Infertility has been estimated to affect approximately 15% of couples attempting to conceive in the United States.¹ Its consequences are manifested in many ways in our society, including the monetary costs of its investigation, diagnosis, and treatment as well as the psychosocial stresses^2,3 it imposes on this portion of our population.

Causes of infertility potentially amenable to surgical treatment include tuboperitoneal disease and abnormalities of the uterine cavity. These are estimated to account either alone or in part for the infertility of 40% of couples.⁴ Anatomic findings within this broad category include adhesions, implants of endometriosis, and partial or complete tubal obstruction. Their most common causes are prior surgery, endometriosis, and infection (either clinically recognized or unrecognized). With regard to abnormalities of the uterine cavity, some conditions such as Asherman's syndrome are surgically correctable causes of infertility. The contribution to the development of infertility of other surgically correctable pathologic findings, such as uterine septa or intracavitary myomas, is variable and is thought to depend on the specific characteristics of each lesion.

Over the past several decades, new techniques and instruments have been introduced that have the potential of restructuring the performance of reproductive pelvic surgery. First was the recognition of a role of “microsurgery” in the performance of these procedures. The second, which is continuing to evolve and is less well established, is endoscopic surgery as an alternative to laparotomy. Third is the choice for tissue incision or excision with the use of electrosurgery, sharp dissection, or lasers. A proper role for the latter topic also continues to be evaluated, but its application appears to have peaked because many surgeons are reducing their use of lasers.

Therefore, more than previously, the role of surgical aspects of infertility is undergoing re-examination. This review attempts to describe considerations in the decision-making process in regard to whether, when, and how to perform reproductive pelvic surgery. An introduction to each of these advances is given, followed by an evaluation of individual surgical operations. Direct comparisons of surgical series conducted under varying conditions are not entirely appropriate, but they do allow guidance for the aforementioned questions. The series included in the tables were selected from the literature; more complete listings are described in the references. Additionally, pregnancy outcome in many of the reports had to be modified based on the information provided to conform to the subset desired (e.g. conception rates versus term deliveries). Finally, it should be recognized that the assisted reproductive technologies (ART) can also be considered an alternative to surgical repair in some patients with extensive tuboperitoneal disease. The appropriate applications of surgical treatment via laparotomy, laparoscopy, or ART vary among patients and are likely to be modified as advances are made in these areas. (A discussion of the role of ART in the treatment of tuboperitoneal-based infertility is beyond the context of this chapter; the reader is referred to the ART section of this series.)

Microsurgery

Use of microsurgery in the performance of reproductive pelvic procedures was initially described by Swolin in 1967.⁵ Microsurgery in this context includes, but is not limited to, the use of magnification. The advantage of magnification is that it allows close inspection so as to improve the ability to discriminate between normal and pathologic tissue and to allow the use of fine-caliber microsurgical instruments and sutures.⁶ Other tenets of gynecologic microsurgery include achieving meticulous hemostasis, minimizing tissue handling, preventing desiccation of tissue, avoiding introduction of foreign bodies (e.g. talc) into the operative field, using fine suture material of low tissue reactivity, and precisely reapproximating tissue planes.^6,7

Although most of these tenets are probably correct, one that may be incorrect is the value of precise tissue approximation. In animal studies, suture closure of the ovarian cortex was associated with greater, not lesser, adhesion development.⁸ It remains unclear whether this represents a foreign body reaction to the sutures, a response to the increased tissue handling required to place the sutures, a consequence of tissue anoxia, or a combination of all these factors. Regardless of the actual mechanism, this report⁸ and others like it appeared to call into question the routine “reperitonealization” of all peritoneal and serosal defects, particularly those that do not protect vital structures. Finally, important corollaries exist to two of the tenets of microsurgery: achieving meticulous hemostasis and minimizing tissue handling. Although the presence of blood at the operative site increases postoperative adhesion development, it is important that hemostasis be achieved in a manner that devitalizes as little surrounding tissue as possible. When possible, the size of pedicles should be minimized and use of electrosurgery should be restricted to the actual bleeding site. With regard to tissue handling, manipulation of structures is required to achieve exposure and perform the procedure. However, tissue damage can often be minimized by the use of atraumatic graspers, moist (not dry) pads, and, when feasible, grasping of tissue structures to be excised.

A less recognized, yet extremely important, characteristic affecting the results of microsurgical gynecological procedures is the experience of the surgeon. Oelsner and coworkers⁹ examined this issue directly, assessing microsurgical skill as a function of the number of isthmic reanastomoses performed on the rabbit fallopian tube. In evaluations of pregnancy rates, nidation index, and scanning electron microscopy sections of the anastomotic sites, they demonstrated a positive correlation between increasing experience and successful surgical outcome. A second report indirectly addressed this issue. DeCherney and associates¹⁰ examined the failure rate of microsurgical tubal anastomoses, and noted that, compared with an initial success rate of approximately 50%, pregnancy outcome improved with experience, reaching a plateau at a rate of approximately 70%.

Direct comparison of clinical outcome of surgical procedures performed by macrosurgery versus microsurgery is difficult because of differences in the procedures performed, in the extent of coexistent pelvic disease, and in chronology. Introduction of different centers and surgeons further complicates such comparisons. These observations notwithstanding, several investigators have conducted such examinations and have found trends favoring successful pregnancy with microsurgery.^11,12,13,14

Many investigators have advocated adoption of the principles of gynecologic microsurgery^{7,15,16,17,18,19}; its use and efficacy are described in subsequent sections of this chapter dealing with specific operative procedures. Use of these principles, however, should not be limited to the microsurgeon, but should be employed by all surgeons performing pelvic operations so as to minimize postsurgical development of pelvic adhesive disease.

Operative Endoscopy

DeCherney, in 1985, predicted that “the obituary of laparotomy for pelvic reconstructive surgery has been written; it is only its publication that remains.”^20,21 More than 15 years later, this prophesy remains almost as controversial as when it was written. Clearly, a wide variety of the reproductive pelvic surgical procedures performed at laparotomy can also be performed at laparoscopy or hysteroscopy. This list includes adhesiolysis, fimbrioplasty, neosalpingostomy, linear salpingostomy, fulguration/vaporization of endometriosis, transection of uterosacral ligaments, drainage of ovarian cysts, and removal of uterine septa. Later sections of this review describe the clinical efficacies of these procedures as performed by laparotomy or by laparoscopy/hysteroscopy. The reader is also referred to recent reviews for more in-depth considerations.

Application of Lasers

Several investigators have examined the application of lasers for the performance of reproductive pelvic surgical procedures, both at laparotomy and in endoscopic procedure. The most frequently used type to date is the carbon dioxide (CO₂) laser;²² others now in use include the argon, the potassium titanyl phosphate (KTP-532), and the neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers. A comparison of characteristics of these different types of lasers is made in Table 1. Efficacy of their use is described for individual procedures. In general, there has been no evidence that use of a laser per se results in a greater reduction of adhesions or improvement in pregnancy outcome, compared with other surgical modalities.^23,24,25 However, individual surgeons, based on their own experience, equipment availability, and preference, may find use of a particular laser to be most advantageous for the performance of these procedures.^26,27,28,29

TABLE 1. Properties of Surgical Lasers

Adhesiolysis

Pelvic adhesions have been identified as a major contributing cause of infertility. In these patients, goals of reconstructive pelvic surgery include lysis of adhesions that interfere with physiologic processes of ovum release, pickup, and transport and minimal subsequent development of postoperative adhesions.

Classification of the type or extent of pelvic adhesion has been described in several previous reports.^{30,31,32,33,34,35} Jessen³⁴ described an improved pregnancy rate in the presence of low-grade compared with high-grade adhesions (64% versus 22%, respectively). Subsequently, Hulka and colleagues³¹ classified the extent and type of adnexal adhesions, and later the same authors demonstrated their prognostic value.³³ Pregnancy was more likely to occur when more than 50% of the ovary was visible and when adhesions were filmy and avascular, rather than dense and vascular. Similarly, Caspi and coworkers³² demonstrated that pregnancy rates were higher in association with fine, avascular as opposed to fibrous, coarse adhesions. In these reports, as well as those of Young and associates,³⁵ the significance of adhesions (as assessed by the pregnancy rate) was clouded by the classification systems, which also relied on tubal patency (and performance of fimbrioplasties and salpingostomies).

The report that has most closely assessed the role of periadnexal adhesions alone on pregnancy outcome is that of Bronson and Wallach.³⁰ They scored adhesions at varying locations (right and left ovaries, fallopian tubes, pelvic sidewalls, broad ligaments, cul-de-sac, and rectosigmoid) and observed that pregnancy rates were lower among women with high adhesion scores, although the difference was not significant. Importantly, however, in these studies looking at pregnancy outcome,^{30,31,32,33,34,35} the incidence, extent, and severity of adhesions at the time the women were trying to conceive is not known, nor were there extensive controls for other factors that may contribute to infertility.

Adhesiolysis has traditionally been performed by sharp dissection or electrosurgery; more recently, it has also been performed using the CO₂ and argon lasers^36,37 and linear cutters. A comparison of pregnancy outcome after adhesiolysis at laparotomy and at laparoscopy with various techniques is shown in Table 2.^{38,39,40,41,42,43,44,45,46} In general, the use of microsurgical techniques has led to a trend for improvement in pregnancy outcome after adhesiolysis. As shown, in women in whom there is no distal tubal obstruction, adhesiolysis can be expected to lead to pregnancy in 50% to 60% of cases. Use of the CO₂ laser, compared with nonlaser techniques, has not resulted in improvements in pregnancy outcome,⁴³ nor has it resulted in consistent reductions in the adhesions observed at the time of second-look laparoscopy.⁴⁷ Consistent with these findings is the report of Pittaway and colleagues,⁴⁸ which described no reduction in postoperative intraperitoneal adhesion formation in rabbits and rats, respectively, with the CO₂ laser as compared to electrocautery.^48a

TABLE 2. Pregnancy Outcome Following Adhesiolysis

As a result of technological advances, it is now possible to perform adhesiolysis (and other reproductive pelvic surgical procedures) at laparoscopy. Although relatively minor procedures can be performed by most laparoscopists, treatment of more extensive disease requires advanced training and experience. In experienced hands, laparoscopic treatment (usually involving multiple-puncture techniques) appears to yield results similar to those achieved with laparotomy.^45,46 However, no well-controlled studies examining this issue have been performed.

