What for save a pipe after extrauterine?

[Litta]

One month ago to me have operated a uterine pipe in occasion of ectopic pregnancy. A pipe have saved (she at me unique), but to become pregnant in the natural way did not recommend. So what for it or her have left? In fact mucous in a place of implantation it is not so functional, that many times over increases or enlarges risk repeated extrauterine. Why all so aspire to organosohranjajushchim to operations? What does she give in this case?

[dr_medvedev]

Esteem http: // www.drdonnica.com/fastfacts/00005325.htm



Probability to become pregnant with the saved pipe more than 80 %, and without a pipe - 0 %. As you consider or count it was necessary to act or arrive?

[Litta]

Hello, dear Michael Vladimirovich!

Very pleasantly again you here to meet.

The question has arisen that itself the doctor, operirovshaja a pipe, did not advise to become pregnant in the natural way, and to resort to a way of an extracorporal fertilization. But to me is known also that presence of pipes at EKO is undesirable (besides because of risk extrauterine).

It also has confused me finally.:confused:

I here had assumptions, that the ovary ceases to work, if there is no pipe. There is no demand - there is no also an offer. I am not right?

[dr_medvedev]

Thanks.



At EKO clean or remove the hydrosalpinxes, not changed pipes do not delete. You do not have absolute indications for EKO. Simply it is necessary to be prepared for following pregnancy and in case of repeated extrauterine (the probability of all up to 10 %) to be ready (the good doctor, Methotrexatum or is better to clean or remove already a pipe).

If again there will be a similar trouble then it will be already possible to think about EKO

[boris]

Litta!



One month ago to me have operated a uterine pipe in occasion of ectopic pregnancy. A pipe have saved (she at me unique), but to become pregnant in the natural way did not recommend. So what for it or her have left? In fact mucous in a place of implantation it is not so functional, that many times over increases or enlarges risk repeated extrauterine. Why all so aspire to organosohranjajushchim to operations? What does she give in this case?

In your question already there are arguments in favour of more radical decision, however exist, as you were convinced, and other opinions.



Apparently the part of experts considers or counts:



That after the spent operative measure and without that the changed uterine pipe becomes more functional.



That, uterine truba-something reminding a pipe vodoprovldnuju and its or her canalization restores it not only its or her permeability for a contrast agent entered during the moment of inspection under pressure, but also its or her functional ability normally to move an ootid



That 80 % resulted or brought in the advertizing leaflet are a probability of offensive or approach of pregnancy, instead of an opportunity of its or her canalization.

* (even in the most optimistical researches in this occasion the probability of offensive or approach of pregnancy after similar interventions does not exceed 60 %)





Except for that even in the resulted or brought advertizing leaflet in black and white the author specifies:



What even in such safe country as America 40-50 women in a year perish owing to ectopic pregnancy.



That the most serious risk factors of development of ectopic pregnancy and factors raising or increasing risk of its or her repetition just also are:





Previous ectopic pregnancy

The transferred or carried operations on uterine pipes

And also in case of planning procedure eko the probability of offensive or approach of ectopic pregnancy raises or increases at women with previous ectopic beremennostjami.



You do not have absolute indications for EKO.

It would be desirable to remind Michael Vladimirovichu, that one of the first indications for carrying out of procedure eko just and was -peritoneal sterility or barrenness. Later these indications have been considerably expanded.

Probably it is possible to expect that day when at the woman with one already operated uterine pipe, will come or step (most likely the third) an extrauterine pregnancy or a salpingocuesis and after that at it or her it is valid pojavjatsja ABSOLUTE indications.

There are also alternative variants. Consecutive carrying out organsohranjajushchih operations and to wait the moment when carrying out by a method of an auxiliary reproduction will be impossible by virtue of the reasons connected with the years of the patient.



If again there will be a similar trouble then it will be already possible to think about EKO When I hear similar statements always it would be desirable to ask the author to present on this place of the person, at which *quot; has happened similar ?NO?nO??Oy*quot; somebody from the close relatives and to reflect a mortality 40-50 it it is a lot of or a little?????



Would like to note, that in the same, quoted by the author of data, Staffs or States (and not only) already for a long time have solved a problem of a choice as it cynically sounds, but from economic positions since money for treatment there have got used to consider or count and the most part is paid not by the patient, and the insurance companies.



Now it is proved, that at treatment of -peritoneal sterility or barrenness application of method EKO is more profitable (more cheaply), than the surgical methods of treatment directed on restoration of permeability of uterine pipes.







Van Voorhis BJ, Syrop CH.Cost-effective treatment for the couple with infertility. Clin Obstet Gynecol. 2000 Dec; 43 (4):958-73. University of Iowa Hospitals and Clinics, Department of Obstetrics and Gynecology, Iowa City 52245, USA.

Philips Z, Barraza-Llorens M, Posnett Evaluation of the relative cost-effectiveness of treatments for infertility in the UK.J.Hum Reprod. 2000 Jan; 15 (1):95-106.

