Guideline No. 435: Minimally Invasive Surgery in Fertility Therapy

ObjectiveTo evaluate the benefits and risks of minimally invasive procedures in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.Target PopulationPatients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.Benefits, Harms, and CostsMinimally invasive reproductive surgery can be used to treat infertility, improve fertility treatment outcomes, or preserve fertility. All surgery has risks and associated complications. Reproductive surgery may not improve fertility outcomes and may, in some instances, damage ovarian reserve. All procedures have costs, which are borne either by the patient or their health insurance provider.EvidenceWe searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix A for MeSH search terms).Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceGynaecologists who manage common conditions in patients with infertility.SUMMARY STATEMENTS

• 1.Laparoscopy is useful in determining the etiology of infertility if pelvic imaging has normal results (moderate).
• 2.Clinicians should question the therapeutic value of laparoscopy if fertility treatment is accessible and defer laparoscopy until such treatment proves unsuccessful (high).
• 3.In patients with minimal or mild endometriosis, resection or ablation significantly increases unassisted conception rates (moderate).
• 4.By extrapolation, a minimum of 20 patients with unexplained infertility would need to undergo laparoscopy to result in 1 additional unassisted conception (high).
• 5.In patients with multiple failed cycles of in vitro fertilization, laparoscopy may improve the cumulative pregnancy rate by increasing unassisted conception rates (low).
• 6.Fibroids of type 0–2 (submucosal) in the 2011 International Federation of Gynecology and Obstetrics (FIGO) staging system, and cavity-distorting intramural fibroids, are likely to have a negative effect on fertility (moderate).
• 7.It is unclear whether removing FIGO type 3–7 (non-cavity-distorting) fibroids increases pregnancy rates following fertility treatment (low).
• 8.Laparoscopic myomectomy may be preferable to laparotomy, depending on the number and size of the fibroids and the surgeon’s experience (low).
• 9.Surgical repair of distally occluded fallopian tubes can improve the likelihood of unassisted pregnancy but also increases the risk of ectopic pregnancy (low).
• 10.Removal or tubal ligation of unilateral hydrosalpinx may increase unassisted pregnancy rates (low).
• 11.Surgical repair or recanalization of proximal tubal obstruction results in unassisted pregnancy rates of 33% to 61% (low).
• 12.Ovarian cystectomy for benign, non-endometriosis cysts may negatively affect ovarian reserve, although to a lesser degree than endometrioma excision (moderate).
• 13.Laparoscopic ovarian drilling appears to be as effective as gonadotropins in inducing ovulation and clinical pregnancy but may result in lower live birth rates (low).
• 14.Ovarian transposition before radiotherapy appears to improve the probability of residual ovarian function (moderate).
• 15.The beneficial effect of ovarian transposition may be diminished in women over 30 years of age (low).
• 16.Unassisted pregnancy and live births are possible after ovarian transposition (very low).
• 17.Laparoscopic treatment of ovarian endometriosis and endometriomas must balance the improvement in fecundity with the damage to ovarian reserve (high).
• 18.Laparoscopy should not be regarded as the first-line treatment of infertility associated with endometriosis (high).
• 19.Laparoscopic endometrioma resection is associated with a lower recurrence rate than drainage and/or ablation, but it has a higher risk of negatively affecting ovarian reserve (moderate).

RECOMMENDATIONS

• 1.Laparoscopy should not be routinely offered in the initial evaluation of unexplained infertility (strong, high).
• 2.Laparoscopy can be offered to younger patients after unsuccessful fertility treatment (strong, high).
• 3.Clinicians may offer laparoscopy to patients with unexplained infertility and multiple failed cycles of in vitro fertilization (conditional, low).
• 4.Clinicians may consider myomectomy in patients with FIGO type 0–2 (submucosal) fibroids and unexplained infertility, particularly if the patient is undergoing fertility treatments (conditional, low).
• 5.Myomectomy is not recommended in asymptomatic patients with FIGO type 3–7 (non-cavity-distorting) fibroids for the sole purpose of increasing spontaneous conception rates (conditional, low).
• 6.Myomectomy should not be performed for the sole purpose of reducing miscarriage rates (conditional, low).
• 7.Distal tubal surgery should be reserved for patients in whom in vitro fertilization is not accessible (conditional, low).
• 8.Removal or ligation of hydrosalpinx before embryo transfer significantly increases pregnancy rates (strong, high).
• 9.Removal of non-endometriosis ovarian cysts for the sole purpose of increasing fertility is not recommended (conditional, moderate).
• 10.Laparoscopy is the recommended approach for ovarian cystectomy (conditional, moderate).
• 11.Sutures or hemostatic sealants are recommended over bipolar cautery for hemostasis during cystectomy (conditional, low).
• 12.Laparoscopic ovarian drilling can be considered in patients with polycystic ovary syndrome resistant to oral agents if gonadotropins are not accessible (conditional, moderate).
• 13.In patients undergoing pelvic radiotherapy, ovarian transposition should be considered to improve post-treatment ovarian function (conditional, moderate).
• 14.Before performing ovarian transposition pelvic radiation, clinicians should consider referral to a reproductive endocrinologist and possible egg/embryo cryopreservation. Although unassisted pregnancies and live births are possible after ovarian transposition, transvaginal ovarian access for in vitro fertilization is difficult. There is also a high probability that pelvic radiation will result in a uterine environment incapable of carrying a pregnancy, necessitating a gestational carrier (conditional, low).
• 15.While laparoscopic treatment is not first-line for infertility associated with endometriosis, it can be offered to patients with endometriosis and a history of infertility if there are other indications for surgery (e.g., pain); counselling should consider the patient’s age, duration of infertility, and ovarian reserve (conditional, low).
• 16.Patients should be comprehensively counselled about the risk that endometrioma surgery will diminish ovarian reserve (strong, high).
• 17.Laparoscopic endometrioma resection is indicated if there are concerns about access to the follicles for egg retrieval in in vitro fertilization (moderate, low).