Fibroids - EXCEMED · PDF fileEffect of Uterine Fibroids on IVF Outcome Subserosal - Fahri...

Rudi Campo MDLeuven Institute for Fertility and Embryology

LIFELeuven - Belgium

Fibroids

Fibroids and IVF outcome

1 Scientific evidence

2 Diagnostic strategy

3 Hysteroscopic surgery

4 Laparoscopic surgery

Effect of Uterine Fibroids on IVF Outcome

Subserosal

- Fahri 1995 normal- Elder-Garcia 1998 normal- Healy 2000 normal- Oliveira 2004 normal

Subserosal myoma seems not to influence

the IVF outcome


Submucosal

- Fahri 1995 decreased- Elder-Garcia 1998 decreased- Healy 2000 decreased - Shokeir (PRCT) 2010 decreased

Scientific evidence that Submucosal myoma interferes negatively with the success rate

First statement

If a myoma protrudes in the uterine cavity it is likely to interfere with the reproductive outcome

Conservative resection of submucosal myoma is recommended prior to any ART procedure

Intra mural myoma The Problem

Intra mural myoma are myomas completely surrounded by muscular wall of the uterus however they vary in size number and distance to the endometrial cavity

The effect of intramural fibroids on fertility and outcome of IVF treatment remain poorly understood

A new approach is necessay

Effect of Intra mural fibroids on IVF

MRI has demonstrated the clinical significance of the myometrial architecture

Junctional zone

small central zone of increased density

IMPORTANT IN REPRODUCTION

Submucosal myoma

Outer myometrium

Larger outer hypodenser zone

Subserosal myoma

Less cytogenetic abnormalities

Pattern of vascularisation

Expression of SSH receptors

More responsive to GnRH analogue

Fewer recurrences after surgery

Submucosal Uterine Fibroidsdiffers from subserosal fibroids

Literature showing conflicting results for IVF outcome in patients with intramural myoma

Fahri 1995 normal

Stovall 1998 decreased

Elder-Geva 1998 decreased

Ramzy 1998 normal

Healey 2000 decreased

Hart 2001 decreased lt 5 cm

Surrey 2001 normal

Check 2002 probably decreased

Ajayi 2003 decreased

Oliveira 2004 normal if lt 4cm

Bulleti 2004 decreased

Pritts 2009 decreased

Effect of INTRAMURAL myoma

Studies are inconclusive due to lack of correct documentation of size amount and localisation Study design is mostly retrospective

Questions are bull Does a myoma originating from the JZ myometrium

but with no penetration into the uterine cavity influences the reproductive outcome

bull If so is their a cutt of in size and amount of myoma

Q1 Scientific evidence

The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment a systematic review and meta-analysis

19 observational studies comprising 6087 IVF cycles were included

Sunkara SK Khairy M El-Toukhy T Khalaf Y Coomarasamy AHum Reprod 2010 Feb25(2)418-29


The presence of non-cavity-distorting intramural fibroids showed a significant decrease in the

live birth (RR = 079 95 CI 070-088 P lt 00001) clinical PRs (RR = 085 95 CI 077-094 P = 0002)

in women with non-cavity-distorting intramural fibroids compared with those without fibroids following IVF treatment

Q2 Size and amount

Fibroids not encroaching the endometrial cavity and IVF success rate a prospective study

Somigliana E De Benedictis S Vercellini P Nicolosi AE Benaglia L Scarduelli C Ragni G Fedele LSmall Myoma no influence

Hum Reprod 2011 Apr26(4)834-9

Q2 Size and amount


In asymptomatic patients selected for IVF small (less than 05 cm) fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure

There was no significant relationship between clinical outcome and either the number or size of the fibroids

Q2 Size and amount

Those findings are in conflict with the findings of Khalaf et al 2006 who also studied the effect of small intramuralUterine fibroids

IVF ICSI results in 322 women without fibroids and 112 with fibroids in 606 cycles were studied

Live birth rate in the study group was significantly lower (plt005) and the cumulative live birth rate was reduced by 47