With uv. A moderator of a forum Fruitless marriage or spoilage

B.Kamenetsky

[dr_medvedev]

Apparently the part of experts considers or counts:

That after the spent operative measure and without that the changed uterine pipe becomes more functional.



It is what part *quot; ?N?a???Oo*quot; so considers or counts? Or you about me?



That, uterine truba-something reminding a pipe vodoprovldnuju and its or her canalization restores it not only its or her permeability for a contrast agent entered during the moment of inspection under pressure, but also its or her functional ability normally to move an ootid



Criticism *quot; ?oU?a*quot; it is not known whom? About what besides experts you speak the patient? If to choose such *quot; ??Nu?a?y?U*quot; the approach - specify who so considers or counts particularly and on the basis of what you have drawn such conclusions.



That 80 % resulted or brought in the advertizing leaflet are a probability of offensive or approach of pregnancy, instead of an opportunity of its or her canalization.

* (even in the most optimistical researches in this occasion the probability of offensive or approach of pregnancy after similar interventions does not exceed 60 %)



1. I have specified the link for the patient, instead of for us and it not the advertizing leaflet.

2.80 % resulted or brought under the link are a probability of restoration of permeability, and here, that write about frequency of repeated extrauterine pregnancies or salpingocueses: In general, the ratio of intrauterine to recurrent ectopic pregnancies is about 6:1 but it rises to about 10:1 if the other tube appears normal.



Except for that even in the resulted or brought advertizing leaflet in black and white the author specifies:

What even in such safe country as America 40-50 women in a year perish owing to ectopic pregnancy.

That the most serious risk factors of development of ectopic pregnancy and factors raising or increasing risk of its or her repetition just also are:



Previous ectopic pregnancy

The transferred or carried operations on uterine pipes

And also in case of planning procedure eko the probability of offensive or approach of ectopic pregnancy raises or increases at women with previous ectopic beremennostjami.



If it is the advertizing leaflet, the colleague that he advertises or promotes? An extrauterine pregnancy or a salpingocuesis? Thanks for translation or transfer. So there also it is written. I congratulate you on knowledge of English tongue.



It would be desirable to remind Michael Vladimirovichu, that one of the first indications for carrying out of procedure eko just and was -peritoneal sterility or barrenness. Later these indications have been considerably expanded.



Thanks that have reminded. To tell the truth I did not know about it or this:-) Speech here goes, dear colleague, not about sterility or barrenness, and about expediency of conservation of the UNIQUE pipe at an extrauterine pregnancy or a salpingocuesis.



Probably it is possible to expect that day when at the woman with one already operated uterine pipe, will come or step (most likely the third) an extrauterine pregnancy or a salpingocuesis and after that at it or her it is valid pojavjatsja ABSOLUTE indications.

There are also alternative variants. Consecutive carrying out organsohranjajushchih operations and to wait the moment when carrying out by a method of an auxiliary reproduction will be impossible by virtue of the reasons connected with the years of the patient.



Allow to notice, that precise references, instead of imaginations on a subject of the future here are necessary.



When I hear similar statements always it would be desirable to ask the author to present on this place of the person, at which *quot; has happened similar ?NO?nO??Oy*quot; somebody from the close relatives and to reflect a mortality 40-50 it it is a lot of or a little?????



1. I give identical references to any patients, even if they my relatives

2. The mortality 40-50 on 300 million is less, than from bee stings or you did not press more in detail in a jungle of statistics?



Would like to note, that in the same, quoted by the author of data, Staffs or States (and not only) already for a long time have solved a problem of a choice as it cynically sounds, but from economic positions since money for treatment there have got used to consider or count and the most part is paid not by the patient, and the insurance companies.

Now it is proved, that at treatment of -peritoneal sterility or barrenness application of method EKO is more profitable (more cheaply), than the surgical methods of treatment directed on restoration of permeability of uterine pipes.







Van Voorhis BJ, Syrop CH.Cost-effective treatment for the couple with infertility. Clin Obstet Gynecol. 2000 Dec; 43 (4):958-73. University of Iowa Hospitals and Clinics, Department of Obstetrics and Gynecology, Iowa City 52245, USA.

Philips Z, Barraza-Llorens M, Posnett Evaluation of the relative cost-effectiveness of treatments for infertility in the UK.J.Hum Reprod. 2000 Jan; 15 (1):95-106.

With uv. A moderator of a forum Fruitless marriage or spoilage

B.Kamenetsky



It was a question, dear Boris Aleksandrovich not about sterility or barrenness. You esteem more closely or attentively from the very beginning.



Wait for continuation.

[dr_medvedev]

Fertil Steril. 1990 Feb; 53 (2):227-31. Related Articles, Links



Reproductive outcome after conservative surgery for unruptured tubal pregnancy - a 15-year experience.



Langer R, Raziel A, Ron-El R, Golan A, Bukovsky I, Caspi E.



Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Israel.



