Fertility surgery : overview

Last presentations – click to start presentation

Fertility basics : fertility is a probability of conception

Fundamental to understand fertility and infertility are MFR (monthly fecundity rate ) and CPR (cumulative pregnancy rate

MFR (monthly fecundity rate ): is the probability of conception in one month
CPR (cumulative pregnancy rate : is the cumulative probability of conception over the next 6 or 12 months
A normal couple in Europe will have a nearly 50% of conception the first month (MFR). Since the most fertile will be pregnant the remaining population will be less fertile, and after 1 year of infertility the MFR has dropped to 10.  Yet  after 1 year of infertility still 80% of couples will get pregnant spontaneously over the following years

after 2 years of infertility the cumulative pregnancy rate drops to 50%
after 5 years : less than 20% will get pregnant spontaneously

Which investigations for infertility ?

The investigations aim to estimate the probability of conception expressed as MFR and CPR.  This is based upon an evaluation of the

Unfortunately many of the infertility basics have been forgotten since IVF is a solution to almost all forms of infertility ie ovulation problems as LUF eventually as a consequence of endometriosis, transport problems as adhesions or tubal mucosal damage,  implantation problems as adenomyosis, cervical problems as  immunologic infertility and most of the male factor problems. The availability and the relative success rates of IVF moreover have lead  to an overuse of IVF while infertility surgery has become disregarded.

Do we always need a diagnostic laparoscopy ?

A fertility exploration investigates all infertility factors. Without a laparoscopy it is impossible to know whether there are adhesions (eg after infection or surgery) or whether there is endometriosis.  The decision to perform a diagnostic laparoscopy therefore is caught between the following dilemma

an early and systematic laparoscopy has the advantage that diagnosis is complete and that eventual mechanical problems are resolved (if surgery can be done simultaneously).  It however carries the risk that the laparoscopy reveals a normal pelvis and thus did to help the fertility.

delaying a diagnostic laparoscopy risks to loose time whenever a treatable mechanical problem exist

All decisions are based upon the knowledge that

after 1 year of infertility still 80% will get pregnant spontaneously over the following years

after 2 years of infertility the cumulative pregnancy rate drops to 50%

after 5 years : less than 20% will get pregnant spontaneously

Therefore a diagnostic laparoscopy is planned after 1 year of infertility in Belgium

Fertility surgery should be done during the diagnostic laparoscopy ?

Ideally this should be done but practically ………..

the absence of a CO2 laser : the quality of endometriosis surgery is less, and the intervention takes a longer time with more adhesions .

a ‘slow or less experienced surgeon ‘ has more adhesions because surgery takes longer and because of more surgical trauma

Surgery beyond the level mastered : causes damage (destruction of the ovary) and incomplete excision of endometriosis or unnecessary bowel resections and thus IVF.

Problems of fertility surgery