Adhesion reformation after reproductive pelvic surgery occurs frequently, even with the use of microsurgical techniques and surgical adjuvants.⁴⁹ Although adhesion reformation was defined in one report⁴⁹ as a redevelopment of adhesions at sites that were subjected to adhesiolysis at the time of the initial procedure, other authors have used the same term to refer to different situations, thereby creating considerable confusion in the literature.⁵⁰ To provide a common terminology for comparison of efficacy of different techniques and adjuvants in reducing postoperative adhesions, a classification system has been proposed that takes into consideration the presence or absence of adhesions initially, and whether a surgical procedure other than adhesiolysis was performed at that site (Table 3). Importantly, this classification also includes the concept of de novo adhesion reformation (the development of adhesions, observed at the time of the second-look procedure, for which adhesiolysis was not performed at the time of the initial procedure). As shown in Table 4, de novo adhesion formation can be a frequent problem after microsurgery performed at laparotomy, occurring in 58% of available ovaries and at almost one third of all available sites in those affected.⁵¹

TABLE 3. Classification of De Novo Adhesion Formation and Adhesion Reformation

TABLE 4. De Novo Adhesion Formation*

It had been suggested, anecdotally, that procedures performed by laparoscopy might be less likely to be followed by the postoperative development of pelvic adhesions. Theorized explanations included reductions in tissue drying, tissue manipulation, and introduction of foreign materials and lack of packing of bowel. However, in a multicenter study evaluating adhesion reformation at a second-look pro-cedure after laparoscopic adhesiolysis, adhesion reformation was identified in 66 of 68 subjects (97%).⁵² However, laparoscopic adhesiolysis was able to reduce significantly the extent of pelvic adhesions, to approximately half of what was present initially. De novo adhesion formation occurred in only 8 (12%) of these 68 women, and in 11 (23%) of 47 available sites in those affected. This suggests that de novo adhesion formation (not adhesion reformation) may occur less frequently after laparoscopic surgery, but confirmation of this hypothesis will require properly controlled studies.

Surgical adjuvants have been used frequently after adhesiolysis and other types of intra-abdominal reproductive pelvic surgical procedures. The rationale for use of adjuvants is to minimize development of postoperative adhesions and to maximize maintenance of tubal patency after the initial surgical procedure. As shown in Table 5, a variety of agents have been used for this purpose. This use has been described in detail in several reviews.^{15,53,54,55,56,57,58,59,60,61}

TABLE 5. Classes of Surgical Adjuvants Used in an Attempt to Minimize the Occurrence of Postoperative Adhesions

Despite application of microsurgical technique and use of surgical adjuvants by experienced surgeons, the development of postoperative adhesions is an all too frequent occurrence.^{62,63,64,65,66,67,68,69} Currently, no serum marker or scanning technique is consistently able to identify adhesions, and a repeat operative procedure is required for evaluation. As shown in Table 6, pelvic adhesions were identified at the time of second-look laparoscopy in 55% to 100% of women who had undergone reproductive pelvic surgical procedures. Such adhesions represent both adhesion reformation and de novo adhesion formation.⁷⁰ Inasmuch as such adhesions might impair the ability to conceive, there appears to be room for improvement in preventing postoperative adhesion development. In a poll of the members of the Society of Reproductive Surgeons, Holtz⁷¹ reported widespread use of agents for this purpose throughout the United States, including perioperative antibiotics, corticosteroids, and antihistamines and intraoperative instillation of 32% dextran 70 (Hyskon). The literature is replete with conflicting results for most adjuvants, and their efficacy is not well established. A potential explanation is differences in the pathologic conditions being treated.

TABLE 6. Pelvic Adhesions Noted as Second-Look Procedures

Three groups have demonstrated fundamental differences between adhesion formation and adhesion reformation in animal models. Holtz and associates^72,73 described reduction in adhesion formation with 32% dextran 70, but a similar inhibition of adhesion reformation could not be achieved with higher doses of dextran. Similarly, Elkins and coworkers^74,75 observed a greater extent of adhesion reformation than adhesion formation after dextran treatment. Finally, Diamond and associates^76,77 compared adhesion formation and reformation models and noted a greater extent of adhesions in the latter.

In the survey of the members of the Society of Reproductive Surgeons, Holtz⁷¹ reported that 45% performed second-look laparoscopy on occasion. There are several benefits of second-look procedures after reconstructive pelvic surgery. Such procedures allow for assessment of the adnexal disease, allowing patients to assess their potential for fertility and plan accordingly. Second, they provide an opportunity to lyse adhesions that have reformed (or to perform additional procedures as needed, such as vaporization of endometriosis or deagglutination of fimbria). Third, based on the previously established principles that pelvic adhesions can cause infertility^30,32,45 and that lysis of adhesions is associated with pregnancy establishment in many women,^30,32,45 performance of second-look laparoscopy may improve the pregnancy rate after reproductive pelvic surgery, although this theoretical improvement has yet to be substantiated. Trimbos-Kemper and colleagues⁶⁷ and Jansen⁷⁸ reported that second-look laparoscopy was associated with a significant reduction in the subsequent observation of permanent pelvic adhesions, but the pregnancy rate was not improved. Trimbos-Kemper and coworkers⁶⁷ did, however, note a reduction in the occurrence of ectopic pregnancies after salpingostomies in women who underwent early second-look laparoscopy. Finally, for the benefit of the surgeon, performance of second-look laparoscopy allows for feedback as to the surgical success of the procedures previously performed.

If second-look laparoscopy is to be performed, Swolin⁷⁹ recommended that it be done early (6 to 8 weeks) to improve the possibility of lysis of postoperative adhesions. Subsequently, Raj and Hulka⁸⁰ examined second-look laparoscopies performed up to 2 years after the initial procedure and demonstrated that bleeding was more common if the procedure was performed after 12 weeks or before 2 weeks. In the former case, bleeding was attributed to increased density and vascularity of the adhesions; in the latter, bleeding was attributed to granulation tissue. Between 2 and 12 weeks, the adhesions were filmy and more amenable to lysis. Surrey and Friedman⁶⁵ observed that attempted adhesiolysis 6 months after the initial procedure was associated with more dense and vascular adhesions than were present at 6 to 8 weeks. DeCherney and Mezer⁶³ also compared early (4 to 16 weeks) versus late (approximately 18 months) second-look laparoscopy; in the former group, 60% of patients had thicker neovascular adhesions. Finally, Daniell and Pittaway,⁶⁸ McLaughlin,⁶⁴ and Diamond and coworkers⁶² have also observed that adhesions at “early” second-look laparoscopy are more likely to be filmy and avascular, making them more susceptible to easy lysis. However, in multiple studies involving an opportunity for early second-look laparoscopy after the initial surgical procedure, there appeared to be no difference in the type (filmy and avascular versus dense and vascular) of adhesions observed at second-look laparoscopy.^{47,80a,80b,80c}

Distal Tubal Obstruction: Complete

The surgical treatment of complete fimbrial occlusion is a neosalpingostomy: the creation of a new tubal ostia. Performance of neosalpingostomy is associated with a subsequent tubal patency rate of approximately 90% to 95%;⁸¹ however, pregnancy rates are only about 30% (Table 7).^{82,83,84,85,86,87,88,89} With prolonged follow-up of 5 years, pregnancy rates of 42% have been achieved.⁹⁰ Comparison of series of macrosurgical and microsurgical neosalpingostomies fails to demonstrate an advantage of microsurgery. Again, however, a study designed to directly compare the two techniques has not been performed. Both Mage and Bruhat⁸⁶ and Tulandi and Vilos⁸⁷ have compared microsurgical neosalpingostomies performed by laser and nonlaser techniques. Each group reported no difference in pregnancy outcome.

TABLE 7. Pregnancy Outcome After Surgical Treatment of Complete Distal Tubal Obstruction

Performance of neosalpingostomy at laparoscopy has been reported by several groups.^36,40,89,91 Pregnancy results appear to be less than for comparable reports at laparotomy. However, the patient selection for neosalpingostomy at laparoscopy includes women who refuse laparotomy, and therefore the patient populations may not be comparable.

The relatively poor pregnancy outcome after neosalpingostomy, compared with other types of reconstructive pelvic surgical procedures, and despite re-establishment of tubal patency in most patients, is thought to be caused in large part by intraluminal tubal pathology. The presence of coexistent pelvic adhesions, which restrict tubal motility and ovum capture, has also been implicated in reduction of successful pregnancy outcome.

Intraluminal tubal abnormalities primarily represent the pathologic sequelae of infection, although changes can also occur in response to endometriosis or exposure to diethylstilbestrol (DES)⁹² in utero. Chronic postinfectious histologic intraluminal changes observed include the presence of intraluminal adhesions, loss of villous folds, and ciliary destruction. It is unclear whether the latter is caused by the increased hydrostatic pressure resulting from tubal occlusion or is an effect of the infectious process itself.

Classifications of pregnancy outcome after neosalpingostomy have been based on intratubal and extratubal characteristics. Screening for these characteristics, to assess the likelihood of establishing a pregnancy, is performed by hysterosalpingography and laparoscopy, respectively. Rock and colleagues⁹³ developed a classification of distal tubal obstruction based on hydrosalpinx diameter, rugal pattern, extent of fimbrial damage, and extent of coexistent pelvic adhesions (Table 8); they were able to demonstrate a deterioration in outcome as the extent of disease progressed from mild to moderate to severe.

TABLE 8. Rock Classification of the Extent of Tubal Disease With Distal Tubal Obstruction

More recently, Boer-Meisel and coworkers⁸⁵ used a system for classification of hydrosalpinges to establish intrauterine pregnancy rates with good, intermediate, and poor outcome (77%, 21%, and 3%, respectively). The factors used for this analysis were the nature and extent of pelvic adhesions, the hydrosalpinx diameter, the hydrosalpinx tubal wall thickness, and the macroscopic assessment of the condition of the endosalpinx.

After surgical correction of complete distal tubal obstruction, the most likely time to conceive is more than 1 year after the surgical procedure.^42,82,94 This time lag is thought to be required because of the tubal mucosa needs to regenerate after the damage that occurred while a hydrosalpinx was present. According to two preliminary descriptions, the surgery-to-conception interval after neosalpingostomy can be reduced if the procedure is performed with the CO₂ laser;^81,95 however, no further substantiation of this possibility has been forthcoming.

New diagnostic techniques to predict the likelihood of establishing a pregnancy after distal tubal obstruction are tuboscopy and fimbrial biopsy. In the former technique, a narrow-diameter scope or fiber is passed into the fimbrial ostium at the time of laparoscopy or laparotomy, or through the tubal cornua, which is visualized hysteroscopically. This allows direct examination of the intraluminal anatomy and identification of adhesions, areas of deciliation, and flattening of the mucosal folds. In early studies with this technique, the findings correlated significantly with subsequent pregnancy outcomes and therefore may be helpful in referral of patients for tubal repair and ART.^{96,97,98,99,100,101} This may particularly be the case as technologies for transcornual viewing are improved, making this an office procedure. Therefore, tuboscopy may be beneficial in preoperative patient screening. Regarding fimbrial biopsy, Donnez and associates⁴² showed that the ciliation index obtained on microbiopsy was impaired in the presence of tubal disease and that the index was predictive of subsequent pregnancy outcome.

