SART Fertility Experts - Surgery Before IVF Egg Retrieval and/or Embryo Transfer

Host Dr. Cristin Slater interviews Dr. Joseph Findley about pelvic conditions that can affect pregnancy rates with IVF.  He discusses the indications and pros and cons to do surgery before IVF egg retrieval and/or before embryo transfer with certain medical conditions.

Welcome to the SART Fertility Expert Podcast. Today we're going to talk about surgery before IVF, egg retrieval, and IVF embryo transfer. We're lucky enough to have Dr. Joseph Findley with us.

Dr. Findley is an assistant professor at Case Western Reserve University School of Medicine, and he is also a fertility physician at the University Hospital of Cleveland Medical Center. He is a current chairperson of the Surgery of Reproductive Surgeons Electronic Communications, so he is a perfect person and very high qualified to talk about this. Welcome, Dr. Findley.

Thank you very much. Oh, and can I make one amendment to that? Of course. No longer the chair of the Electronic Communications Committee.

I'm a member of that committee. I've moved on and I'm currently a board member at large for that society. Great.

We've got lots of experience with reproductive surgery, and today we're going to talk about surgery before IVF, egg retrieval, and or embryo transfer. And we know that most people don't want to have surgery, but I feel that there are indications at times for quality of life and to improve IVF success rates. Today we have very, very high success rates with in vitro fertilization, IVF.

When we transfer a PGT-proven, genetically proven, high-quality embryo blastocyst, we're getting 60 to 70 percent baby, which is quite high. But there are times when people have conditions, pelvic conditions, where surgery is indicated for improving quality of life and potentially improving their success rate at IVF. So today we're going to talk about when is surgery indicated or recommended for different conditions, such as fallopian tube surgery, endometriosis, if there's an ovarian mass, if there's an uterine fibroid, and if there's a uterine anomaly, such as a septum.

So we'll talk about tubal surgery first. So Dr. Findley, what is a hydrosalpinges, and then what is the data regarding implantation if you keep a hydrosalpinges intact versus having the hydrosalpinges removed before an embryo transfer? Absolutely. So a hydrosalpinges, kind of as the name implies, hydro is water or fluid, and salpinges is essentially a tube, a fallopian tube.

So when fluid accumulates in the fallopian tube, there is thought to be a concomitant decrease in likelihood of success with an embryo transfer or likelihood of implantation successfully occurring that will result in ongoing pregnancy and delivery. So the question is, what is the nature of the hydrosalpinges? How did it get there? And what predisposing factors do individuals have? So in most cases, the hydrosalpinges is due to some sort of inflammation that has occurred in the pelvis, whether that is inflammation from a prior infection, sometimes from a prior surgery, or from a condition like endometriosis. The results in occlusion of the fallopian tube with the distal side and subsequent fluid accumulation within the fallopian tube.

The reason why we care about this is because when patients are attempting to become pregnant, we've seen decreases in likelihood of success with becoming pregnant, even when ART is used, when the hydrosalpinges is visible on ultrasound. And it's thought that this fluid that accumulates within the fallopian tube is somewhat inflammatory in nature, and that that fluid can essentially leak backwards into the cavity of the uterus, causing increased levels of inflammation and potential mechanical flushing, keeping the embryo from having the ability to essentially set up shop successfully. And so when hydrosalpinges is visible at rest on ultrasound, the fertility impact with an embryo transfer is thought to be a 30 to 50% decrease in likelihood of success, when, again, this is seen on imaging.

Okay, that is impressive. So if you remove the hydrosalpinges, potentially, you would not have that 30 plus percent decrease in implantation rate. Excellent.

Correct. So most studies have suggested that when you either remove the fallopian tube that is full of fluid, or provide some means of occlusion, so placing a clip used for tubal sterilization across the proximal tube to keep this fluid transferring from the tube and into the cavity. Anything that breaks up that communication between the hydrosalpinges and the cavity of the uterus is thought to essentially remove that reduction in likelihood of success.

That makes sense. Great. So now we'll move on to ovarian cysts.

