{"paper_id":"479801c6-469a-4349-a19e-0b43235ebb28","body_text":"Role of general gynaecologists in the prevention of infertility \nErtan Saridogan MD, PhD, FRCOG \nConsultant in Reproductive Medicine and Minimal Access Surgery \nUniversity College London Hospitals \nCorrespondence: ertan.saridogan@nhs.net \n  \n\nAbstract \nGynaecologists are frequently involved in the management of conditions which may result \nin reduced fertility or treatments they administer can lead to infertility. Sexually transmitted \ninfections and pelvic inflammatory disease are the most common cause of tubal damage, \ngynaecologists can play an important role in the identification and early treatment. Pelvic \nsurgery for conditions such as leiomyoma, ovarian cysts and endometriosis can lead to \npelvic adhesions and iatrogenic infertility. Avoiding unnecessary operations by careful \nassessment of women with these conditions, and identification of those who can be \nmanaged without surgery may avoid future risk of infertility. When surgery is clinically \nindicated, primary prevention of pelvic adhesions would be of paramount importance. Good \nsurgical technique and use of anti-adhesion agents may reduce development of pelvic \nadhesions. Ovarian surgery for endometriomas and other benign cysts should be performed \nin the hands of experienced surgeons or in ‘centres of clinical expertise’, and maximum \nefforts should be made to preserve normal ovarian tissue as much as possible. \n \nKeywords: Infertility, prevention, gynaecologists, pelvic surgery, adhesions \n \n \n  \n\nInfertility is estimated to affect approximately one in six couples [1]. Whilst some of the \ncauses of infertility are not preventable, others may be avoidable or risk reducing strategies \nmay be applicable to limit occurrence or impact. Gynaecologists are frequently involved in \nthe management of conditions which may result in reduced fertility or treatments they \nadminister can lead to infertility. Furthermore, they have a role in education of their \npatients, and the population in general, and are in a position to increase awareness of \ncauses of infertility.  \nThe common causes of female infertility are ovulation disorders, tubal infertility, \nendometriosis and unexplained infertility [1]. This article will give an overview of what role \ngeneral gynaecologists may play in the prevention of infertility. \n \nTubal damage secondary to infection \nTubal infertility is most commonly due to pelvic inflammatory disease (PID) secondary to \nsexually transmitted infections (STI). Other causes of tubal damage are postsurgical \nadhesions, endometriosis and intraabdominal infections secondary to inflammatory \ngastrointestinal disorders and perforated appendicitis.  \nSTIs mostly affect young population. Chlamydia trachomatis is the most common reportable \ndisease in the USA and, together with Neisseria gonorrhoea, is a common cause of PID [2]. \nApproximately 10-20% of women with untreated chlamydia will develop PID, and up to 18% \nwomen who develop PID will eventually suffer from tubal infertility [3]. Even subclinical \nchlamydia and gonorrhoea infections are associated with tubal infertility [4]. Although \ndetection and treatment of subclinical infection may not necessarily prevent subsequent \n\ninfertility [4], it is well understood that women who delay seeking treatment have a higher \nrisk of infertility [2]. Hence, identification and treatment of these women in general \ngynaecology clinics is likely to reduce risk of future infertility. This requires identification and \nscreening of women at risk of STIs, low threshold for suspicion of subclinical or clinical PID, \nappropriate testing, early treatment and partner screening/treatment. \nPostsurgical adhesions \nPostsurgical adhesions are one of the most frequent side effect of abdominal and pelvic \nsurgery. Whilst the majority of women with postoperative adhesions may not suffer any \nadverse outcomes, a significant number will experience infertility by distorting the pelvic \nanatomy and interfering with gamete and embryo transfer [5]. High risk gynaecological \nprocedures for adhesion formation are myomectomy, endometriosis surgery, ovarian \ncystectomy and tubal surgery [6]. Both laparoscopic and open procedures may cause \nadhesions. Adhesion formation is an inherent process in endometriosis but adhesions after \novarian cystectomy or myomectomy are usually de novo events.  \nThe first and most effective approach to prevention of adhesions related to surgical \nprocedures is to avoid unnecessary operations. In the absence of significant symptoms, \nfunctional cysts can be managed expectantly as they almost always resolve spontaneously. \nSimilarly, operations on small and asymptomatic benign ovarian cysts are usually avoidable, \nas long as there is no uncertainty about the nature of the cyst.  \nMany women with fibroids are asymptomatic and anxiety over future fertility may be the \nonly reason why they seek their removal. Although the fibroids are common, they are \nthought to be the only cause of infertility in only 1-3% of infertile patients [7]. Adhesions are \nfound in up to 96% of women after a laparoscopic or open myomectomy [8]. For these \n\nreasons, gynaecologists should resist the temptation to agree to a myomectomy operation \nin asymptomatic women who have not tried to become pregnant. \nThe second step of prevention is good surgical technique. Some of the surgical principles \nthat may reduce adhesion formation include careful/atraumatic tissue handling, avoidance \nof starch containing gloves and dry towels/sponges, diligent haemostasis, limiting use of \ndiathermy and suture material, choosing fine and non-reactive suture material, using \nfrequent irrigation/aspiration to reduce drying of tissues, reducing pneumoperitoneum \npressure for laparoscopic surgery and taking measures to reduce risk of infection [6]. These \nmeasure reduce but do not eliminate adhesion formation altogether. Gynaecologists who \nperform pelvic surgery should adopt these approaches in all women to reduce adhesion \nformation, particularly in those who have future fertility plans. \nUse of adhesion-reducing agents is the last step in prevention of pelvic adhesions. Site \nspecific mechanical barriers as physical separators are the most promising agents that aim \nto separate traumatised peritoneal surfaces during the postoperative 3-5 days when \nperitoneal healing occurs [6]. A systematic review suggests these agents are potentially \neffective in reducing postoperative adhesion formation, but the evidence is lacking on \nimproved fertility outcomes [9]. \n Adhesion formation inside uterine cavity is another cause of infertility. Intrauterine \nadhesions (IUA) may form following pregnancy related complications or intrauterine \nsurgery. Prolonged retention of products of conception or placental material after a \ndelivery, termination of pregnancy or surgical management of miscarriage in the presence \nof inflammation/infection is a well-known predisposing factor for IUA. Intrauterine surgical \nprocedures such as hysteroscopic myomectomy and division of septum (septoplasty or \n\nmetroplasty) are the other common causes of IUA. Hysteroscopic surgery which does not \nextend to the level of myometrium, such as polyp removal, is less likely to cause adhesions \n[10]. The best approach for the management of prolonged products of conception to \nprevent IUA is not clearly known. Obviously, avoidance of leaving placental material in the \nuterine cavity after delivery or ensuring complete evacuation of the uterine cavity during a \ntermination of pregnancy or surgical management of miscarriage would be the most \neffective way of prevention, by avoiding prolonged retention of products of conception and \nsubsequent inflammation. Once prolonged retention occurs, the least traumatic elimination \nof the products of conception, use of ultrasound guidance and administration of \nintrauterine anti- adhesion agents may be helpful. The role of hysteroscopic tissue removal \nsystems remains to be proven, but these are likely to be useful by targeted removal of the \nretained tissue and