The fertility outcome is presented in 118 patients after conservative surgery for unruptured tubal pregnancies. This patient group experienced 142 pregnancies, 127 of which were intrauterine (89.4 %). The intrauterine pregnancies (IUPs) occurred in 83 patients (70.3 %) and 63.5 % (75/118) had live births. The recurrence rate of tubal pregnancy was 12.7 %. Of the 65 patients with a normal contralateral tube 53 (81.5 %) followed surgery with an IUP, 76.1 % a live birth, and 7.7 % a recurrent tubal pregnancy. Fifty-seven percent of the patients with a single tube followed with an IUP, and 47.6 % had a live birth. The recurrence of tubal pregnancy in this group was 28.5 %. Of the patients who underwent expression of tubal gestation, 60.6 % followed with an IUP, and 57.5 % with a live birth with no recurrence of tubal pregnancy.



At women with a unique pipe by which the salpingostomy has been made, frequency of normal pregnancy has made 57 %, repeated extrauterine was at 28,5 %.

Or, Boris Aleksandrovich, is better at once a pipe ottjapat and to you on EKO for greater or big to our measures of a money? So your way?

[dr_medvedev]

Unfortunately I absolutely do not have time to search for set of links, but the reference to do or make a salpingotomy and to leave a unique pipe at an extrauterine pregnancy or a salpingocuesis progressing or broken or disturbed as tubal abortion as at the given patient, it is duplicated in the majority of modern domestic and foreign managements or manuals and is confirmed not by opinions *quot; aoOO?ONOo*quot;, and made researches. It does not cause or cause any doubts in the sane -gynecologist. There will be questions under links - write.

[boris]

Uv. Michael Vladimirovich!



It is pleasant, that the subject you has mentioned or touched (in fact not all correspondents respond three times without a stopping).



Unfortunately I absolutely do not have time to search for set of links, but the reference to do or make a salpingotomy and to leave a unique pipe at an extrauterine pregnancy or a salpingocuesis progressing or broken or disturbed as tubal abortion as at the given patient, it is duplicated in the majority of modern domestic and foreign managements or manuals and is confirmed not by opinions *quot; aoOO?ONOo*quot;, and made researches. It does not cause or cause any doubts in the sane -gynecologist. There will be questions under links - write. Certainly I have time, and this subject me very much interests, and for this reason I the second day seriously study the given literatures (to not be proofless (read ridiculous))

I within the next few days shall give you the given reason answer. To me it is pleasant, that the subject has interested you.



Or, Boris Aleksandrovich, is better at once a pipe ottjapat and to you on EKO for greater or big to our measures of a money? So your way? Or to receive third extrauterine, after eko (when the patient has paid I quote: *quot; for greater or big to our measures nN?N??*quot;)





It is what part *quot; ?N?a???Oo*quot; so considers or counts? Or you about me? Try to guess from three times.









Thanks that have reminded. To tell the truth I did not know about it or this:-) Speech here goes, dear colleague, not about sterility or barrenness, and about expediency of conservation of the UNIQUE pipe at an extrauterine pregnancy or a salpingocuesis. Such researches exist. In the nearest I shall prompt some days to you literary data.





Allow to notice, that precise references, instead of imaginations on a subject of the future here are necessary. I can repeat only, that the discussed subject more than is interesting to me also I in the nearest some days I shall try to convince (not only you) what is it at all imaginations on a subject budujushchego.

[dr_medvedev]

Dear Boris Aleksandrovich, I on a regular basis am engaged in operations at an extrauterine pregnancy or a salpingocuesis and this subject too is extremely interesting to me. With pleasure I esteem your data and if they will convincing it quite can affect or influence my practical activities.



In turn, I shall try to study also the literature concerning though on vskidku data on unique pipe in Pabmede to find it was not possible, it will be necessary to look more closely or attentively.

[Litta]

It is very interesting to read kordinalno different opinions in occasion of the given problem.

For me there is only illogical a conclusion of the doctor operated me which has saved to me a pipe and... Has directed on EKO.



I wish to specify a situation: at me odnorogaja a uterus and, accordingly, the right appendages was never. Nevertheless, to become pregnant and give birth child (girl 2 years) me was possible. In second time has become pregnant on a background of feeding by a breast. As a result of change of a hormonal background as it seems to me, and the peristalsis of a unique pipe has been broken or disturbed. As during operation solderings what or druhih disturbances it was revealed not.

[dr_medvedev]

It is very interesting to read kordinalno different opinions in occasion of the given problem.

For me there is only illogical a conclusion of the doctor operated me which has saved to me a pipe and... Has directed on EKO.



I wish to specify a situation: at me odnorogaja a uterus and, accordingly, the right appendages was never. Nevertheless, to become pregnant and give birth child (girl 2 years) me was possible. In second time has become pregnant on a background of feeding by a breast. As a result of change of a hormonal background as it seems to me, and the peristalsis of a unique pipe has been broken or disturbed. As during operation solderings what or druhih disturbances it was revealed not.