Second statement

It is not yet very clear when non-cavity-distorting intramural fibroids will influence the pregnancy outcome in IVF

Myoma mapping seems mandatory to document the relation to the JZ myometrium

Intra mural myoma should be classified either to the submucous or sub serosal group

The diagnostic strategy is challenged

Fibroids and IVF





What do we have to know

1 Cavity involvement

2 Number of myomata

3 Size and location

Proper diagnosis of fibroids

Ultrasound

Fluid Mini-Hysteroscopy

Kontrast sonography

One Stop Uterine diagnosis


Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up

Supplemantary exams necessary

When

1 dd adenomyoma ndash myoma

2 Multiple myoma

3 Diffuse enlargement of uterine wall

How

1 NMR imaging (3D US )

2 Hysteroscopic Myometrial exploration

LIFE vzw Leuven Institute for Fertility amp Embryology

Findings at MRI JZ Myoma


Allocation of Myoma to OM or JZM


MRI for diagnosis of Adenomyosis and Adenomyoma

Loss of differentiation JZ - OM

Normal


Enlarge the hysteroscopic diagnosis with

exploration of JZ myometrium

Trophy Hysteroscope acc to Campo

New generation of hysteroscope with interesting characteristics

named after the multicentre study TROPHY ldquoTrial of Outpatient

Hysteroscopyrdquo for which it was designedEl-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy ndash (TROPHY) in IVF Reprod Health 2009 Dec 3620

Spirotome acc to Gordts

A device made to harvest high quality samples from soft tissues

built on the pioneering concept of a cutting helix on a cutting cannula

New Tools for exploration of the JZ myometrium

Trophy Scope 29 mm compactscope with Innovative gliding mechanism for accessory sheets

Can be loaded with accessory sheets which can be activated in case of necessity by gently push on the bottom and forward movement till locking in the active position supplementary functions are available without the need to remove the hysteroscope

Trophy Scope Diagnostic accessory sheet

In active positionAtraumatic cervical dilatation up to 37 mm under visual controlCreating double flowBlocking of cervix in case of passive outflow

In free positionSuction device for endometrial samplingGuide for ultrasound guided intrauterine procedures like positioning Embryo

transfer catheter or for Spirotome endomyometrial biopsy

active freepassive

Trophy Scope Operative accessory sheet

In passive position

Operative sheet does not interfere

the diagnostic phase (29mm)

In active positionAtraumatic cervical dilatation

up to 44 mm under visual control

Creating double flow and blocking

function in case of passive outflow

Introduction of 5 Fr instruments without

compromising inflow


It is built on the pioneering concept of a cutting helix on a cutting

cannula well identified by Ultrasound


Spirotome

The sample is harvested by turning the helix into the diseased area under

direct vision or ultrasound guidance The cannula turns subsequently over the

helix to free the sample from the surroundings

Spirotome myometrial biopsy

HSC post spirotome biopsy


Trophy Scope - Spirotome - US

Guide for ultrasound guided

Spirotome endomyometrial biopsy

cutting helixcutting cannula

Trophy Scope ndash Spirotome - Ultrasound

Exploration of JZ myometrium with Trophy hysteroscope

Resection intramural myoma

Resection adenomyoma


Fibroids and IVF



3 Conventional hysteroscopic surgery


Conventional Hysteroscopic Surgery

TYPE 0 TYPE 1 TYPE 2

The ESGE classificationof submucous myomas

Size volume = 43r3

bull2 cm ~ 42 cm3 8 min



Emanuel MH et al Fertil Steril 199768881-6

Operating time of critical importance

Reduction in volume of the fibroidsby GnRH-a therapy

Distension fluid

Monopolar surgery using non-ionic solutions

sa manitol sorbitol or glycine has higher risk of

side effects due to fluid overload effect

Stop surgery as soon as 1 L of fluid losses

Bipolar surgery using ionic solutions (saline)

