Laparoscopic procedure can help to treat infertility

Amin Milki

A study from medical school researchers demonstrates that a minimally invasive procedure to diagnose and treat a common gynecologic disorder may be a useful way for women to combat infertility problems.

During the study, which appeared in the December issue of the Journal of Fertility and Sterility, 22 of 29 women who had previously undergone unsuccessful in vitro fertilization were able to conceive following laparoscopic treatment of endometriosis.

"If you fail IVF, it's not the end of the story," said Amin Milki, MD, professor of obstetrics and gynecology and a co-author, explaining the significance of the study's findings. "You might have a chance to conceive if you treat your endometriosis."

Endometriosis is a condition in which endometrium tissue, normally found lining the uterus, spreads to other areas within a woman's pelvic cavity and abdomen, usually the fallopian tubes, ovaries and intestines. The condition is known to interfere with fertility; as many as 25 to 50 percent of infertile women have endometriosis.

In many cases, treating a woman's endometriosis can pave the way for a pregnancy. The researchers note in their paper that other studies have shown a 20 to 65 percent pregnancy rate following laparoscopic treatment. Milki noted that most pregnancies occur within the first six months after surgery.

Although checking for endometriosis was once the standard for women with fertility problems, it is increasingly common for these women to undergo hormonal treatments, artificial insemination and even IVF without being evaluated—or treated—for endometriosis. Among the reasons that these steps are skipped: The diagnosis and treatment of endometriosis require surgery, and some women and physicians worry about the risks of undergoing a surgical procedure.

The average patient's age is also a factor, according to Milki. Some older women are hesitant about doing the procedure and taking a wait-and-see approach, especially considering IVF yields more immediate results.

"More than one-third of our patients are over 40," said Milki, who directs Stanford's IVF clinic. "Although we suspect some women might have endometriosis and could benefit from laparoscopy, we don't have much time to wait. These patients want an immediate answer."

If initial IVF treatments fail, patients and their partners tend to choose additional IVF treatment, egg donation or even adoption over endometriosis treatment. "It is not unusual for patients and health-care providers to perceive IVF as the final treatment for infertility," the authors noted in their paper.

The researchers launched this study to further evaluate the benefit of laparoscopy—a procedure in which specialized tools with cameras attached are inserted through small holes in the body—for women with unexplained infertility. The retrospective study looked at patients in their mid-30s who had failed IVF treatment and were offered laparoscopic evaluation and management as an alternative to additional IVF treatments, egg donation or adoption.

Twenty-nine women underwent the laparoscopy, while 35 chose not to. Camran Nezhat, MD, an adjunct clinical faculty member of surgery and obstetrics and gynecology who was a pioneer in the field of laparoscopic surgery, performed each procedure.

Nezhat and the team found that all 29 laparoscopy patients had endometriosis. After the treatment, more than three-fourths of the women (22) conceived; seven of these pregnancies came after subsequent IVF treatments. Thirty-seven percent—13 of 35—of women in the non-laparoscopy group conceived, and 11 of the pregnancies came after IVF.

"The study shows there is hope for these couples, even when they've experienced failed IVF," said Nezhat.

Milki said the fact that Nezhat performed each procedure could be the reason the pregnancy rate in this study is higher than the rates in past studies. "We believe the remarkably high pregnancy rate achieved in the patients who underwent laparoscopic evaluation is a reflection of the thorough surgical technique," the researchers said in the paper.

Do the encouraging results mean every woman should get a laparoscopy before undergoing IVF? "Not necessarily," said Milki. "But even being biased by the success of IVF and the promptness to which it can lead to pregnancy, I can see the wisdom of doing a laparoscopy."

The researchers say a multicenter, randomized clinical trial is now needed to further evaluate the procedure.

Other study authors include Stanford's Eva Littman, MD, and Ruth Lathi, MD; Linda Guidice, MD, now at UCSF, and Bulent Berker, MD, now at Ankara University in Turkey.