Now, we know people can have ovarian cysts that are simply fluid unilocular, which can be usually come and go, but if they need to be removed, can be easily removed with transvaginal cyst aspiration in the clinic. But what if you have an adenoxal mass that's solid, such as an endometriosis solid cyst, or a dermoid ovarian cyst? What are the pros and cons to either leaving these cysts intact prior to an egg retrieval, or to remove the cyst before the egg retrieval? That's an excellent question, and certainly one that unfortunately doesn't have the most simple answer. So when talking about adenoxal masses, especially endometriomas and teratomas, the etiology of the cysts themselves and the nature, meaning the size and location of each of those cysts, all play a factor in someone's success with subsequent fertility treatment.

So in general, patients with endometriosis are thought to have a decreased likelihood of success with fertility treatments, and that's due to the potential impact that endometriosis has not only on ovarian reserve, so egg number, egg quantity, but also of egg quality. And it's thought that that is due to the inflammatory nature of endometriosis. With endometriomas, the decision to move forward with fertility treatment versus surgery first really kind of depends upon the whole clinical picture and the individual patient.

So for patients who have large endometriomas, typically greater than four to five centimeters in average diameter, those are thought to have a more significant negative impact on likelihood of success. So it is appropriate to move forward with surgery prior to doing fertility treatment for large lesions like that. Ones that are smaller are not thought to have as much of an impact on fertility treatment, so those are ones that can often be watched.

However, anytime I'm talking about endometriosis with patients and does surgery versus fertility treatment make sense first, you always have to factor in symptomatology. So for patients who are having significant pain, significant symptoms, and they're interested in having that be the primary directive for their surgical treatment rather than simply improving fertility outcomes, moving forward with surgery makes sense if symptomatology is driving things. When pain and daily symptoms aren't as much of a factor, then it's a matter of looking at size like we talked about, but also potential location of the lesions.

So if you have a somewhat large lesion, if it's below the four centimeters, say maybe three, three and a half centimeters, but it's centrally located or located in such a way on imaging that it is going to obscure the ovary and limit us from being able to retrieve eggs, it may make sense to remove that lesion prior to moving forward with an IVF cycle. The flip side is for folks who've had multiple prior surgeries or folks who have had previous cysts removed from the ovaries or prior adnexal surgery, the concern that you have to weigh there is will another surgery significantly decrease ovarian reserve? Is there potential risk for injury to the ovary that might decrease your likelihood of success with the subsequent IVF cycle? So lots that we have to consider and keep in mind when we're looking at these lesions, but in general, ones that I operate on are ones that are primarily symptomatic and we're shooting for symptomatic improvement for the patient in addition to improving fertility success. Ones that are quite large or ones that are located in such a way that they're going to keep us from accessing areas of the ovary and will ultimately limit the number of eggs that we're able to retrieve because of their presence.

I agree. Well said. Yes, I have seen reports, journal publications where ovarian reserve has been decreased 40% with unilocular cyst removal.

But like you said, if it improves your quality of life, then that's part of the decision making that justifies surgery. And just one other thing to add there is if you have information about an individual lesion for a patient and you see it's one that is quickly growing, quickly progressing, things like that, that's something else to kind of keep in the back of your mind because ones that are quickly growing, once they've crossed that sort of threshold, they're at increased risk of both continuing to grow and potentially rupturing. And so those are things that you would want to avoid as well.

Good point. Kind of along that lines with endometriosis, I know there's data to support doing surgery to remove the implants of just endometriosis, not endometriosis cysts prior to embryo transfer. And what are your thoughts or what are your discussions with patients regarding this? Absolutely.

So again, endometriosis in general is one that is pretty complex and convoluted when looking at its impact on fertility and hence the decision to move forward with surgery prior to fertility treatment or not as a complex one. So again, symptomatology certainly plays a role. But in general, the recommendation is and most studies would support operating for patients who have moderate to severe or stage three or stage four endometriosis prior to proceeding with fertility treatment.

Most again, most studies, not all, have suggested that doing so and doing that surgery improves their likelihood of success. The tough part is that endometriosis severity is staged surgically. So for someone who hasn't had a prior surgery, you don't always know what their endometriosis stage is.

So a lot of what you're going off of it is imaging findings. Imaging findings again can be misleading because not all endometriosis can be seen on imaging. But if you have someone that has stigmata of severe endometriosis, such as bilateral ovarian cysts greater than three to four centimeters in size, then you pretty much know that you can expect stage three to four endometriosis being present.