Isotonic hyperhydration is less dangerous

In young patients up to 4 L of losses can be

accepted

Hysteroscopic Myomectomy

Always use a pressure and flow controlled pump system to work at minimal necessary pressure

Always perform continuous fluid balance independently of the medium used


Operative Hysteroscopy Resectoscope Uni or Bipolar

Non ionic fluid

Unipolar polyp and myomaresection

Ionic fluid

First generation Bipolar (Versapoint)

Loop is smaller

chips are smaller

Longer OR time

Bipolar cautery induces

more bubbles

Bipolar resectoscope new generation

low-energy

Two or more small active electrodes very close to each other (active and return electrode)

bull Use Saline as distention medium

bull limited spread of electrical effect the current flow is essentially limited to a small area and it requires less voltage less risk for adhaesion formation

bull Loop different shape and size Different surgical

manoeuvres

bull Need of Modern generator


Storz bipolar resectoscope new generation

Return electrode opposite

side

Larger active electrode

Minimal gas bubbles

production

Less risk of perforation

Different surgical technique

Bipolar hysteroscopic myomectomy


Long-term results depend on

bull Uterine Size (Plt0001)

bull Number of myomas (Plt0001)

The surgery-free percentage of 165 patients with normal sized uteri and not more than two

myomas was 943 (+- 18) at 2 years and 903 (+- 30) at 5 years

bull Type ( intra-mural part)

bull Size of myoma (significant increase of amount of particles between 2 and 3 cm)

Long-term results depend on the presence of concomitant pathology

or is a result of incomplete surgery

Emanuel MH Wamsteker K Obstet Gynecol 1999 May93743-8

Third Statement

1 Junctional Zone Myoma should preferentially be treated by hysteroscopy

2 Feasibility of hysteroscopic surgery is predominantly related with size location and amount of myoma

3 Independently of distension medium used continuous fluid balance and flow distension control is mandatory

4 Complication risk is related to experience and surgical technique used

Fibroids and IVF





Introduction

Intramural myoma larger than 4 cm related to the JZ myometriumschould be operated on

Laparoscopic approach has had an important evolution over the

years

Series with high success rate are done by experts =gt it is difficult to extrapolate to less experienced surgeons

Laparoscopic myomectomy needs expert skills in haemostasis dissection and suturing

How to minimize blood loss

bullA lot of techniques in order to minimize blood loss

GnRH agonists

Intramyometrial vasopressine

Oxytocin IV 40 mUImin intraoperatively

Use of tourniquet or penrose at the lower part of uterus

Laparoscopic Myomectomy

J Ferro IVI Valencia Spain

Tips amp tricks ndash minimize blood loss

Clipping of the uterine arteries and infundilopelvic ligaments is another very efficient method

Artery ligation versus Control group (n=152)

173 +- 91 mL vs 402 +- 131 mL blood loss

62 vs 2075 reccurence rate

Alborzi S et al A comparison of combined laparoscopic uterine artery ligation and myomectomyversus laparoscopic myomectomy in the treatment of symptomatic myoma Fertil Steril 2009


Technique Incision

Incision

J Ferro A Wattiez

Tips amp tricks- dissection

Tips amp tricks- closure

bull One versus multiples layers controversial

bull Adequate closure of the dead space to minimize the risk of hematoma formation

bull Interrupted figure of eight sutures are usually sufficient monocryl 1 or 0 with extracorporeal notes =gt extra strength

bull For the serosa approximate with interrupted 20 sutures if necessary (monofilament)


Removal Clips

Anti- adhesion agents

Fourth Statement

LAPAROSCOPIC MYOMECTOMY offers comparable results tolaparotomic myomectomy

Laparoscopic approach reduces adhesion formation blood loss and hospital stay

Laparoscopic myomectomy seems indicated in the infertile patient for the treatment of intramural myomarsquos

Laparoscopic Myomectomy requires a skilled laparoscopic surgeon with expert suturing skills optimal instrumental support and knowledge of some trickrsquos to provide an optimal result