Actually cardinal opinion here one. At close or attentive perusal of the answer of Boris Aleksandrovicha Vy will understand, that it is a question of peritoneal sterility or barrenness. That is my colleague has not absolutely understood your question (read probably quickly) moreover and has responded not absolutely beautifully (but it now our internal so to say). While look or see statistics on *quot; opportunities ?aiNON?N?NOy*quot;, resulted or brought by me. Can compare these digits to digits successful beremennostej, received by means of EKO.

I wish to emphasize, that Boris Aleksandrovich the competent expert on sterility or barrenness and to its or his opinion you can quite listen. But so has left. During the further discussion you will understand who it correct decision was right also will help or assist you to make.

[Litta]

How much or As far as I have understood, even EKO me does not relieve from repeated extrauterine? Considering odnorogost uteruses and its or her extended horn, more likely even increases or enlarges risk of ectopic pregnancy.





I understand, what is it two different questions, but it would not be desirable to get or start new top.

Today the interesting situation with my right ovary was found out. During a laparoscopy the right ovary, as well as the right pipe, has not been found at all, and also anomaly of a structure of a uterus (odnorogost) is confirmed. Considering or examining;surveying the med.dokumenty their structure or frame and the sizes, with corresponding or meeting US-pictures has come across results of US of the inspection, the year spent a floor back in which BOTH are described mine an ovary.



So to that now to believe? Who from doctors could be mistaken? Whether how now to learn or find out esl from me the second ovary?

[dr_medvedev]

How much or As far as I have understood, even EKO me does not relieve from repeated extrauterine?

Yes. For EKO it would be more preferable to clean or remove a pipe. Its or her time have left are a chance to become pregnant WITHOUT EKO.



Considering odnorogost uteruses and its or her extended horn, more likely even increases or enlarges risk of ectopic pregnancy.

odnorogost here not and. All business in the remained pipe with the changed ciliary or vibrating epithelium.



I understand, what is it two different questions, but it would not be desirable to get or start new top.

And it or he also does not need to be got or started. Once again I repeat speech does not go about EKO.



Today the interesting situation with my right ovary was found out. During a laparoscopy the right ovary, as well as the right pipe, has not been found at all, and also anomaly of a structure of a uterus (odnorogost) is confirmed. Considering or examining;surveying the med.dokumenty their structure or frame and the sizes, with corresponding or meeting US-pictures has come across results of US of the inspection, the year spent a floor back in which BOTH are described mine an ovary.

So to that now to believe? Who from doctors could be mistaken? Whether how now to learn or find out esl from me the second ovary?



Situation very curious. The laparoscopy is certainly more authentic, but the ovary has so specific ehostrukturu what to accept on US for an ovary something another very difficultly. It is possible to assume, that the ovary is, but he has been covered by a layer of a peritoneum and laparoskopist it or him simply could not see, though, certainly, it is improbable.

It is possible to repeat precisely once again US. This information is necessary to you.

[Slepuha]

Dear Litta!

It seems to me, you all over again need to understand with conformity of data of a laparoscopy and US. And whenever possible, unequivocally. For this purpose you need to consult with the attending physician and to pass or take place additional inspection.

Excision of a pipe does not mean an adnexectomy, i.e. the ovary remains on a place.

Certainly, it is necessary to aspire to conservation of an organ. But it is necessary to remember, that after operation functionality of a pipe is broken or disturbed and there is on 100 %. The risk of complications - occurrence of a repeated extrauterine pregnancy or salpingocuesis essentially raises or increases. The conclusion - a situation remains at the discretion of the doctor and if there is an opportunity also the patient.

[Litta]

It, really, is improbable as before operation asked the doctor to examine closely or attentively appendages from the right party or side.

[Litta]

Business in that, dear Olga what to specify results of a laparoscopy it is not obviously possible (for this purpose to me will have again to lay down on an operating table). Before operation the doctor was preduprezhdyon about possible or probable absence of appendages from the right party or side and, accordingly, I have asked a situation to clear. I hope, that during operation there for all have carefully looked. The conclusion one - from the right party or side is not present appendages and there was never, a uterus odnorogaja.

, certainly, I shall make US again, but on arms or hand I have pictures of TWO ovaries, which absolutely different in the sizes and the form.

[boris]

Uv. Michael Vladimirovich!







So emotional statement of the positions is connected, naturally, not with the attitude or relation to you personally, and with the attitude or relation to a discussed problem. Probably I also have got excited, therefore I apologize.







Naturally, not being engaged in operative surgery I at all do not plan to discuss with you advantage of those or other methods reconstructive surgeons at various clinical situations. Except for that my plans do not include also discussion of various methods of discontinuing of ectopic pregnancy.



And here prospects of genesial health, expediency of carrying out of this or that method of treatment of STERILITY or BARRENNESS (including surgical) - this subject is rather interesting to me.



Nevertheless, I was not too lazy and have seriously enough studied the available information, concerning or touching reconstructive surgery of uterine pipes, surgical tactics at ectopic pregnancy, variants of post-operational treatment, etc.







So.