Distal Tubal Obstruction: Incomplete

Comparison of outcome after surgical treatment of incomplete distal tubal obstruction is difficult because of the diversity of pathology it may represent. The clinical findings range from slight fimbrial agglutination to peritubal bands to fimbrial phimosis causing near-total occlusion and can occur in association with varying degrees of pelvic adhesions. Therefore, analysis of efficacy of treatment of incomplete distal tubal obstruction must be carefully scrutinized. A summary of pregnancy outcomes after such procedures is shown in Table 9.¹⁰² These results tend to be better than those for complete distal obstruction, probably reflecting less intratubal damage. Although follow-up is limited, surgical treatments with the CO₂,¹⁰³ argon,³⁶ KTP-532,¹⁰⁴ and Nd:YAG¹⁰⁵ lasers have been described; their use has not been associated with improved pregnancy rates. Few series describe pregnancy outcome after laparoscopic treatment of incomplete fimbrial obstruction; therefore, analysis of the relative efficacies of laparoscopy and laparotomy as methods of treatment is premature.

TABLE 9. Pregnancy Outcome After Surgical Treatment of Partial Distal Tubal Obstruction

Various systems have been used to classify endometriosis.^{106,107,108,109} Most early reports used the Acosta classification,¹⁰⁶ grouping cases into mild, moderate, and severe stages based on the location and extent of endometriosis and the degree of pelvic adhesions. Classifications by Kistner and associates¹⁰⁷ and by the American Fertility Society (now called the American Society for Reproductive Medicine) were subsequently established,¹⁰⁸ followed by a revised classification by the latter group in 1985,¹⁰⁹ which is pictured in Figure 1. Use of classifications is advantageous because the scoring confers an extent of disease, allowing comparison of reports from different investigators and centers.

The relative efficacy of different methods of treating endometriosis is not well defined; in some reports, pregnancy outcome was no different with observant management than it was with medical or surgical treatment.^110,111 However, a recent large, well-designed, multicenter trial did identify improvement in pregnancy outcome after surgical treatment of mild endometriosis.^111a The most widely used medical agents are danazol^112,113 and gonadotropin-releasing hormone (GnRH) analogues.^114,115 These agents are used alone for treatment of mild and moderate endometriosis, and in combination with surgery (both preoperative and postoperative) for treatment of these stages as well as severe endometriosis. The relative efficacies of these varied forms of treatment and the appropriate indications for concomitant therapy currently are unclear. An in-depth discussion of studies describing the medical and medical-surgical treatment of endometriosis is beyond the scope of this chapter; the reader is referred to published reports.^{111a, 112,113, 116,117,118}

Pregnancy outcome after treatment is the most important end point for infertile couples; an assessment of outcome is given in Table 10.^{119,120,121,122,123,124,125,126,127,128,129,130} Considering the use of laparoscopy for reproductive pelvic surgery, more series have been described for the treatment of endometriosis than for other procedures. From the numbers in these reports (which are limited in part by lack of comparable life table analyses of outcome), it appears that, in experienced hands treatment at laparoscopy and at laparotomy are equally efficacious, not only for mild and moderate endometriosis but for severe and extensive endometriosis as well. This observation is consistent with a recent extensive meta-analysis of equivalent pregnancy outcome after treatment at laparoscopy and at laparotomy.^130a Individual investigators^131,132 have treated large endometriomas laparoscopically with high pregnancy rates resulting. In many series of laparoscopic treatments for endometriosis, the CO₂ laser has been used.^{123,124,125,126,127,128,129} However, similar pregnancy rates obtained with nonlaser laparoscopic techniques have also been described.¹³⁰ Other lasers that have been used for laparoscopic treatment of endometriosis are the argon,¹³³ KPT-532,¹⁰⁴ and Nd:YAG,^134,135 types. Nevertheless, pregnancy outcome as an end point has its limitations, in that many factors can impair fertility after adequate treatment of endometriosis; furthermore, pregnancy can occur after inadequate treatment of endometriosis, and pregnancy can occur despite recurrence or persistence of endometriosis. Several investigators have tried to correct for other possible factors by looking at pregnancy outcome in women in whom endometriosis is the sole cause identified for infertility; slight improvements in pregnancy outcome have been identified.³³

TABLE 10. Pregnancy Outcome After Surgical Treatment of Endometriosis
Click here to view Table 10.

Endometriosis is noted to be present in 2% to 47% of women after surgical or medical treatment,¹³⁶ the actual likelihood depending, in part, on the initial severity of endometriosis and the treatment undertaken. However, it has been difficult to differentiate recurrent from persistent endometriosis. Three types of reports suggest that persistence may be more likely than previously recognized. First, microscopic implants of endometriosis not visible to the naked eye (or to the eye with magnification) are frequently present.^137,138,139 Second, many implants do not have the gross purplish macroscopic appearance that has become clinically recognized as endometriosis; they may be clear, yellow, red, or black, or they may be represented by converging vascular patterns or white scarring.¹⁴⁰ Third, recognized implants of endometriosis may extend from the identified lesion beneath the peritoneum.¹⁴¹ For the latter, it has been suggested that visualized lesions be treated so as to include the immediately surrounding (normal-appearing) peritoneum. The actual surface area that should be treated, and whether such treatment affects rates of recurrence or persistence or pregnancy outcome, have not been established.

The extent of recurrence or persistence of endometriosis is best assessed at second-look laparoscopy; however, this requires performance of an additional operative procedure. Clearly, a nonoperative method of assessment would have tremendous advantages. A potential candidate is the serum marker is CA-125, a membrane antigen that is present in many conditions, including epithelial serous ovarian carcinoma.^142,143 The antigen concentration is elevated in women with endometriosis, and initial studies suggest the level correlates with the severity of disease and with its clinical course.^142,143 Another technique that has been evaluated is an endometrial antibody assay.¹⁴⁴ Although only a small number of subjects were examined, the antibody level did appear to correlate with observations at second-look laparoscopy. Additional studies are required to further examine the potential of these markers.

Tubal Anastomosis and Implantation for Tubal Obstruction

An overview of pregnancy outcome after tubal anastomosis and tubal implantation procedures is shown in Table 11.^{145,146,147,148,149,150,151,152,153,154,155,156} Compared with other types of reproductive pelvic surgical procedures, pregnancy outcome is best after tubal anastomosis, approaching 70% in many series. Many factors affect the outcome of surgical procedures designed to re-establish tubal continuity, including the cause of the obstruction, its location, the extent of coexistent pelvic disease, the length of the resulting tube after patency is restored, and the length of time since tubal blockage.

TABLE 11. Pregnancy Outcome After Tubal Anastomosis/Tubal Implantation

Among women desiring reversal of previous tubal ligations, the method of tubal occlusion is a major prognostic factor in subsequent pregnancy outcome. The best results are obtained with Hulka clips or fallope rings; the worst outcome follows unipolar cautery, and intermediate pregnancy rates are achieved after segmental resection or bipolar cautery. These differences may be partially explained by the resultant length of tube after anastomosis, increasing tubal length correlating directly with improved pregnancy outcome. An additional factor may be the extent of damage to the tubal blood vessel arcade; both human and animal studies have suggested a possible role of this network in ovulation and pregnancy outcome. In tubocornual anastomosis, an additional advantageous prognostic factor is preservation of as much of the intramural segment of the fallopian tube as possible.¹⁴⁹

The length of time between tubal ligation and reversal has been shown to be a prognostic factor, correlating inversely with subsequent pregnancy outcome. However, it is likely that this relation reflects the natural decline in fecundity with advancing maternal age, as opposed to an effect on the tubes per se.

DeCherney and coworkers¹⁰ examined the causes of failure to conceive in 35 women who underwent midsegment tubal anastomosis. A surgically related factor (bilateral tubal reocclusion) was noted in only 20% of these couples. In the remaining couples, ovulatory dysfunction was present, the husband had not previously fathered a child, or the infertility was unexplained.

Location of tubal occlusion is another major prognostic factor. Those women with tubal blockage that allows anastomosis to be performed generally have improved conception rates, compared with those requiring tubal implantation. In their in-depth review of surgical management of uterotubal obstruction, Musich and Behrman¹⁵⁷ concluded that microsurgical anastomosis has replaced implantation as the primary method for re-establishment of tubal patency under most circumstances. Exceptions were surgeon preference and complete intramural occlusion. In a review of all series in the literature from 1965 to 1982 describing pregnancy outcome after uterotubal implantation and tubocornual anastomosis, Haseltine and Von Arras¹⁵⁸ demonstrated improved pregnancy rates after anastomosis. Additionally, anastomosis obviates the decision of whether a conception occurring after a tubal implantation procedure should always be delivered by cesarean section and reduces the risk of uterine rupture at the site of implantation, a complication that has been described with the implantation technique.¹⁵⁹

Women who have undergone fimbriectomy for sterilization represent a special category because the surgical correction required is a neosalpingostomy. In two small series of such women, pregnancy occurred in 57% (4/7)¹³ and 44% (4/9) of patients.¹⁶⁰

Lasers have seen limited application in tubal anastomosis. Kelly and Roberts⁸⁸ described excision of blocked tubal stumps with the use of a CO₂ laser. It is unclear whether this procedure has any advantages over nonlaser techniques. Other investigators have attempted to anastomose the fallopian tube by “welding” with the CO₂ laser but have noted this technique to be of little value.¹⁶¹

The feasibility of laparoscopic tubal anastomosis has now been demonstrated by Gray et al.²⁰⁵ It remains to be determined whether pregnancy outcome in such patients can approach the success observed at laparotomy.

The rate of occurrence of ectopic pregnancy has increased over the past several decades owing to alterations in sexual activity and perhaps to the advances in reproductive pelvic surgery. With regard to the latter, the ability to establish and maintain tubal patency in damaged tubes may allow conception to occur in women who previously would have been sterile, even though the extent of the tubal damage precludes (or reduces) the ability of the fertilized ovum to transgress the tube and reach the uterine cavity. Although this is only a theory, such a possibility is pertinent because of the issue of whether gamete intrafallopian transfer procedures should be performed on women with damaged but patent fallopian tubes. Currently, it is unclear whether such women are at an increased risk for a tubal ectopic pregnancy.