Take Home message

Submucous myoma should always be removed prior to IVF

Hysteroscopic resection is the gold standard to treat those myoma

Intramural myoma originating from the sub endometrial

myometrium and larger than 4 cm are treated by Laproscopy

Subserosal myoma do not influence the outcome of IVF and are not removed for this indication

More info on the special training

programsin endoscopic

surgery

ESGEORG

More info on the ESGE website

wwwesgeorg

See you in London

Rudi Campo Stephan GordtsPatrick PuttemansRoger MolinasSylvie GordtsMarion Valkenburg Ivo Brosens

Leuven Institute for Fertility

amp Embryology

Trophy Scope a new generation

Interesting Characteristics

Gliding system that provides

Diagnostic ( 29 mm ) and

Operative (44 mm)

possibilities in one instrument

This hysteroscope has been named after the multicentre study

TROPHY ldquoTrial of Outpatient Hysteroscopyrdquo for which it was designed

El-Toukhy T Campo R et al Trial of Outpatient Hysteroscopy - [TROPHY] in IVF Reprod Health 2009 Dec 3620

Fibroids and IVF outcome






Subserosal



the IVF outcome


Submucosal



First statement









Junctional zone



Submucosal myoma

Outer myometrium


Subserosal myoma








Fahri 1995 normal



Ramzy 1998 normal



Surrey 2001 normal



















Q2 Size and amount




Q2 Size and amount




Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






Subserosal



the IVF outcome


Submucosal



First statement









Junctional zone



Submucosal myoma

Outer myometrium


Subserosal myoma








Fahri 1995 normal



Ramzy 1998 normal



Surrey 2001 normal



















Q2 Size and amount




Q2 Size and amount




Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






Submucosal



First statement









Junctional zone



Submucosal myoma

Outer myometrium


Subserosal myoma








Fahri 1995 normal



Ramzy 1998 normal



Surrey 2001 normal



















Q2 Size and amount




Q2 Size and amount




Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





First statement









Junctional zone



Submucosal myoma

Outer myometrium


Subserosal myoma








Fahri 1995 normal



Ramzy 1998 normal



Surrey 2001 normal



















Q2 Size and amount




Q2 Size and amount




Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)











Junctional zone



Submucosal myoma

Outer myometrium


Subserosal myoma








Fahri 1995 normal



Ramzy 1998 normal



Surrey 2001 normal



















Q2 Size and amount




Q2 Size and amount




Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)












Fahri 1995 normal



Ramzy 1998 normal



Surrey 2001 normal



















Q2 Size and amount




Q2 Size and amount




Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)


















Q2 Size and amount




Q2 Size and amount




Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Q2 Size and amount




Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Q2 Size and amount




Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Second statement





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Fibroids and IVF







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)







2 Number of myomata

3 Size and location


Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Ultrasound


Kontrast sonography



Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






Ultrasound

Hysteroscopy

Contrast sonography

Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Overview of set up


When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






When


2 Multiple myoma


How










Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)












Normal


















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






















active freepassive


In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






In passive position








compromising inflow





Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)









Spirotome
















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)

















Fibroids and IVF








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)








Size volume = 43r3







Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






Distension fluid








accepted






Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)









Non ionic fluid


Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Ionic fluid


Loop is smaller

chips are smaller

Longer OR time


more bubbles


low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






low-energy





manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)








manoeuvres





side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)







side


Minimal gas bubbles

production















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)

















Third Statement





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Fibroids and IVF





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Introduction



years





GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)







GnRH agonists













Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)














Technique Incision

Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Incision

J Ferro A Wattiez








Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)












Removal Clips


Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






Fourth Statement





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)





Take Home message








surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)







surgery

ESGEORG


wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)






wwwesgeorg

See you in London



amp Embryology





Operative (44 mm)







amp Embryology





Operative (44 mm)









Operative (44 mm)





Fibroids - EXCEMED · PDF fileEffect of Uterine Fibroids on IVF Outcome Subserosal - Fahri...

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Transcript of Fibroids - EXCEMED · PDF fileEffect of Uterine Fibroids on IVF Outcome Subserosal - Fahri...