Or if they have physical exam findings suggesting significant adhesive disease, nodularity on the utero-sacral ligaments, things that would suggest seclusion of the posterior cul-de-sac, these are patients that I would lean more towards operating on prior to moving forward with fertility treatment. Whereas if symptoms aren't as severe, they don't have the physical exam findings, they don't have the imaging findings, then those are individuals that we may say probably best to move forward with IVF first. That makes sense.

It's great that we can have these discussions with patients and kind of go through their individual history and see what makes sense for them. Moving on to fibroids. Fibroids are very common in women.

Approximately 40% of women by the time they're age 40 will have them. And fibroids can be in different locations in the uterus. They can be on the outside external surface, which doesn't affect fertility, or in the muscle or actually inside the uterine cavity.

What is the data regarding implantation rates for embryos put into uteruses that have fibroids in these different locations? With uterine fibroids, as you suggested, location absolutely matters. So ones that are thought to have the greatest negative impact on implantation and carrying a pregnancy are ones that are submucosal in nature, or ones that are clearly located within the endometrial cavity. When this is the case, they are thought to decrease the likelihood of success of an embryo transfer by about 10 to 30%.

So not 100%. So again, it's worth having a discussion between patients and physicians. Is this a fibroid that, given a patient's certain clinical presentation, would benefit from being removed prior to fertility treatment or not? But again, the thought is that submucosal fibroids, ones that are physically in the cavity of the uterus, are thought to decrease likelihood of success with the transfer by about 10 to 30%, and that is reversed following removal of the fibroids.

Now, ones that are outside the cavity, that are larger, greater than 5 centimeters in diameter, and are located primarily intramural, meaning in the wall of the uterus, but not directly in the cavity, those ones, if they are thought to distort the shape of the cavity of the uterus, those are thought to have a negative impact as well, though it's not as clear and not as marked as the ones that are clearly submucosal. So those are fibroids that are going to require a bit further discussion, have a bit more nuance assigned to whether or not they should be removed prior to an IVF cycle. In that situation, I'll often have the discussion with patients about symptomatology.

Are we expecting symptomatic improvement from removal of such a fibroid? Or historically, have they had pregnancy complications that might be attributed to the presence of such a fibroid, such as recurrent pregnancy loss or implantation failure, recurrent implantation failure with a frozen embryo transfer? Or have they had other obstetric complications, such as fetal malpresentation or premature rupture of membranes or deliveries, things like that? They can all potentially be associated with the presence of larger fibroids. Yes, it does seem like if the fibroid is in the submucous fibroids in the uterine cavity, it is recommended to remove those to increase the implantation by 10 to 30%. And that type of surgery can be done without an incision, which is nice.

Typically, it's just outpatient procedure. And I agree, you have to take individual approaches when you have these fibroids that are in the muscle and they're abutting the cavity, not distorting the cavity, like how much impact do they have? And I do like when discussing with the patients, taking individual approach, like how many embryos do they have? Have they had failed transfers? If they've had prior surgeries, like prior rheumectomies, that could come into play as well. And even fibroids that are located on the serosal surface of the uterus, if they're large enough, they can potentially cause issues too.

So I've personally had patients who have gone through prior pregnancies, had significant growth of subserosal fibroids that have either resulted in pain due to necrosis or torsion, or significant subserosal fibroids that have grown that resulted in incarcerated uterus or pelvic outlet obstruction. So these are all discussions and all things that you have to discuss with the patient historically, to come up with an individual approach for what's going to be best for them. Very good point.

It's true, because even if they do get pregnant, you want them to have a pregnancy that's healthy without complications and for them to feel good during their pregnancy. So with uterine anomalies, they do affect three to 7% of women. And there are some anomalies that we don't do surgery on, such as a bicornate uterus, or duplication of the uterus.

But there is an anomaly, it's called a uterine septum. And if you could let us know, what is a uterine septum, and when is it indicated or recommended to remove the uterine septum? Absolutely. So when each patient is forming as an embryo in their own mother's uterus, there are different structures that come together and fuse in certain ways to form what we know as the female urogenital tract.