Once a tubal ectopic gestation is diagnosed or highly suspected, options for surgical therapy are whether to preserve or remove the fallopian tube and whether to perform the procedure at laparoscopy or at laparotomy. These decision are based on the location of the ectopic pregnancy and the extent of tubal damage. Cornual ectopic pregnancies are almost exclusively treated at laparotomy. Isthmic, ampullary, and infundibular ectopic pregnancies are more likely to be amenable to conservative management. Isthmic ectopic gestations are usually treated by segmental resection. Tubal ampullary and infundibular gestations can be treated by linear salpingostomy along the antimesenteric border. When the criteria listed in Table 12 are met, this procedure can be performed at laparoscopy, sparing the patient the increased morbidity associated with laparotomy. The safety of this procedure has been established by two large series describing its use.^162,163 For a detailed description of these options, the reader is referred to published reviews.^{164,165,166,167} A summary of pregnancy outcome after treatment of ectopic pregnancies in selected series is shown in Table 13.^{168,169,170,171}

TABLE 12. Criteria for Consideration of Performance of Laparoscopic Linear Salpingostomy for

  Hemodynamically stable patient
  Acceptance by the patient of performance of laparotomy if needed
  Tubal gestation no greater than 3 cm in greatest diameter
  Adequate pelvic access
  Availability of necessary laparoscopic equipment
  Availability of personnel experienced in performing endoscopic procedures
  Surgeon experienced in operative laparoscopy

TABLE 13. Pregnancy Outcome After Treatment of Tubal Ectopic Pregnancies

Women who have had ectopic gestation have a 8% to 13% risk of a repeat ectopic gestation.^{169,172,173,174} This risk is independent of whether the initial ectopic pregnancy was treated conservatively or by salpingectomy. Among those treated conservatively, repeat ectopic gestation is equally likely to occur in the tube with the initial ectopic gestation as in the contralateral tube.¹⁷⁵ This suggests that the processes that contributed to the initial ectopic pregnancy (whether pathologic disease or innate variants in tubal motility) are likely to affect each fallopian tube.

Among women with two prior ectopic pregnancies, the risk for a third ectopic gestation increases to 20%.¹⁷⁶ Among those with an ectopic pregnancy in a sole remaining fallopian tube treated conservatively, the subsequent pregnancy rate ranges in most series from 32% to 60%, with a repeat ectopic pregnancy rate of 12% to 40%.¹⁶² Women who have undergone a segmental resection for treatment of an ectopic pregnancy and have a patent contralateral tube are at risk for development of a repeat ectopic pregnancy in the blind, ending distal segment of the partially resected tube.¹⁷⁷

Medical treatment of ectopic pregnancy has been suggested as an alternative to surgical treatment,^178,179 administered either systemically or by direct injection into the ectopic pregnancy. The chemotherapeutic agent most frequently used is methotrexate. This would appear to have its greatest utility when the ectopic gestation can not be localized or when surgical treatment has failed to eradicate all trophoblastic tissue. However, some centers use medical therapy as an alternative to surgical treatment.¹⁸⁰ Patients treated in this fashion should be counseled regarding the need for serial β-human chorionic gonadotropin (β-hCG) titers, as well as the frequent description of increased pain after methotrexate administration, even when treatment is successful. To date, the greatest likelihood of failure with medical therapy appears to be in patients in whom a fetal heartbeat can be identified in the eccyesis.

Because of the risk of a persistent ectopic pregnancy after conservative treatment, patients should be monitored until the β-hCG level becomes negative. The term “persistent” ectopic pregnancy may mean different things to different investigators. Although some would include patients whose titers are falling slowly, we have reserved this term for patients with rising titers after initial therapy and those who become symptomatic, necessitating further intervention. Although an early series described no persistent ectopic pregnancies among 79 sequentially treated ampullary ectopic gestations,^181,182 we have observed a rate of approximately 10%. The only two factors associated with persistent ectopic pregnancy that could be identified were smaller ectopic size and younger gestational age. It is unclear why the incidence of persistent ectopic pregnancy varied so greatly between these two reports. However, the second series was collected during a period when vaginal ultrasonography was used to exclude intrauterine pregnancies and identify tubal gestations. It is tempting to speculate that earlier identification of ectopic pregnancies by vaginal ultrasonography (and hence earlier treatment) was associated with a more viable eccyesis (i.e. less surrounding blood clot), with the result that surgical removal was less complete.

Before the widespread availability of agents for induction of ovulation in women with polycystic ovary syndrome, ovarian wedge resection was a common method used to achieve ovulation. In theory, such a procedure reduced ovarian steroid production, temporarily allowing follicular development to resume. In one series, after wedge resection, resumption of ovulation occurred in 91% of the patients; however, subsequent conceptions occurred in only 48%.¹⁸³

A potential cause for this discrepancy between ovulation and conception rates is the postoperative development of pelvic adhesions. Kistner¹⁸⁴ noted peritubal and previous adhesions at culdoscopy in 16 women after wedge resection. Weinstein and Polishuk¹⁸⁵ reported that 14% of women undergoing ovarian wedge resection and a subsequent second-look procedure developed pelvic adhesion. This number undoubtedly represents an underestimation, because only a selected group of nonpregnant patients underwent the second-look procedure. Buttram and Vaquero¹⁸⁶ and Toaff and coworkers¹⁸⁷ reported the presence of adhesions in 59 of 59 and 7 of 7 women, respectively.

A “pseudo-wedge resection” has been performed at laparoscopy in women with polycystic ovary syndrome.¹⁸⁸ This procedure involved draining ovarian cysts with the use of electrocautery. Ovulation subsequently occurred in 57 (92%) of 62 women undergoing this technique. Of 35 women with polycystic ovary syndrome as the sole cause of infertility, conception occurred in 24 (69%) after electrocautery treatment. This procedure has also been performed with the use of the CO₂ laser.¹⁰⁴ As yet, no systematic assessments of postoperative adhesion formation after this technique have been performed, although Gjonnaess¹⁸⁸ described their appearance in only one of six women in the initial series described above. However, the length of time that these women continue to ovulate spontaneously may be limited.

Fertility After Appendectomy and Cesarean Section

Two operations that women of reproductive age have frequently undergone are appendectomy and cesarean section. Several reports have examined the effects of these procedures on subsequent infertility. Trimbos-Kemper and associates¹⁸⁹ noted a 42% incidence of tubal abnormalities among women who had undergone appendectomy; however, this was not statistically greater than the 37% incidence in the control group. Mueller and coworkers¹⁹⁰ observed that women who underwent appendectomy with findings of an unruptured appendix were not at increased risk for infertility. However, those women with a ruptured appendix at the time of appendectomy were significantly more likely to be infertile.

Among American women who underwent cesarean section for their first childbirth, Hemminki and colleagues¹⁹¹ described a reduction in subsequent fertility, compared with controls. This reduction was attributed to physical difficulties related to the operation and potentially may have been caused by the cesarean section. Hemminki¹⁹² subsequently confirmed these findings in a report based on the Swedish Birth Registry, again demonstrating that women who undergo cesarean section have fewer children later.

A variety of congenital and acquired abnormalities of the uterus have been suggested as factors possibly contributing to the establishment of an infertile state. Several of these conditions and advances in their surgical management are described here. For a summary of uterine distention media used for hysteroscopy, the reader is referred to the review by Diamond and coworkers.¹⁹³

Asherman's Syndrome

Asherman's syndrome is the presence of adhesions within the uterine cavity. The most common cause is infection after curettage of a pregnant or recently pregnant uterus. Such adhesions partially or completely obliterate the uterine cavity and are diagnosed by hysteroscopy, hysterosalpingography, or both. Obliteration of the uterine cavity by adhesions causes amenorrhea in its most severe forms and is a contributing factor to infertility. Among those women with intrauterine adhesions who are able to conceive, only a small percentage are able to carry the pregnancy to term; this percentage increases markedly after lysis of the intrauterine adhesions.^194,195 Treatment of these adhesions currently is at the time of hysteroscopy. Although lysis can be performed bluntly with the hysteroscope, adhesions in the noncentral sections of the uterine cavity may be missed; alternative therapy is by dilatation and curettage of the uterus or with hysteroscopic scissors, electrosurgery, or lasers. Pregnancy outcome after surgical treatment of Asherman's syndrome is shown in Table 14.^{196,197,198,199} Relative efficacies of the various methods of lysing the intrauterine adhesions has not been examined.

TABLE 14. Prenancy Outcome After Treatment of Asherman's Syndrome in Women Attempting Conception

Removal of a uterine septum has traditionally been performed at laparotomy by either the Jones or the Tompkins technique. The rationale for performance of this operative procedure is that the septum might contribute to infertility or early miscarriage if the embryo were to “implant” on it; poor survival is attributed to inadequate blood supply to the uterine septum.²⁰⁰

Although such elimination of the septum reduces the likelihood that a pregnancy will miscarry, it is likely that adhesions that develop as a result of such procedures reduce the actual conception rate. Therefore, before a metroplasty at laparotomy is performed, women have been given the opportunity to conceive and carry pregnancies. Additionally, because infertility is rarely caused by uterine anomalies alone,²⁰¹ these couples should undergo the same rigorous evaluation as infertile couples without uterine anomalies.

Several groups have described the performance of hysteroscopic “metroplasties.”²⁰² These procedures involve incision of the septum and have been performed with hysteroscopic scissors, resectoscope, and the Nd:YAG laser. The procedures are performed concomitantly with laparoscopy, so that if uterine perforation does occur, it can be identified immediately and damage to pelvic structures can be minimized. Although difficulties identifying both cavities may occur, complications in experienced hands have been minimal. Pregnancy rates with these techniques or abdominal metroplasty are listed in Table 15 and appear to be similar to the success rates after conventional metroplasty.^{203,204,205,206,207,208,209,210,211,212,213} Additionally, the hysteroscopic procedures can be done on an outpatient basis, without the morbidity associated with laparotomy. In a report comparing outcomes in one center, Fayez²⁰⁶ compared abdominal and hysteroscopic metroplasties and observed no significant difference in results at postoperative hysterosalpingography or in subsequent pregnancy outcome. However, hysteroscopic procedures were associated with decreased operating time, less blood loss, and shorter hospitalization. For these reasons, many have concluded that it is reasonable to perform prophylactic hysteroscopic “metroplasties” in women undergoing infertility evaluations, before assessing whether conception occurs and pregnancy outcome after conception.