due avoidance of unnecessary trauma to the unaffected part of the \ncavity. \nHysteroscopic myomectomy is known to be associated with a significant risk of intrauterine \nadhesions. IUA formation was reported in 7.5% infertile women who underwent fibroid \nresection [11]. Good surgical technique, avoiding use of excessive diathermy and \npreservation of endometrium as much as possible are important steps in reducing the risk. \nThis risk is significantly higher in the presence of multiple fibroids [12]. Exposure of \nmyometrium on opposing walls of the uterus is probably the main mechanism in this \nsituation. Hence, resecting fibroids on opposing walls of the uterus in different sittings may \nbe a good strategy to reduce risk of IUA. \n \n \n\nEndometriosis \nWomen with endometriosis are more likely to experience infertility, a prospective study \nshowed that women with laparoscopically diagnosed endometriosis are 1.78 times more \nlikely to experience infertility in the future [13]. It is therefore important to manage \nendometriosis carefully in women who have not tried for a pregnancy yet, and particularly \npaying attention to preserving ovarian reserve and prevention of adhesions. Some of these \nwomen may eventually require treatment with assisted reproductive technologies and good \novarian reserve would probably optimise their chances of a successful outcome. A Joint \nWorking Group of European Society for Gynaecological Endoscopy, European Society of \nHuman Reproduction and Embryology and World Endometriosis Society published \nrecommendations on the optimal surgical techniques for endometriomas [14] and described \napproaches to preserve ovarian reserve. These include assessment of the ovarian reserve \nbefore deciding on surgery, possible fertility preservation if ovarian reserve is already \ncompromised, using the least traumatic technique, application of anti-adhesion agents and \nreferring the woman to a centre of expertise where the necessary skills for surgery is \navailable. Postoperatively, long term use of combined oral contraceptives, either cyclically \nor continuously has been demonstrated to reduce endometrioma recurrence and should be \noffered to those women who do not plan to become pregnant [15]. \nOvarian cysts \nOvarian cysts in women are relatively common and some of these require surgical \ntreatment due to symptoms, or because of anxiety on the nature of the tumour or future \nrisk of ovarian torsion. Sometimes, repeat operations are performed for recurrent cysts or \novaries are removed due to inability to preserve healthy ovarian tissue or clinical suspicion \n\nof possible malignancy. These result in diminishing ovarian function, and can compromise \nthe woman’s fertility or fertility treatment in the future, as explained in the endometriosis \nsection above. Good diagnostic assessment, use of high quality imaging and tumour \nmarkers, when required, are essential before deciding on surgical management. Operating \non functional cysts should be avoided, relatively small asymptomatic benign cysts can \nusually be managed expectantly and normal ovarian tissue can be preserved when surgery \nfor benign cysts is required, even if the cyst is very large. Oophorectomy for benign cysts in \nyoung women or girls is usually unnecessary. The recommendations described for the \nmanagement of endometriomas above would be applicable to the other benign ovarian \ncysts. \nSummary \nGeneral gynaecologists have a significant role to play in the prevention of infertility. Some of \nthe causes of infertility are iatrogenic and secondary to pelvic surgery. Careful assessment of \nwomen with gynaecological conditions such as fibroids and ovarian cysts, and identification \nof those who can be managed without surgery may avoid potentially eliminate fertility \ndifficulties secondary to pelvic adhesions in these women. When surgery is clinically \nindicated, primary prevention of pelvic adhesions would be of paramount importance. The \nmeasures to avoid postoperative adhesions include good surgical technique and potentially \nuse of