De mortius aut bene aut nihil. (About dead or it is good, or anything)





I have found not less than hundreds researches since 1990 devoted not only operative tactics but reconstructive surgery of uterine pipes as a whole. At their studying me all time did not leave or abandon sensation, that I go on the big international cemetery where here and there are audible zazdravnye speeches about suddenly left in the world other great surgeons. (the Majority of clauses or articles memoirs of authors with the description of their victories) very or very much remind.



Well and if it is serious, overwhelming number of jobs on operative tactics and reconstructive surgery not randomizirovany, practically all (probably everything, at least I could not find out others) have descriptive character and if spend the analysis as a rule retrospective.



I fine understand what to execute serious research (with the verified design) it is appreciable expenses not only mental, but also material. However at the analysis of retrospective researches that subjectivity by virtue of which them dokazatelnost seriously suffers is guessed.



Nevertheless in survey materials in different sources there is digit 60 of %, as offensive or approach of pregnancy after carrying out of reconstructive operations on uterine pipes more often.



Fertility after ectopic pregnancy and indications of ART J Gynecol Obstet Biol Reprod (Paris.) 2003 Nov; 32 (7 Suppl):S83-92. Bouyer J, Fernandez H, Coste J, Pouly JL, Job-Spira N.



There is no simple answer to the problem of fertility after one ectopic pregnancy. Results reported in the literature have been satisfactory with rate of subsequent pregnancy about 60 % and the risk of new ectopic pregnancy (EP) around 28 %. We have deliberately excluded studies before 1990 except when the methodology was particularly good or the treatment particularly interesting. Strict and exhaustive criteria were lacking in most of these studies due to widely varying aims, the prospective or retrospective nature of the data, the number of patients included, and varying therapeutic decision-making schemes. Many patients were lost to and no mention is given concerning the proportion of patients who desired a subsequent pregnancy. Infertility factors were not considered in most cases. We were looking for fertility results according to treatment used. Among the 50 studies we retained, pregnancy rates after ectopic pregnancy were satisfactory whatever treatment was used, with laparoscopy being the gold standard. Medical treatment was at least as effective as surgical treatment. Associated infertility factors appeared to be the most important for fertility outcome. It is unfortunate that so few study have analyzed outcome in these patients without considering risks factors of EP, infertility factors and the proportion of women who attempted to conceive again.







It is a lot of it or a little? I Think, that it is a lot of, .



If to consider or examine;survey that fact, that almost third from them (28 %)-are repeated ectopic pregnancy.







Frequency of ectopic pregnancy at carrying out of procedure of an extracorporal fertilization on the order below also does not exceed 4 %.







BMC Pregnancy Childbirth. 2003 Nov 7; 3(1) :7. Milki AA, Jun SH.Ectopic pregnancy rates with day 3 versus day 5 embryo transfer: a retrospective analysis.

BACKGROUND: Blastocyst transfer may theoretically decrease the incidence of ectopic pregnancy following IVF-ET in view of the decreased uterine contractility reported on day 5. The purpose of our study is to specifically compare the tubal pregnancy rates between day 3 and day 5 transfers. METHODS: A retrospective analysis of all clinical pregnancies conceived in our IVF program since 1998 was performed. The ectopic pregnancy rates were compared for day 3 and day 5 transfers. RESULTS: There were 623 clinical pregnancies resulting from day 3 transfers of which 22 were ectopic (3.5 %). In day 5 transfers, there were 13 ectopic pregnancies out of 333 clinical pregnancies (3.9 %). The difference between these rates is not statistically significant (P = 0.8).







The majority of jobs executed in 90th years really unequivocally consider or examine;survey a problem of tactics of treatment at -peritoneal sterility or barrenness in favour of reconstructive surgery. However it is necessary to remember, that at this time (the beginning 90) efficiency of application of methods of an auxiliary reproduction did not exceed 10-15 %, and till 1978 (year of a birth of Louise Brown, the first the child from a test tube ) no alternative methods of treatment of tubal sterility or barrenness were considered or examined;surveyed at all.



Not subtly, that the majority of jobs of this time is investigated or researched with various variants of improvement of an operative measure.



However already in the middle 90 there are researches which consider or examine;survey and compare efficiency of alternative methods of treatment.



See further

[boris]

Fertil Steril. 1995 Dec; 64 (6):1051-61. In vitro fertilization versus tubal surgery: is pelvic reconstructive surgery obsolete? Benadiva CA, Kligman I, Davis O, Rosenwaks Z.

Department of Obstetrics and Gynecology, New York Hospital-Cornell Medical

Center, New York 10021, USA.

OBJECTIVE: To compare the results of pelvic reconstructive surgery withcumulative success rates of IVF for couples with tubal factor infertility.



DATARESOURCES: Outcomes of pelvic surgery were obtained from a review of articlesfrom the literature identified by directed Medline searches. Cumulativepregnancy rates of 771 couples with tubal factor infertility treated at theCornell IVF program between December 1989 and December 1992 were calculated bylife-table analysis.