TABLE 15. Pregnancy Outcome After Metroplasty for Uterine Septum

Uterine fibroids are a frequent finding, and they occur with increased frequency in older women prior to menopause. Although uterine fibroids are a recognized cause of pregnancy loss,^214,215 as a general rule they are considered to be a rare cause of infertility.²¹⁵ However, in specific circumstances they may contribute to infertility, as when fibroids cause tubal occlusion at the cornua of fill the uterine cavity or when gestations try to implant in endometrium overlying a fibroid. In the latter case, impaired blood flow to the implantation site could prevent successful nidation. For an in-depth review of myomas, reproductive function, and pregnancy outcome, the reader is referred to the summary by Rossi and Diamond.²¹⁶

Despite the general consensus that myomas rarely cause infertility, conception rates after myomectomy average approximately 50% (Table 16).^{217,218,219,220,221,222} This apparent paradox can perhaps be explained by concomitant treatment of other tuboperitoneal disease at the time of myomectomy (e.g. endometriosis, tubal obstruction, pelvic adhesions). In fact, Berkeley and colleagues²¹⁷ noted conception in only one (16%) of six women with myoma but no other infertility factors. Assessment of the use of the CO₂ laser in abdominal myomectomy has been limited. McLaughlin²²⁰ noted a subsequent pregnancy rate of 33% and described a reduction of approximately one third in blood loss with the CO₂ laser, compared with nonlaser technique.

TABLE 16. Pregnancy Outcome After Treatment of Uterine Fibroids

Many surgeons have begun to treat uterine myomas at laparoscopy.²²³ Pedunculated myomas are often easy to excise from the uterus but can be difficult to remove from the abdominal cavity if they are large. Options include morcellation, posterior colpotomy, and, more recently, minilaparotomy. It remains to be shown whether there are overriding advantages of these options, particularly the minilaparotomy, compared with initial performance of a myomectomy at laparotomy. Even more controversial is the laparoscopic treatment of subserosal or intramural myomas that do not impinge on the uterine cavity. First is the question of why these myomas need to be excised. Second is the question of whether the integrity of the uterine myometrium wall can be adequately established by laparoscopic closure and of the extent of postoperative adhesion development. The latter issue causes particular concern because of the report of a 25% (6/24) incidence of fistulas between the uterine cavity and the abdominal cavity after laparoscopic myomectomies.²²⁴

A potential complication of abdominal myomectomy is the postoperative development of pelvic adhesions, with associated effects on fertility. Neu-wirth^221,222 described hysteroscopic resection of submucous uterine fibroids with subsequent pregnancy in 8 of 28 women. The hysteroscopic procedure, in experienced hands, has the theoretical advantages of reduced hospitalization, operative morbidity, consideration of cesarean section for delivery, and development of postoperative pelvic adhesions. However, it does not allow removal of nonsubmucosal fibroids. The latter factor is potentially important because the rate of symptomatic recurrence of myoma has been reported to be 27% in women with isolated myoma and 59% in those with multiple myomas.²²⁵ In part, the recurrence rate probably varies with the diligence of the surgeon in removing “seedling” myomas at the initial operative procedure.

GnRH analogues have also been used to treat uterine leiomyoma. Although these agents have been successful in reducing the size of the myoma during administration, cessation of treatment has been associated with re-enlargement.^226,227 The analogues have been used in conjunction with surgery to achieve preoperative shrinkage. However, the frequency with which this approach truly enhances the ease of surgery has not been established; some surgeons believe that the myoma capsule is less well defined after GnRH therapy, thereby making the surgery more difficult. One advantage of GnRH pretreatment is the reduction of blood loss; however, it is unclear whether this effect is clinically significant. In anemic patients, GnRH analogues may be used successfully as a temporizing measure to postpone the surgery, allowing the patient to build up her blood count and to donate autologous blood for transfusion should it become necessary. However, myomectomies are infrequently complicated by either large-volume hemorrhage requiring heterologous transfusion or the need to convert to an undesired hysterectomy.²²⁸

One additional consideration regarding the use of GnRH analogues in women with uterine fibroids is that the lesion may actually be a leiomyosarcoma. This is a rare occurrence, but it can be suggested by myomas that fail to shrink in size or actually enlarge during GnRH therapy.^229,230 If a leiomyosarcoma is present, it is usually (95% of the time) the only or the largest myoma present.²³⁰ Finally, it appears that GnRH therapy should not significantly alter the ability of the pathologist to differentiate a benign myoma from a malignant leiomyosarcoma.²³¹

Transplantation

The literature includes a series of reports describing restoration of tubal patency in women with such procedures as transposition of the fallopian tube or anastomosis of one segment of the fallopian tube to the other.^{232,233,234,235,236} Although pregnancies have been achieved in some of these reports, it is not possible to assess what the pregnancy rate would be in large groups of women undergoing such procedures. Three reports in the literature describe transplantation of human fallopian tube into another woman. In all, a dozen attempts have been made, but no pregnancies have been achieved.^237,238,239 Transplantation of the ovaries and fallopian tubes before pelvic radiation for an aneurysmal bone cyst has been performed with subsequent replantation after completion of therapy.²⁴⁰ Conception did occur, but preterm labor developed and a preterm, stillborn male infant was delivered.

Therefore, although there may remain a use for such procedures in individual cases, their efficacy in view of available in vitro fertilization techniques must be evaluated.

Vaginal and Cervical Procedures

Surgical correction of vaginal obstruction is associated with high success rates. Rock and coworkers²⁴¹ noted that 13 of 15 women who were trying to conceive did so after correction of an imperforated hymen, whereas 9 of 19 women attempting to conceive after surgical treatment of a transverse vaginal septum were able to do so. Among the women with transverse vaginal septum, six of seven in whom laparotomy was performed were noted to have endometriosis. The authors suggest that prompt diagnosis of vaginal obstruction in these women may be important to minimize impairment of fertility by endometriosis.

Cervical conization as treatment for cervical dysplasia is not thought to significantly reduce fertility.²⁴² However, the need to individualize the cone to the existing cervical pathology has been emphasized so as to keep this risk to a minimum.²⁴² Although cervical stenosis after conization is rare, it does occur.²⁴³ There is one report of reconstruction of the cervical canal after complete postconization obstruction with the use of a combined vaginal and abdominal approach.²⁴⁴

Pelviscopic Surgery

The term pelviscopic surgery refers to extensive operative laparoscopic procedures involving the use of sutures, Roeder loops, and other laparoscopic instrumentation. The procedures allow laparo-scopic excision of tubal ectopic gestations, ovaries, and tubes, as well as entire adnexa. This technique was pioneered by Semm^245,246 and has been extended by many surgeons in the United States.^{130,247,248,249,250,251} Such techniques have great potential in view of their ability to reduce the morbidity and expense associated with laparotomy; however, they require sophisticated instrumentation and an experienced operative laparoscopist. Additionally, although it was initially demonstrated that laparoscopic procedures were less expensive than the same procedure performed at laparotomy²⁴⁸ (with the savings primarily attributable to a reduction in the length of hospital stay and its associated costs), more recent procedures, in which disposable instruments were used, have generated higher costs. Therefore, ongoing evaluation is needed to assess safety and efficacy.

With the introduction of ART, an alternative to surgery for the treatment of tuboperitoneal disease now exists. The difficulty lies in deciding the risk-benefit ratio for in vitro fertilization (IVF) as opposed to corrective surgical procedures. This is an issue that continues to be addressed, and one for which the answers will change as the success rate, risks, and morbidity of each choice are altered by technological advances. Additionally, the important issue is not the optimal outcome available at leading centers, but the likely outcome where the procedure is to be performed.

The issue of when to refer patients for IVF is beginning to be addressed. Mage and associates²⁵² reviewed the pregnancy outcome after surgery for distal tubal obstruction. Outcome was predicted based on tubal patency, the appearance of the ampullary tubal mucosa, the ampullary tubal wall thickness, and the presence and types of pelvic adhesions. It was recommended that women with more extensive tubal damage or severe adhesions be referred for IVF because of the low intrauterine pregnancy rate and the observation that conceptions that did occur were more likely to be ectopic than intrauterine. Failure to achieve pregnancy among patients with more severe pelvic adhesions has also been identified by the Intraabdominal Laser Adhesion Study Group.²⁵³

An issue that has been raised is whether a second tuboplasty should be performed for the treatment of tuboperitoneal disease, or whether such a patient should be referred for IVF. (Excluded from what would be considered the first tuboplasty would be performance of an appendectomy, treatment of an ectopic pregnancy, excision of an ovarian cyst, and other procedures in which the intent was not the performance of reparative tubal surgery.) There are few studies in the literature that address this issue; their outcomes are listed in Table 17.^254,255,256 Term pregnancy outcome ranged from 8% to 32%, a range not dissimilar from that seen with IVF in many centers. Therefore, a plausible role for repeat tuboplasties may remain. Potentially, the benefit of repeat tuboplasty may be greater if it can be performed at laparoscopy. Even with the use of a multipuncture technique, the morbidity of such a procedure in experienced hands would be less than that associated with laparotomy.

TABLE 17. Pregnancy Outcome After Repeat Tuboplasty

Another issue raised is whether women with bipolar tubal disease should undergo tuboplasty or be referred for IVF. As shown in Table 18, reports describing pregnancy outcome after treatment of bipolar disease are also limited.²⁵⁷ However, 34% of the women in these studies were able to deliver a term pregnancy. Therefore, for each of these questions, it remains for studies to be performed to assess the relative efficacy of surgical versus IVF approaches.

TABLE 18. Pregnancy Outcome After Treatment of Bipolar Tubal Disease

In IVF programs, oocytes are now routinely recovered by laparoscopy and ultrasound-guided aspiration. When most oocyte recovery was by laparoscopy, it was suggested that women with tuboperitoneal disease might benefit from operative procedures to “prepare” the pelvis for IVF, including possible salpingectomies, adhesiolysis, and ovarian suspensions.^{37,258,259,260} However, the rapid development of ultrasound-guided aspiration techniques has obviated this procedure as a means of providing ovarian access. The consideration that remains is whether such adhesions impair follicular development in response to exogenous stimulation, as suggested by Mahadevan and colleagues.¹³⁶ In a subsequent report examining this issue, such a relationship was not observed.²⁶¹ Therefore, there no longer appears to be a reason to perform pre-IVF laparotomies or laparoscopies to “prepare” the pelvis for oocyte recovery.

