruption (impairing oocyte release or tubal retrieval, for example), reduction of the normal ovarian mass by endometriomas, increased peritoneal fluid toxicity, activation of macrophages, or interference with ovulation, endometrial receptivity, tubal motility or ciliary action within the tube. Any factor that has an impact on receptivity or creates a hostile environment might be expected to hamper IVF success, Dr. Diamond said.

However, a number of relatively small studies and a metaanalysis suggest that significant diminishment of success rates for assisted reproductive technologies seems to occur mostly in women with stage III or IV endometriosis and particularly in those with large endometriomas, but not so much in women with less severe endometrial disease. Early studies pointing to impaired pregnancy outcomes may be reflective of difficulties in laparoscopic oocyte retrieval, rather than success of the assisted reproductive technologies (ART) process itself, he said.

Dr. Diamond therefore recommends prior treatment of late-stage endometriosis with GnRH analog and possibly surgery when there is hope of reducing endometriomas, improving the environment for ART, and reducing toxicity associated with extensive endometriosis. The jury is still out with regard to treating stage I-II endometriosis before moving forward with ART, according to Dr. Diamond.