anti-adhesion agents. Ovarian surgery for endometriomas and other benign cysts \nshould be performed in the hands of experienced surgeons or in ‘centres of clinical \nexpertise’, maximum efforts are exercised to preserve normal ovarian tissue as much as \npossible. General gynaecologists also have a role in the identification and early treatment of \n\nsubclinical and overt STIs and pelvic infections, these efforts are likely to reduce likelihood \nof tubal damage and subsequent infertility. \nPractice points \n identify and treat subclinical and clinical pelvic infections \n Avoid unnecessary operations for benign conditions such as fibroids or ovarian \ncysts unless there is an obvious indication \n Use good surgical technique to reduce pelvic or intrauterine adhesion formation \n Consider using anti-adhesion agents after pelvic and intrauterine surgery \n Aim to preserve ovarian tissue and avoid oophorectomy during surgical treatment \nof benign ovarian lesions \nConflict of interest \nThe author has no conflict of interest in relation to this article. \n1. Bhattacharya S, Johnson N, Tijani HA, Hart R, Pandey S, Gibreel AF. Female \ninfertility. BMJ Clin Evid. 2010 Nov 11;2010. pii: 0819. \n \n \n2. *Tsevat DG, Wiesenfeld HC, Parks C, Peipert JF. Sexually transmitted diseases and \ninfertility. Am J Obstet Gynecol. 2017 Jan;216(1):1-9.  \n3. Haggerty CL, Gottlieb SL, Taylor BD, Low N, Xu F, Ness RB. Risk of sequelae after \nChlamydia trachomatis genital infection in women. J Infect Dis 2010;201(Suppl \n2):S134–S155. \n\n4. Wiesenfeld HC, Hillier SL, Meyn LA, Amortegui AJ, Sweet RL. Subclinical pelvic \ninflammatory disease and infertility. Obstet Gynecol. 2012 Jul;120(1):37-43.  \n5. *De Wilde RL, Trew G. Postoperative abdominal adhesions and their prevention in \ngynaecological surgery. Gynecol Surg 2007; 4:161–8. \n6. *De Wilde RL, Trew G. Postoperative abdominal adhesions and their prevention in \ngynaecological surgery. Part 2. Gynecol Surg 2007; 4:243–53. \n7. Whynott RM, Vaught KCC, Segars JH. The Effect of Uterine Fibroids on Infertility: A \nSystematic Review. Semin Reprod Med. 2017 Nov;35(6):523-32.  \n8. *Buckley VA, Nesbitt-Hawes EM, Atkinson P, Won HR, Deans R, Burton A, Lyons SD, \nAbbott JA. Laparoscopic myomectomy: clinical outcomes and comparative evidence. \nJ Minim Invasive Gynecol. 2015 Jan;22(1):11-25.  \n9. *Ahmad G, O’Flynn H, Hindocha A, Watson A. Barrier agents for adhesion prevention \nafte r gynaecological surgery. Cochrane Database of Systematic Reviews 2015, Issue \n4. Art. No.: CD000475.  \n10. *AAGL Elevating Gynecologic Surgery. AAGL practice report: practice guidelines on \nintrauterine adhesions developed in collaboration with the European Society of \nGynaecological Endoscopy (ESGE). Gynecol Surg. 2017;14(1):6.  \n11. Touboul C, Fernandez H, Deffieux X, Berry R, Frydman R, Gervaise A. Uterine \nsynechiae after bipolar hysteroscopic resection of submucosal myomas in patients \nwith infertility. Fertil Steril. 2009 Nov;92(5):1690-3.  \n12. Taskin O, Sadik S, Onoglu A, Gokdeniz R, Erturan E, Burak F, Wheeler JM. Role of \nendometrial suppression on the frequency of intrauterine adhesions after \nresectoscopic surgery. J Am Assoc Gynecol Laparosc. 2000 Aug;7(3):351-4.  \n\n13. Prescott J, Farland LV, Tobias DK, Gaskins AJ, Spiegelman D, Chavarro JE, Rich-\nEdwards JW, Barbieri RL, Missmer SA. A prospective cohort study of endometriosis \nand subsequent risk of infertility. Hum Reprod. 2016 Jul;31(7):1475-82.  \n14. *Working group of ESGE, ESHRE, and WES, Saridogan E, Becker CM, Feki A, Grimbizis \nGF, Hummelshoj L, Keckstein J, Nisolle M, Tanos V, Ulrich UA, Vermeulen N, De Wilde \nRL. Recommendations for the surgical treatment of endometriosis-part 1: ovarian \nendometrioma. Gynecol Surg. 2017;14(1):27.  \n15. Seracchioli R, Mabrouk M, Frascà C, Manuzzi L, Montanari G, Keramyda A, Venturoli \nS. Long-term cyclic and continuous oral contraceptive therapy and endometrioma \nrecurrence: a randomized controlled trial. Fertil Steril. 2010 Jan;93(1):52-6.","source_license":"public-domain-us","license_restricted":false}