The excitement regarding increased endoscopic surgical procedures for treatment of infertility has progressed until recently with relatively little attention to the issue of operative complications and their management. As an example, when we had a patient with ureteral injury, an initial review of the literature yielded no prior reports of this occurrence.²⁶² Eventually, we were able to identify a handful of previously reported cases, and included several other recent cases that had completed litigation to produce a series of five patients. However, in discussing this complication with groups of colleagues, we found that almost all groups had at least one member who had personally experienced this complication or was aware of a similar complication experienced by a physician in their community, indicating this and other complications are occurring but being underreported. As a consequence, surgeons may be less likely to avoid similar recurrences. For a more in-depth review of complications, their identification, management, and avoidance, the reader is referred to a recent publication.²⁶³

Two categories of challenges confront the gynecologic surgeon. The first is to examine the previous success of surgical treatment of tuboperitoneal disease and intrauterine lesions and to compare these results with the efficacy and safety of new innovations in regard to both operative approach (e.g. endoscopy versus laparotomy) and instrumentation (e.g. lasers, operative laparoscopies, hysteroscopies). Additionally, the efficacy of these innovations must be compared with that of nonsurgical means of treatment, namely medical therapy (e.g. danazol and GnRH analogues for endometriosis, methotrexate for ectopic pregnancies) or use of gamete and embryo transfer techniques (e.g. IVF, gamete intrafallopian transfer). The second challenge is to recognize specific areas in which improvement is needed and to develop approaches, devices, drugs, and instruments necessary to overcome them. Such areas include maximizing pregnancy outcome, preventing postoperative adhesion development, identifying accurate, noninvasive methods of assessing intraperitoneal endometriosis and adhesions, and continuing to reduce the operative morbidity associated with gynecologic surgery.

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74. Elkins TE, Bury RJ, Ritter JL et al: Adhesion prevention by solutions of sodium carboxymethylcellulose in the rat: I. Fertil Steril 41: 926, 1984

75. Elkins TE, Ling FW, Ahokas RA et al: Adhesion prevention by solutions of sodium carboxymethylcellulose in the rat: II. Fertil Steril 41: 929, 1984

76. Diamond MP, DeCherney AH, Linsky CB et al: Assessment of carboxymethylcellulose and 32% dextran 70 for prevention of adhesions in a rabbit uterine horn model. Int J Fertil 33: 278, 1988

77. Diamond MP, DeCherney AH, Linsky CB et al: Adhesion reformation in the rabbit uterine horn model: I. Reduction with carboxymethylcellulose. Int J Fertil 33: 372, 1988

78. Jansen RPS: Early laparoscopy after pelvic operations to prevent adhesions: Safety and efficacy. Fertil Steril 49: 26, 1988

79. Swolin K: Electromicrosurgery and salpingostomy long-term results. Am J Obstet Gynecol 121: 418, 1975

80. Raj SC, Hulka JF: Second-look laparoscopy in infertility surgery: Therapeutic and prognostic value. Fertil Steril 38: 325, 1982

80a. Franklin RR, Diamond MP, Malinak LR et al: Reduction of ovarian adhesions by the use of Interceed. Obstet Gynecol 86: 335– 340, 1995

80b. Diamond MP and the Seprafilm Adhesion Study Group: Reduction of adhesions after uterine myomectomy by Seprafilm (HAL-F): A blinded, prospective, randomized, multicenter clinical study. Fertil Steril 66:904–910, 1996

80c. Diamond MP and the Seprafilm Adhesion Study Group: Reduction of de novo postsurgical adhesions by intraoperative precoating with Sepracoat (HAL-C) solution: A prospective, randomized, blinded placebo-controlled multicenter study. Fertil Steril 69:1067–1073, 1998

81. Daniell JF, Diamond MP, McLaughlin DS et al: Clinical results of terminal salpingostomy using the CO₂ laser: Report of the intra-abdominal laser study group. Fertil Steril 45: 175, 1986

82. Gomel V: Salpingostomy by microsurgery. Fertil Steril 29: 380, 1978

83. DeCherney AH, Kase N: A comparison of treatment for bilateral fimbrial occlusion. Fertil Steril 35: 162, 1981

84. Kitchin JD III, Nunley WC Jr, Bateman BC: Surgical treatment of distal tubal occlusion. Am J Obstet Gynecol 155: 524, 1986

85. Boer-Meisel ME, te Velde ER, Habbema JDF et al: Predicting the pregnancy outcome in patients treated for hydrosalpinx: A prospective study. Fertil Steril 45: 23, 1986

86. Mage G, Bruhat M-A: Pregnancy following salpingostomy: Comparison between CO₂ laser and electrosurgery procedures. Fertil Steril 40: 472, 1983

87. Tulandi T, Vilos GA: A comparison between laser surgery and electrosurgery for bilateral hydrosalpinx: A 2-year follow-up. Fertil Steril 44: 846, 1985

88. Kelly RW, Roberts DK: Experience with the carbon dioxide laser in gynecologic microsurgery. Am J Obstet Gynecol 146: 585, 1983

89. Daniell JF, Herbert CM: Laparoscopic salpingostomy utilizing the CO₂ laser. Fertil Steril 41: 558, 1984

90. Russell JB, DeCherney AH, Laufer N et al: Neosalpingostomy: A comparison of 24 and 72 month follow-up time shows increased pregnancy rate. Fertil Steril 45: 296, 1986

91. Mage G, Bruhat MA: Pregnancy following salpingostomy: Comparison between Co₂ laser and electrosurgery procedures. Fertil Steril 40: 472, 1983

92. DeCherney AH, Cholst I, Naftolin F: Structure and function of the fallopian tube following exposure to diethylstilbestrol (DES) during gestation. Fertil Steril 36: 741, 1981

93. Rock JA, Katayama KP, Martin EF: Factors influencing the success of salpingostomy techniques for distal fimbrial obstruction. Obstet Gynecol 52: 591, 1978

94. Harris WJ, Daniell JF: Use of corticosteroids as an adjuvant in terminal salpingostomy. Fertil Steril 40: 785, 1983

95. Tulandi T, Farag R, McInnes RA et al: Reconstructive surgery of the hydrosalpinx with and without the carbon dioxide laser. Fertil Steril 42: 839, 1984

96. Henry-Suchet J: Pregnancy rates alter distal microsurgical tuboplasty: Influence of various factors [Abstract]. 12th World Congress on Fertility and Sterility, Singapore, October 1986

97. Henry-Suchet J, Loffredo V, Tesquier L, Pez JP: Endoscopy of the tube (tuboscopy): Its prognostic value for tuboplasties. Acta Eur Fertil 16: 1349, 1985

98. Brosens I, Boeckx W, Delattin PH et al: Salpingoscopy: A new preoperative diagnostic tool in tubal infertility. Br J Obstet Gynaecol 94: 768, 1987

99. Kerin J, Daykhovsky L, Grundfest W et al: Falloscopy, a microendoscopic transvaginal technique for diagnosing and treating endotubal disease incorporating guide wire cannulation and direct balloon tuboplasty. J Reprod Med 35: 606, 1990

100. Hershlag A, Seifer DB, Carcangia ML et al: Salpingoscopy: Light microscopic and electron microscopic correlations. Obstet Gynecol 77: 399, 1991

101. Shapiro BS, Diamond MP, DeCherney AH: Salpingoscopy: An adjunctive technique for evaluation of the fallopian tube. Fertil Steril 49: 1076, 1988

102. Patton GW Jr: Pregnancy outcome following microsurgical fimbrioplasty. Fertil Steril 37: 150, 1982

103. Diamond MP, Daniell JD, Martin DC et al: Unpublished data.

104. Daniell JF: Personal communication, 1986.

105. Vasquez JM, Schorge JO, Demarque AM, Diamond MP: The use of sculptured quartz fiber optic cables and neodymium:yttrium aluminum garnet laser in laparoscopic surgery (in preparation).

106. Acosta AA, Buttram VC, Besch PK et al: A proposed classification of pelvic endometriosis. Fertil Steril 42: 19, 1973

107. Kistner RW, Siegler AM, Behrman SJ: Suggested classifications for endometriosis: Relationship to infertility. Fertil Steril 28: 1008, 1977

108. American Fertility Society: Classification of endometriosis. Fertil Steril 32:633, 1979

109. American Fertility Society: Revised classification of endometriosis. Fertil Steril 43:351, 1985

110. Olive DL, Lee KL: Analysis of sequential treatment protocols for endometriosis-associated infertility. Am J Obstet Gynecol 154: 613, 1986

111. Guzick DS, Rock JA: A comparison of danazol and conservative surgery for the treatment of infertility due to mild or moderate endometriosis. Fertil Steril 40: 580, 1983

111. Diamond MP, DeCherney AH: Nafarelin for the treatment of endometriosis [Letter]. N Engl J Med 319: 519– 520, 1988

112. Barbieri RL, Ryan KJ: Danazol: Endocrine pharmacology and therapeutic applications. Am J Obstet Gynecol 141: 453, 1981

113. Schmidt CL: Endometriosis: A reappraisal of pathogenesis and treatment. Fertil Steril 44: 157, 1985

114. Meldrum DR, Padridge WM, Karow WG et al: Hormonal effects of danazol and medical oophorectomy in endometriosis. Obstet Gynecol 62: 480, 1983

115. Schriock E, Monroe SE, Henzl M et al: Treatment of endometriosis with a potent agonist of gonadotropin releasing hormone (nafarelin). Fertil Steril 44: 583, 1985

116. Malinak LR, Wheeler JR: Endometriosis. In Aiman J (ed): Infertility: Diagnosis and Management, pp 255–275. New York: Springer-Verlag, 1984

117. Muse KN, Wilson EA: How does mild endometriosis cause infertility? Fertil Steril 38: 145, 1982

118. Buttram VC, Betts JW: Endometriosis. Curr Probl Obstet Gynecol 11: 11, 1979

119. Rock JA, Guzick DS, Sengos C et al: The conservative surgical treatment of endometriosis: Evaluation of pregnancy success with respect to the extent of disease as categorized using contemporary classification systems. Fertil Steril 35: 131, 1981

120. Buttram VC: Surgical treatment of endometriosis in the infertile female: A modified approach. Fertil Steril 32: 635, 1979

121. Gordts S, Boeckx W, Brosens I: Microsurgery of endometriosis in infertile patients. Fertil Steril 42: 520, 1984

122. Garcia CR, David SS: Pelvic endometriosis: Infertility and pelvic pain. Am J Obstet Gynecol 129: 740, 1977

123. Daniell JF: Combined laparoscopic surgery and danazol therapy for pelvic endometriosis. Fertil Steril 35: 521, 1981

124. Kelly RW, Roberts DK: CO₂ laser laparoscopy: A potential alternative to danazol in the treatment of stage I and II endometriosis. J Reprod Med 28: 638, 1983

125. Martin DC: CO₂ laser laparoscopy for endometriosis associated with infertility. J Reprod Med 31: 1089, 1986

126. Paulson JD, Asmar P: Personal communication, 1986

127. Feste JR: Endoscopic laser surgery in gynecology in reproductive surgery: Postgraduate course syllabus. Chicago: American Fertility Society, 1985