RESULTS: Overall delivery rate per transfer for patientswith tubal factor was 28.9 % (303 deliveries per 1,048 transfers) and did notappear to be affected significantly by the presence of a secondary diagnosis. Asignificant decline in pregnancy rates was observed with advancing age: age *lt; 30years, 48.4 %; 30 to 34 years, 44 %; 35 to 38 years, 28 %; 39 to 40 years, 20 %; 41to 42 years, 9 %; and *gt; 42 years, 4.3 %. Cumulative pregnancy rates for cycles 1to 4 were 32 %, 59 %, 70 %, and 77 %, respectively, in patients with only tubalfactor, and 28 %, 55 %, 62 %, and 75 % in patients with tubal combined with otherassociated infertility factors.



CONCLUSIONS: Our experience suggest that *gt; 70%of women with tubal factor infertility will have a live birth within four cyclesof treatment with IVF. These results compare favorably with the best outcomesafter tubal reconstructive surgery. In older women, because of the rapid declineof fertility potential with advancing age, efforts should be directed toward thetreatment method that provides the highest likelihood of success within theshortest time interval.







I.e. at the most optimistical results of reconstructive surgery turn out sravnimye results (and it in 1995 when the age of application of agonists in programs VRT only began, that in a consequence has seriously changed efficiency of application of these methods), but we do not forget about complications, and first of all about repeated ectopic beremennostjah. Except for that additional factors, such as age and time of achievement desirable result (pregnancy are considered or examined;surveyed also.)



Int J Fertil Menopausal Stud. 1995 Nov-Dec; 40 (6):297-302. Primary therapy for tubal disease: surgery versus IVF. Gocial B.



Philadelphia Fertility Institute, PA 19107, USA.



Infertility involves fallopian tube occlusion or other malfunction in over 25 % of cases. Reconstructive surgery offers the possibility of natural conception, but the success rate overall is less than 30 % and if the hydrosalpinx is severe or other factors are involved, much lower than that. IVF-ET currently offers a much higher success rate. Although the cost of IVF per cycle is over three-fourths the total cost of tubal surgery, the eventual success rate of IVF is so much better than that of surgery that the costs per baby delivered are some 10 % lower. In addition, more infertile couples are rewarded in their quest to have a child.



T.e already in the middle 90 the expediency of application of alternative methods is compared.







In the practice I daily collide or face with patients which spent numerous reconstructive interventions on uterine pipes. Always amazes nothing explainable persistence (I do not consider or examine;survey a material interest, it would be desirable to think that this factor does not render influence on decision-making) surgeons, which with a difference in a year carry out one behind another interventions and if to gather all reports (and I had to see up to 5 consecutive operations in the anamnesis), the first, that is evident is almost identical description of a status of internal organs of the beginning for a moment of operation and standard operative actions. However later year after carrying out of an intervention, that adherent or adhesive process (and after an intervention under the previous report it or him already is not present), an impassable uterine pipe (become passed or taken place;permeable after an intervention) at a repeated intervention are described as on a gauge of year prescription and . The similar intervention is spent. I had to see FIVE reports at ONE woman.



Unfortunately to find any serious publications, concerning expediency of carrying out of repeated interventions at trubno peritoneal sterility or barrenness it was not possible to me (basically the description of clinical cases.).



Bewilderment is caused with tactics of reconstructive surgery in women with the expressed adherent or adhesive process in a small basin. Repeatedly met patients approximately with such data:

Peritonitis. Adherent or adhesive process 3-4 items dvust. A sactosalpinx = *gt; Laparoskopija/a laparotomy, Heroic efforts surgeon on remission of uterine pipes, oporozhneniju sactosalpinxes and to excising or coretraction of solderings = and gt; the Woman waits year, and even two, waits for offensive or approach of pregnancy (since she piously believes, that all solderings are removed, and pipes became freely passed or became taken freely place;became freely passable) At this time for fastening results of an intervention accepts BADy, goes on gynecologic massage ( improving blood supply of a uterus both uterine pipes and dividing or sharing;parting again formed solderings ), takes basal temperature (such impression that this habit is passed with milk of mother) = *gt; the Repeated operative measure = and gt; Adherent or Adhesive process 3-4 items dvust. A sactosalpinx = *gt; references about year expectation. Massage = *gt;



Then the patient comes to us and, that we recommend excision of sactosalpinxes before planned procedure eko the first to her are since their presence almost twice reduces probability of offensive or approach of pregnancy in programs VRT (auxiliary genesial technologies)







See further

[boris]

ReprodBiomedOnline. 2002; 4 Suppl 3:37-9. How to treat hydrosalpinges: IVF as the treatment of choice. StrandellA.



