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Infertility Surgery Is Dead; Viva IVF!

Posted 01-22-2008 at 10:35 AM by IVF Doctor
Updated 01-30-2008 at 12:06 PM by IVF Doctor
An interesting little article appeared in the January issue of Fertility & Sterility, the official organ of the American Society for Reproductive Medicine (ASRM) and Society for Assisted Reproductive Technology (SART). With Alan DeCherney, MD, (Editor-in Chief of Fertility and Sterility and Chief of the Reproductive Biology and Medicine Branch of the National Institute of Child Health and Human Development of the National Institutes of Health, Bethesda, MD) as the senior author (though not in his formal professional capacities) this piece concluded that infertility surgery was practically passé and, in its place, in vitro fertilization (IVF) should be considered treatment of choice (Fertil Steril 2008; 89:232-6).

The article, of course, refers mostly to tubal surgery, which easily can be replaced by IVF. This is most interesting, since DeCherney built much of his early career in the field of reproductive endocrinology and infertility on his special surgical expertise. An authoritative voice, making this point, was long overdue. The thousands of unnecessary diagnostic and/or therapeutic laparoscopies and/or hysteroscopies, still performed as part of so-called routine diagnostic infertility work ups, and prior to much more efficient and cost-effective IVF, bear witness to the need of such an opinion statement. Only too bad that such a position statement has not yet come from ASRM!

To patients undergoing such work ups and receiving a recommendation for surgery, we suggest that they offer their physician a referral to this publication. In addition, however, also ask a very simple question: How, doctor, will my surgery change your treatment plans? Since there are really almost no indications left for surgery in modern infertility care (for exceptions see below), you will probably get no good answer. But, even if you do get a seemingly logical answer, we suggest a second opinion before agreeing to go under the knife. Remember, there is no “little” surgery! Surgery is only “unremarkable” if you are not the one under anesthesia.

So when is surgery indicated, after all? Only three scenarios come to mind: (1) an abnormal uterine cavity that can be corrected before IVF in order to maximize implantation chances for embryos; (2) the removal or clipping of large hydrosalpinges before IVF (which, because of backflow of toxic tubal fluid into the cavity, have been reported to reduce pregnancy rates with IVF, if left unattended); (3) myomectomies, when fibroids greatly distort the uterine cavity.

DeCherney et al put it best in the last paragraph of their paper noting that “surgical management should only be reserved for cases in which ART (i.e., IVF) was not initially effective.” And, they concluded, “...it becomes increasingly clear that infertility surgery is dead: only the obituary remains.”

- The IVF Doctor
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