128. Davis GD: Instruments and methods: Management of endometriosis and its associated adhesions with the CO₂ laser laparoscope. Obstet Gynecol 68: 422, 1986

129. Nezhat C, Crowgey SR, Garrison CP: Surgical treatment of endometriosis via laser laparoscopy. Fertil Steril 45: 778, 1986

130. Reich H, McGlynn F: Treatment of ovarian endometriomas using laparoscopic surgical techniques. J Reprod Med 31: 577, 1986

130a. Shamma FN, Diamond MP: Postoperative adhesion development after operative laparoscopy: Evaluation at early second-look procedures. In Adamson D, Martin D (eds): An Atlas of Endoscopic Management of Gynecologic Disease. Philadelphia: Lippincott Raven Publishers, 1996

131. Martin DC: Personal communication, 1986

132. Nezhat C: Personal communication, 1986

133. Keye WR, Dixon J: Photocoagulation of endometriosis with the argon laser through the laparoscope. Obstet Gynecol 62: 383, 1983

134. Lomano JM: Laparoscopic ablation of endometriosis with the YAG laser. Lasers Surg Med 3: 179, 1983

135. Lomano JM: Photocoagulation of early pelvic endometriosis with the Nd:YAG laser through the laparoscope. J Reprod Med 30: 77, 1985

136. Mahadevan MM, Wiseman D, Leader A et al: The effects of ovarian adhesive disease upon follicular development in cycles of controlled stimulation for in vitro fertilization. Fertil Steril 44: 489, 1985

137. Wheeler JM, Malinak LR: Recurrent endometriosis: Incidence, management and prognosis. Am J Obstet Gynecol 146: 247, 1983

138. Brosens I, Vasquez G, Gordts S: Scanning electron microscopy study of the pelvic peritoneum in unexplained infertility and endometriosis [Abstract]. Fertil Steril 41: 215, 1984

139. Murphy AA, Green WR, Bobbie D et al: Unsuspected endometriosis documented by scanning electron microscopy in visually normal peritoneum. Fertil Steril 46: 522, 1986

140. Jansen RPS, Russell P: Nonpigmented endometriosis: Clinical, laparoscopic, and pathologic definition. Am J Obstet Gynecol 115: 1154, 1986

141. Brosens IA, Cornillie FJ, Vasquez G: Etiology and pathophysiology of endometriosis. In Gonadotropin Down Regulation in Gynecological Practice, pp 81–102. New York: Alan R Liss, 1986

142. Barbieri RL, Niloff JM, Bast RC et al: Elevated serum concentrations of CA-125 in patients with advanced endometriosis. Fertil Steril 45: 630, 1986

143. Pittaway DE, Fayez JA: The use of CA-125 in the diagnosis and management of endometriosis. Fertil Steril 46: 790, 1986

144. Chihal HJ, Mather S, Holtz GL et al: An endometrial antibody assay in the clinical diagnosis and management of endometriosis. Fertil Steril 46: 408, 1986

145. Siegler AM, Perez RJ: Reconstruction of fallopian tubes in previously sterilized patients. Fertil Steril 26: 383, 1975

146. Hodari AA, Vibhasiri S, Isaag AY: Reconstructive tubal surgery for midtubal obstruction. Fertil Steril 28: 620, 1977

147. Jones HW Jr, Rock JA: On the reanastomosis of fallopian tubes after surgical sterilization. Fertil Steril 29: 702, 1978

148. McCormick WG, Torres J, McCanne LR: Tubal reanastomosis: An update. Fertil Steril 31: 689, 1979

149. Donnez J, Casanas-Roux F: Prognostic factors influencing the pregnancy rate after microsurgical cornual anastomosis. Fertil Steril 46: 1089, 1986

150. McComb P: Microsurgical tubocornual anastomosis for occlusive cornual disease: Reproducible results without the need for tubouterine implantation. Fertil Steril 46: 571, 1986

151. Diamond MP, Christianson CD, Daniell JF: Microsurgical reanastomosis of the fallopian tubes: Increasing successful outcome for reversal of previous sterilization procedures. South Med J 75: 443, 1982

152. Gomel V: Microsurgical reversal of female sterilization: A reappraisal. Fertil Steril 33: 587, 1980

153. Meldrum DR: Microsurgical tubal reanastomosis: The role of splints. Obstet Gynecol 57: 613, 1980

154. Lavy G, Diamond MP, DeCherney AH: Pregnancy following tubocornual anastomosis. Fertil Steril 46: 21, 1986

155. Williams GFJ: Tubo-uterine implantation. Lancet 33: 825, 1969

156. Levinson CJ: Implantation procedures for intramural obstruction: Pure bilateral implantation in 45 patients. J Reprod Med 26: 347, 1981

157. Musich JR, Behrman SJ: Surgical management of tubal obstruction at the uterotubal junction. Fertil Steril 40: 423, 1983

158. Haseltine FP, Von Arras JA: Management of cornual disease of the uterus. Semin Reprod Endocrinol 2: 146, 1984

159. Woolam GL, Pratt JH, Wilson RD: Uterine rupture following tubal implantation. Obstet Gynecol 29: 415, 1967

160. Novy MJ: Reversal of Kroener fimbriectomy sterilization. Am J Obstet Gynecol 137: 198, 1980

161. Baggish MS, Chong AP: Carbon dioxide laser microsurgery of the uterine tube. Obstet Gynecol 58: 111, 1981

162. Pouly JL, Mahnes H, Mage G et al: Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steril 46: 1093, 1986

163. DeCherney AH, Diamond MP: Pregnancy following lap-aro-scopic linear salpingostomy. Obstet Gynecol 70: 948, 1987

164. Diamond MP, DeCherney AH: Surgical techniques in the management of ectopic pregnancy. Clin Obstet Gynecol 30: 200, 1987

165. DeCherney AH, Maheux R: Modern management of tubal pregnancy. Curr Probl Obstet Gynecol VI:9, 1983

166. Lavy G, Diamond MP, DeCherney AH: Ectopic pregnancy following tubal surgery. Fertil Steril 47: 543, 1987

167. Schenker JG, Evron S: New concepts in the surgical management of tubal pregnancy and the consequent postoperative results. Fertil Steril 40: 709, 1983

168. DeCherney AH, Kase N: The conservative surgical management of unruptured ectopic pregnancy. Obstet Gynecol 54: 451, 1979

169. Nagamani M, London S, St Amand P: Factors influencing fertility after ectopic pregnancy. Am J Obstet Gynecol 149: 533, 1984

170. Timonen S, Nieminen U: Tubal pregnancy: Choice of operative method of treatment. Acta Obstet Gynecol Scand 46: 327, 1967

171. Cartwright PS, Herbert CM, Maxson WA: Operative lap-aro-scopy for the management of tubal pregnancy. J Reprod Med 37: 589, 1986

172. Schoen JA, Nowak RJ: Repeat ectopic pregnancy. Obstet Gynecol 45: 542, 1975

173. Sherman D, Langer R, Sadovsky G et al: Improved fertility following ectopic pregnancy. Fertil Steril 37: 497, 1982

174. Langer R, Bukovsky I, Herman A et al: Conservative surgery for tubal pregnancy. Fertil Steril 38: 427, 1982

175. Hallat JG: Tubal conservation in ectopic pregnancy: A study of 200 cases. Am J Obstet Gynecol 154: 1216, 1986

176. DeCherney AH, Silidker JS, Mezer HC et al: Reproductive outcome following two ectopic pregnancies. Fertil Steril 43: 82, 1985

177. Diamond MP, DeCherney AH: Distal segment tubal pregnancy after segmental resection for an isthmic pregnancy. J Reprod Med 33: 236, 1988

178. Rodi IA, Sakuer MV, Garrill MJ et al: The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: Preliminary experience. Fertil Steril 46: 811, 1986

179. Tanaka T, Hayashi H, Kutsuzawa T et al: Treatment of interstitial ectopic pregnancy with methotrexate: Report of a successful case. Fertil Steril 37: 851, 1982

180. Stovall TG, Long FW: Combined Algorithm for the Diagnosis of Ectopic Pregnancy in Extrauterine Pregnancy: Clinical Diagnosis and Management. Chap 9. New York: McGraw Hill, 1993

181. DeCherney AH, Diamond MP: Laparoscopic salpingostomy for ectopic pregnancy. Obstet Gynecol 70: 948, 1987

182. Seifer DB, Gutmann JN, Doyle MB et al: Persistent ectopic pregnancy following laparoscopic linear salpingostomy. Obstet Gynecol 76: 1121, 1990

183. Adashi EY, Rock JA, Guzick D et al: Fertility following bilateral ovarian wedge resection: A critical analysis of 90 consecutive cases of polycystic ovary syndrome. Fertil Steril 36: 320, 1981

184. Kistner RW: Peri-tubal and peri-ovarian adhesions subsequent to wedge resection of the ovaries. Fertil Steril 20: 35, 1969

185. Weinstein D, Polishuk WZ: The role of wedge resection of the ovary as a cause for mechanical sterility. Surg Gynecol Obstet 141: 417, 1975

186. Buttram VC, Vaquero C: Post-ovarian wedge resection adhesive disease. Fertil Steril 26: 874, 1974

187. Toaff R, Toaff ME, Peyser MR: Infertility following wedge resection of the ovaries. Am J Obstet Gynecol 124: 92, 1976

188. Gjonnaess H: Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 41: 20, 1984

189. Trimbos-Kemper T, Trimbos B, van Hall E: Etiological factors in tubal surgery. Fertil Steril 37: 384, 1982

190. Mueller BA, Daliny JR, Moore DE et al: Appendectomy and the risk of tubal infertility. N Engl J Med 314: 1506, 1986

191. Hemminki E, Graubard BI, Hoffman HJ et al: Cesarean section and subsequent fertility: Results from the 1982 National Survey of Family Growth. Fertil Steril 43: 520, 1985

192. Hemminki E: Effects of cesarean section on fertility and abortions. J Reprod Med 31: 620, 1986

193. Diamond MP, Lavy G, DeCherney AH: Hysteroscopic use of Dextran 70. Contemp Obstet Gynecol 34: 29, 1989

194. March CM, Israel R: Gestational outcome following hysteroscopic lysis of adhesions. Fertil Steril 36: 455, 1981

195. Diamond MP, Polan ML: Intrauterine synechiae and leiomyomas in the evaluation and treatment of repetitive spontaneous abortions. Semin Reprod Endocrinol 7: 111, 1989