And the uterus itself is one that fuses in the midline from the essentially joining of two malarian ducts that essentially join in the midline to form a singular uterus, and in most cases, a singular uterine cavity. When it all goes smoothly, end up with one uterus with a single lumen where a pregnancy would grow. Unfortunately, there are many situations that can arise where there is inadequate fusion of those structures, and then subsequent resorption of the medial aspect of the walls when fusion occurs.

So when that happens, you can have partial fusion of the two malarian ducts to form one singular uterus, but the medial walls don't fully resort, and what you end up with is a fibromuscular band of tissue that is often longitudinal in nature, so from the fundus of the uterus extending down towards or even through the cervix and resulting in what's called a uterine septum. And the reason why this is significant is because there is a significant association between the presence of these septums and an increased likelihood of having infertility, as well as an increased likelihood of having miscarriage or fetal malpresentation or premature rupture of membranes in preterm delivery when these are present. The tough thing about uterine septae is that they are not always uniformly diagnosed for patients, so we don't know what the true incidence is.

So many patients who will have uterine septae will never know that they had one. They're able to become pregnant, pregnancies will go along without a hitch, and they'll deliver a baby, and so they'll go on living their lives not even knowing that this was ever something that was there or was ever even a factor. The ones that we typically diagnose are ones that are associated after or associated with a prior miscarriage or prior obstetric complication.

So for patients who have a prior obstetric complication, the decision of whether or not to move forward with a surgical repair of a septum prior to doing fertility treatment is a bit more easy. You know that it's something that's had a negative impact on this individual before, you want to do what you can to set them up for success moving forward with treatment. Unfortunately, now that we're doing much more imaging, and imaging is much more accurate than it ever has been, we're now diagnosing these septae in younger individuals who have never even attempted pregnancy.

So the question is what do we do for patients where these are discovered incidentally, and there the decision again becomes a bit more convoluted. You have to have a conversation with patients regarding the potential association between infertility and obstetric outcomes, but you can't say that it's 100 percent and you don't know which ones of these septums are going to become problematic in the future. Typically, when I'm having this discussion, it's a matter of trying to gauge where the patient is, and what their fertility expectations for life are moving forward, and essentially make a shared decision.

For some folks, when they're discovered incidentally, we leave things alone and years later they'll come back either before attempts to becoming pregnant or after a negative obstetric outcome for a surgery, or other folks choose to have surgery primarily. So there's no wrong answer here, but to say that every single septum needs surgery prior to attempts to become pregnant, the data does not support that. I agree, and like you said, there's such a huge variation in these uterine septums.

Some uteruses will have a septum that's 1.5 centimeters long, and there's others that are taking the entire uterine cavity. That's a consideration too, and also some septums are more fibrous, avascular, may not have good blood supply for when the placenta attaches, and there's some septums that have more of a combination of a muscular and a fibrous component. So these are all things I think with more imaging we can assess, you know, the different natures of the septums, and then the pregnancy history, and like you said, to kind of have a discussion with the patient.

Absolutely, and I think you bring up a good point. Just simply the presence of something that we see as a septum does not always equal a negative impact because the quality of that septum, the characteristics of that septum, whether it's more muscular or more fibrous in nature is key. Ones that are fibrous are not thought to be able to provide appropriate blood flow and nutrients to a pregnancy should a pregnancy implant upon it, so those pregnancies are not going to turn out well.

So those septums that are more fibrous in nature are ones that, you know, patients would benefit more from, you know, primary removal, whereas ones that are more muscular, those areas have good blood flow. They're not thought to have as much of a negative impact and, you know, oftentimes can be left alone. There have been times where I've gone back for procedures and, you know, essentially we resect septums until we start seeing healthy, you know, bleeding tissue, and when we get to that point, oftentimes we'll stop because even if there is still an indent, the fact that you have good blood flow to that area means that a pregnancy can implant and potentially do well there.

Yes, that's excellent to know. I really appreciate all of your expertise with surgery before IVF and embryo transfer. I feel like we've kind of gone through a lot of the diagnosis that people have, and hopefully this will be helpful to those who are seeking information and also wishing best success to those who are considering surgery before their IVF, egg retrieval, and embryo transfer.

I appreciate you participating in this and wishing all best success to everyone out there. Thank you. Absolutely.

Thank you very much for having me.