Twotreatment options are available for patients suffering from tubalinfertility due to hydrosalpinges. Surgical distal tubal repair is appropriateonly for patients with preserved tubal mucosa, otherwise the subsequentintrauterine pregnancy rate is unacceptably low and the ectopic pregnancy ratetoo high. The alternative treatment, IVF, has also demonstrated low success ratein patients with untreated hydrosalpinges, possibly due to leakage of fluid intothe uterus. Salpingectomy has been suggested as a method to overcome thenegative influence of the hydrosalpingeal fluid on implantation and embryodevelopment. A randomized controlled trial in Scandinavia has demonstrated abenefit of salpingectomy in patients with hydrosalpinges that were large enoughto be visible on ultrasound. If only the first cycle was considered, patientshaving undergone salpingectomy expressed significantly higher clinical pregnancy (46 % versus 22 %) and birth (40 % versus 17 %) rates. It is concluded that patientswith large hydrosalpinges and without prospect of spontaneous conception shouldbe recommended salpingectomy, which truly increases their chances of asuccessful IVF treatment.



By the way more radical tactics of surgical treatment is considered or examined;surveyed and without sactosalpinxes but provided that the surgeon assumes, that there are also others (except for surgical) methods of TREATMENT of STERILITY or BARRENNESS:

Ceska Gynekol. 2001 Jul; 66 (4):259-64. Effect of salpingectomy on the results of IVF in women with tubalsterility-prospective study. Mardesic T, Muller P, Huttelova R, Zvarova J, Hulvert J, Voboril J, Becvarova V, Mikova M, Landova K, Jirkovsky M.

OBJECTIVE: To compare the IVF results after salpingectomy of hydrosalpinges



visible on ultrasound with IVF results in women with tubal infertility but without hydrosalpinx. DESIGN: Prospective study. SETTING: Sanatorium Pronatal, Na Dlouhe mezi 4/12, 147 00, Praha 4. METHODS: 101 women with tubal factor infertility were evaluated. In a prospective study we compared the results of first IVF cycle after salpingectomy of hydrosalpinges visible on ultrasound performed in 51 women (study group) with IVF results of 50 women with tubal infertility (confirmed by HSG and laparoscopy) but without hydrosalpinges and without salpingectomy. RESULTS: The maternal age in both groups (32.4 +/-3.9 in salpingectomy group and 33.0 +/-4.1 in control group), maximum estradiol levels (1392.6 +/-675.8 pg/ml in salpingectomy group vers. 1624.7 +/-909.7 pg/ml in control group), number of oocytes (11.3 +/-5.8 after salpingectomy vers. 11.0 +/-6.1 in controls), number of embryos generated (7.1 +/-4.6 vers. 7.9 +/-4.7) and number of embryos transferred were not statistically different. In their first IVF cycle after salpingectomy has been performed 30 women out of 51 became clinically pregnant (58.8 %), while in control group a clinical pregnancy could be verified in 16 women (32.0 %). Implantation rate in women aftersalpingectomy was 28.2 % vers. 12.3 % in control group. Both implantation rate and pregnancy rate were statistically different at 5 % level of significance.

CONCLUSION: After salpingectomy of hydrosalpinges visible on ultrasound theimplantation rate and clinical pregnancy rate are significantly better whencompared to IVF patients with tubal infertility without the presence ofhydrosalpinges and without salpingectomy. Salpingectomy should be offered to allpatients with hydrosalpinges visible on ultrasound. Moreover, this radicalapproach should be considered even in women with highly damaged tubes butwithout the presence of hydrosalpinges.



The greatest bewilderment causes performance organsohranjajushchih operations on uterine pipes at tubal pregnancy (usually at break of a pipe) with conservation of a stump of a pipe. Not clearly, than the surgeon is guided. It is twice insulting, when after performance of an extracorporal fertilization pregnancy comes in the left stump of a uterine pipe. Before beginning treatment by a method eko I inform the patient on efficiency of treatment, the possible or probable complications, alternative variants of treatment (including naturally reconstructive surgery).



And so efficiency of such treatment can reach or achieve 40-50 % on procedure, and kummuljativnaja frequency (Feichtinger W. 1994)









1 attempt EKO - 20-30 % of success

3 attempts EKO - 70-80 % of success

6 attempts EKO - 90-95 % of success



Risk of an extrauterine pregnancy or a salpingocuesis no more than 4 %. I pay your attention, what is it data of 1994 more years.





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[boris]

Having communicated to the surgeon, here I wish to emphasize (with the surgeon) since the surgeon does not consider or examine;survey alternative methods of TREATMENT of STERILITY or BARRENNESS, and is guided uzkonapravlennymi by references of modern grants or manuals on SURGERY (I wish to emphasize not on TREATMENT of STERILITY or BARRENNESS where various variants of treatment (and surgical are considered or examined;surveyed including) but only variants of surgical treatment) informs the patient on efficiency of the given kind of treatment.

In the resulted or brought arguments in favour of reconstructive surgery



Probability to become pregnant with the saved pipe more than 80 %, and without a pipe - 0 %. You do not see here a share of slyness?

Uninitiated it is complex or difficult enough to person to understand since digits really impress, however:









The opportunity of application of alternative methods of treatment (and then it probably not 0 %) is not considered or examined;surveyed in general

Application of methods of an auxiliary reproduction where total or cooperative efficiency can reach or achieve 90 % is not considered or examined;surveyed.

The resulted or brought 80 % at organosohranjajushchej operations is at all probability to receive pregnancy.