196. Taylor PJ, Cumming DC, Hill PJ: Significance of intrauterine adhesions detected hysteroscopically in eumenorrheic infertile women and role of antecedent curettage in their formation. Am J Obstet Gynecol 139: 239, 1981

197. Neuwirth RS, Hussein AR, Schiffman BM et al: Hysteroscopic resection of intrauterine scars using a new technique. Obstet Gynecol 60: 111, 1982

198. Hamou J, Salat-Baroux J, Siegler AM: Diagnosis and treatment of intrauterine adhesions by microhysteroscopy. Fertil Steril 39: 321, 1983

199. Schenker JG, Margalioth EJ: Intrauterine adhesions: An updated appraisal. Fertil Steril 37: 169, 1982

200. Buttram VC, Gibbons WE: Mullerian anomalies: A proposed classification (an analysis of 144 cases). Fertil Steril 32: 40, 1979

201. Heinonen PK, Pystynen PP: Primary infertility and uterine anomalies. Fertil Steril 40: 311, 1983

202. Chervenak FA, Neuwirth RS: Hysteroscopic resection of the uterine septum. Am J Obstet Gynecol 141: 351, 1981

203. Rock JA, Zacur HA: The clinical management of repeated early pregnancy wastage. Fertil Steril 39: 123, 1983

204. McShane PM, Reilly RJ, Schiff I: Pregnancy outcomes following Tompkins metroplasty. Fertil Steril 40: 190, 1983

205. Gray SE, Roberts DK, Franklin RR: Fertility after metroplasty of the septate uterus. J Reprod Med 29: 185, 1984

206. Fayez JA: Comparison between abdominal and hysteroscopic metroplasty. Obstet Gynecol 68: 399, 1986

207. DeCherney AH, Russell JF, Graebe RA et al: Resectoscopic management of mullerian fusion defects. Fertil Steril 45: 726, 1986

208. Muasher SJ, Acosta AA, Garcia JE et al: Wedge metroplasty for the septate uterus: An update. Fertil Steril 42: 515, 1984

209. Daly DC, Walters CA, Soto-Albors CE et al: Hysteroscopic metroplasty: Surgical technique and obstetric outcome. Fertil Steril 39: 623, 1983

210. Israel R, March CM: Hysteroscopic incision of the septate uterus. Am J Obstet Gynecol 149: 66, 1984

211. DeCherney AH, Polan ML: Hysteroscopic management of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol 61: 392, 1983

212. Valle RF, Sciarra JJ: Hysteroscopic treatment of the septate uterus. Obstet Gynecol 67: 253, 1986

213. Corson SL, Batzer FR: CO₂ uterine distention for hysteroscopic septal incision. J Reprod Med 31: 713, 1986

214. Babaknia A, Rock JA, Jones HW Jr: Pregnancy success following abdominal myomectomy for infertility. Fertil Steril 30: 644, 1978

215. Buttram VC Jr, Reiter RC: Uterine leiomyomata: Etiology, symptomatology, and management. Fertil Steril 36: 433, 1981

216. Rossi G, Diamond MP: Myomas, reproductive function, and pregnancy. Semin Reprod Endocrinol 10: 332, 1992

217. Berkeley AS, DeCherney AH, Polan ML: Abdominal myomectomy and subsequent fertility. Surg Gynecol Obstet 156: 319, 1983

218. Garcia CR, Tureck RW: Submucosal leiomyomas and infertility. Fertil Steril 42: 16, 1984

219. Rosenfeld DL: Abdominal myomectomy for otherwise unexplained infertility. Fertil Steril 46: 328, 1986

220. McLaughlin DS: Metroplasty and myomectomy with the CO₂ laser for maximizing the preservation of normal tissue and minimizing blood loss. J Reprod Med 30: 1, 1985

221. Neuwirth RS: Hysteroscopic management of symptomatic submucous fibroids. Obstet Gynecol 62: 509, 1983

222. Richart RM, Neuwirth RS: Hysteroscopic resection of submucous leiomyoma. Contemp Obstet Gynecol 1: 103, 1985

223. Diamond MPL: Laparoscopic myomectomy. Obstet Gynecol Ann 1: 1, 1994

224. Nezhat C, Nezhat F, Silfen SL et al: Laparoscopic myomectomy. Int J Fertil 36: 275, 1991

225. Malone LJ: Myomectomy: Recurrence after removal of solitary and multiple myomas. Obstet Gynecol 34: 200, 1969

226. Maheux R, Guilloteau C, Lemay A et al: Regression of leiomyomata uteri following hypoestrogenism induced by repetitive luteinizing hormone-releasing hormone agonist treatment: Preliminary report. Fertil Steril 42: 644, 1984

227. Maheux R, Guilloteau C, Lemay A et al: LHRH agonist and uterine leiomyoma: A pilot study. Am J Obstet Gynecol 152: 1034, 1985

228. LaMorte AI, Lalwani S, Diamond MP: Morbidity associated with abdominal myomectomy. Obstet Gynecol 82: 897, 1993

229. Meyer WR, Mayer AR, Diamond MP et al: Unsuspected leiomyosarcoma: Treatment with a gonadotropin-releasing hormone analogue. Obstet Gynecol 75: 529, 1990

230. Schwartz LB, Diamond MP, Schwartz PE: Leiomyosarcomas: Clinical presentation. Am J Obstet Gynecol 168: 180, 1993

231. Gutmann J, Thornton K, Carcangiu M, Diamond MP: Evaluation of leuprolide acetate (LA) treatment on histopathology of uterine myomata. Fertil Steril 61: 622, 1994

232. Haney AF: Utilization of contralateral fallopian tube segments in tubal reanastomosis. Fertil Steril 37: 701, 1982

233. Pittaway DE: Tubal reanastomosis of a contralateral fallopian tube. Fertil Steril 46: 976, 1986

234. DeCherney A, Naftolin F: Homotransplantation of the human fallopian tube: Report of a successful case and description of a technique. Fertil Steril 34: 14, 1980

235. Gomel V, McComb P: Microsurgical transposition of the human fallopian tube and ovary with subsequent intrauterine pregnancy. Fertil Steril 43: 804, 1985

236. Bates GW, Wiser WL: Transposition of the fallopian tube in a woman with a poorly developed uterine horn. Fertil Steril 46: 706, 1986

237. Sillo-Seidl G: The first transplantation of a fallopian tube of frozen material in women. Int J Fertil 20: 106, 1975

238. Cohen BM: Preliminary experience with vascularized fallopian tube transplants in the human female. Int J Fertil 21: 147, 1976

239. Wood C, Downing B, McKenze I et al: Microvascular transplantation of the human fallopian tube. Fertil Steril 29: 607, 1978

240. Cantor B: Transplantation and replantation of the fallopian tubes and ovaries: A technique for patients undergoing pelvic irradiation. Fertil Steril 39: 231, 1983

241. Rock JA, Zacur HA, Dragi AM et al: Pregnancy success following surgical correction of imperforate hymen and complete transverse vaginal septum. Obstet Gynecol 59: 448, 1982

242. Buller RE, Jones HW III: Pregnancy following cervical conization. Am J Obstet Gynecol 142: 506, 1982

243. Jones HW III, Buller RE: The treatment of cervical intraepithelial neoplasia by cone biopsy. Am J Obstet Gynecol 137: 882, 1980

244. Pittaway DE, Daniell J, Maxson W et al: Reconstruction of the cervical canal after complete postconization obstruction: A case report. J Reprod Med 29: 339, 1985

245. Semm K: Endocoagulation: A new field of endoscopic surgery. J Reprod Med 16: 195, 1976

246. Semm K: Advances in pelviscopic surgery. Curr Probl Obstet Gynecol 5: 10, 1982

247. Levine RL: When pelviscopy may be the solution. Con-temp Obstet Gynecol 28: 61, 1986

248. Goodman MP, Johns DA, Levine RL et al: Report of the study group advanced operative laparoscopy (pelviscopy). J Gynecol Surg 5: 353, 1989

249. Reich H, Johns DA, Davis G, Diamond MP: Laparoscopic oophorectomy. J Reprod Med 38: 497, 1993

250. Johns DA, Diamond MP: Adequacy of laparoscopic oophorectomy. J Am Assoc Gynecol Laparosc 1: 20, 1993

251. Johns DA, Diamond MP: Laparoscopically assisted vaginal hysterectomies. J Reprod Med 39: 424, 1994

252. Mage G, Pouly JL, deJoliniere JB et al: A preoperative classification to predict the intrauterine and ectopic pregnancy rates after distal tubal microsurgery. Fertil Steril 46: 807, 1986

253. Diamond MP, Martin DC, Feste J et al: Pregnancy outcome following adhesiolysis at laparotomy and subsequent early second-look laparoscopy [Abstract]. 15th Annual Meeting, Clinical Symposium of Gynecologic Endoscopy, Orlando, FL, November 1986

254. Bellina JH: Microsurgery of the fallopian tube with the carbon dioxide laser: Analysis of 230 cases with a two year follow-up. Lasers Surg Med 3: 255, 1983

255. Thie JL, Williams TJ, Coulam CB: Repeat tuboplasty compared with primary microsurgery for post-inflammatory tubal disease. Fertil Steril 45: 784, 1986

256. Lauritsen JG, Pagel JD, Vangsted P et al: Results of repeated tuboplasties. Fertil Steril 37: 68, 1982

257. Sandor SM: Successful multiple resection and reconstruction of the oviduct. Am J Obstet Gynecol 129: 344, 1977

258. Garcia JE, Jones HW Jr, Acosta AA et al: Reconstructive pelvic operations for in vitro fertilization. Am J Obstet Gynecol 153: 172, 1985

259. DeCherney AH, Tarlatzis BC, Laufer N: A simple technique for ovarian suspension in preparation for in vitro fertilization. Fertil Steril 43: 659, 1985

260. Webster BW, Diamond MP, Maxson WS et al: Clinical outcome in an IVF program in patients with ovarian suspension [Abstract]. Chicago, American Fertility Society, September 1985

261. Diamond MP, Pellicer A, Boyers SP et al: The effects of periovarian adhesions on follicular development in patients undergoing ovarian stimulation for in vitro fertilization embryo transfer [Abstract]., 43rd Annual Meeting of the American Fertility Society, Reno, NV, September 1987

262. Grainger D, Soderstrom R, Schiff S et al: Ureteral injuries at laparoscopy: Insights into diagnosis and management. Obstet Gynecol 75: 839, 1990

263. Corfman R, Diamond MP, DeCherney AH (eds): Complications of Laparoscopy and Hysteroscopy. 2nd ed. Boston: Blackwell Scientific Publications, 1997