**11.1. Tubal infertility**

Endoscopy and ART arenot competitors but complementary.

First trial is the best trial for tubal surgery.

Performing laparoscopic surgery Forendometriosis prior to IVF isveryvaluable in manycases.

There is NO adequate trialscomparing pregnancy rates with tubal surgeryversus IVF.

Per cycle pregnancy rate of IVF: higher

Tubal anastomosis for reversal ofsterilization has significantly higher cummulative pregnancy rate than IVF and ismore cost effective even above 40 years.

Factors affecting counseling for tubal surgery or IVF:



46 Enhancing Success of Assisted Reproduction

receptivity (71)

**11. Keynote points** 

**11.1. Tubal infertility** 


manycases.

Endoscopy and ART arenot competitors but complementary.

First trial is the best trial for tubal surgery.

Per cycle pregnancy rate of IVF: higher

Factors affecting counseling for tubal surgery or IVF:


deleterious effect. Nevertheless, many studies have provided evidence that uterine myomas have a significant effect on IVF outcomes and there is a large body of evidence that treatment of uterine myomas increases fertility and pregnancy rates, and decreases the rate of pregnancy loss (70). There is no doubt that any cavity-distorting myoma should be removed whether completely submucous or interstitial myoma with submucous encroachment. This highlights the central role of prior hysteroscopy as well as saline infusion solonhysterography (SIS) as previously described (39). Not only does sub mucous myoma cause mechanicl interference with implantation, but it also alters endometrial

Controversy exists for interstitial and subserous myomata. The evidence supports treatment of all very large myomas (>7 cm) (70). Subserosal myomas that are smaller than 7 cm in size and intramural myomas of less than 4–5 cm in diameter appear to have little effect on IVF outcomes. Larger intramural and subserosal myomas present a clinical dilemma and more studies are needed to clarify a definitive plan for management (70). In a prospective controlled study, the distance between the intramural myomas and the endometrial lining did not appear to affect the IVF outcome. An insignificant tendency towards improvement

of IVF outcome is found in myomas at more than 5 mm from endometrial lining (72).

In a recent review of literature (73) on myoma and assisted reproduction technology and spontaneous conception, hysteroscopic sub-mucous myoma resection is found to increase pregnancy rates. Intramural fibroids appear to decrease fertility, but the myomectomy does not improve assisted reproduction technology and spontaneous fertility. More high-quality studies are needed to conclude toward the value of myomectomy for intramural fibroids. Subserosal fibroids do not affect fertility outcomes, and removal does not confer benefit.

Performing laparoscopic surgery Forendometriosis prior to IVF isveryvaluable in

Tubal anastomosis for reversal ofsterilization has significantly higher cummulative

There is NO adequate trialscomparing pregnancy rates with tubal surgeryversus IVF.

pregnancy rate than IVF and ismore cost effective even above 40 years.


#### **11.2. Uterine myoma and infertility**

Uterine myoma may affect fertility according to its size, site and associated pathology. Endoscopic approach has a definite role in its management. HM is the gold standard line of management of submucous myoma of suitable size. LM doesn't seem to be superior to conventional open myomectomy regarding fertility and is characterized by both short and long term drawbacks. Uterine myomata would affect IVF/ICSI outcome whenever disturbing the endometrial cavity or large sized. The impact of other types of myomata on IVF/ICSI deserves further studies. Hysteroscopic myomectomy is indicated for intracavitary myomas and submucous myomas having at least 50% of their volume within the uterine cavity. The management of the subfertile women with small intramural fibroids (<5 cm) is still a subject of debate (75,76).