Anamnestic data (I do not think, that at repeated reconstructive interventions results are so optimistical) are not considered

The age of the patient is not considered or examined;surveyed

The opportunity of repetition of ectopic pregnancy is not considered or examined;surveyed

Total or Cooperative cost of reception of desirable result is not considered or examined;surveyed (and at repetition of ectopic pregnancy (and 28 % are sufficient serious probability) and excision of a pipe the patient will pay already for TWO surgical interventions and plus charges on application of methods of an auxiliary reproduction.

By the way about complications:



PolMerkuriuszLek. 2005 Jan; 18 (103):74-7. Analysis of risk factors for ectopic pregnancy in own material in the years1993-2002 Brodowska A, Szydlowska I, Starczewski A, Strojny K, Puchalski A, Mieczkowska E, Wozniak W.

Klinika Rozrodczosci i Ginekologii Pomorskiej Akademii Medycznej w Szczecinie.,



The ectopic pregnancy is still a life-threatening condition. The risk factors for ectopic pregnancy are divided into four groups: 1) mechanic factors, 2) tubal dysfunction, 3) assisted reproductive techniques (ART) and 4) hormonal factors. MATERIAL AND METHODS: On basis of the analysis of medical documentation we determined the risk factors for ectopic pregnancy in 214 patients (aged 18-44, mean 32 +/-9 years) hospitalized in Department of Reproductive Medicine and Gynecology of Pomeranian Medical University between 1993 and 2002. The control group composed 215 patients admitted to the hospital outpatient clinic in the years 1993-2002. RESULTS: The risk factors for ectopic pregnancyevaluated in each group of patients were: history of adnexitis, surgicalprocedures (appendectomy, tubal microsurgery, ovarian cystectomy, adnexectomy, myomectomy, cesarean section, previous conservative surgical treatment ofectopic pregnancy, salpingectomy), appendicitis complicated by peritonitis, endometriosis, conservative treatment of ectopic pregnancy, insertion of IUD, ovarian induction or IVF procedure, uterine defects and smoking. In the examinedgroup 104 patients had a history of surgery (48.5 %) compare to 40 patients inthe control group (18.6 %). Difference between groups issignificant p = 0,034. In 40 cases out of 104 (18.6 %) surgical operations were done two and more times. Statistics proves that surgical procedures in the past occurred significantlymore frequently in the studied than in control group. The most frequentoperations were: conservative surgical treatment of ectopic pregnancy (p =0.000), tubal microsurgery (p = 0.0016), ovarian cystectomy (p = 0.013) andsalpingectomy (p = 0.047). Appendectomies or myomectomies in the past did notincrease the risk of ectopic pregnancy. Additionally, in the examined groupthere were more cases of MTX (Methotrexate) therapy applied in the past becauseof ectopic pregnancy (p = 0.000), more smoking (p = 0.0001) and more adnexitisin the past (p = 0.013). Treated endometriosis in the past, artificialreproductive techniques (ART), peritonitis, IUD application and uterine defectswere no important risk factors for ectopic pregnancy.



CONCLUSIONS: The main riskfactors for ectopic pregnancy are: history of surgical procedures, especiallyconservative surgical treatment of ectopic pregnancy and tubal microsurgery.



Appendectomy or myomectomy do not increase this risk. The other important riskfactors for ectopic pregnancy are: conservative treatment of ectopic pregnancyin the past and smoking. Adnexitis is another risk factor for ectopic pregnancy.



Similar narrowness of views, unwillingness (and can nehotenie) to estimate or appreciate realities of today are rather characteristic for the surgeons-gynecologists who were not deal with specially PROBLEMS of STERILITY or BARRENNESS.





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[boris]

The similar approach as it seems to me, is historically developed (when did not exist methods of an auxiliary reproduction) and conservation of the remained pipe was considered or examined;surveyed from positions let mythical, but chance of offensive or approach of pregnancy. Occurrence of a similar opportunity has not changed the developed stereotypes. Besides the introduction into an age of paid medicine has brought series of factors on which earlier the doctor simply did not reflect.



Let's not dissemble, but the decision to leave a unique uterine pipe frequently is based not on hope about its or her potential opportunity to lead to desirable pregnancy, and on pavor about the possible or probable responsibility (earlier LKK, and today even more often) and impossibility the decision is given reason to prove courts. More often at voniknovenii a similar situation the operating surgeon during an operative measure tries to secure with the sanction manager. Units. Whether not so?



Really to leave "any" uterine pipe much easier, than later to try to prove, that it or her ostavlenie only increased or enlarged risks of complications.



I think, that if the patient has been informed, that frequency repeated ectopic beremennostej to be within the limits of 30 % after one, and two operations so precisely he would not give the consent to carrying out of a similar intervention.



The surgeon usually sounds only the first digit about an opportunity of offensive or approach of pregnancy.



Whether slyness it???



Similar uzkonapravlennye views are widespread enough. In fact there are also andrologies which years raise or increase parameters spermogrammy at the man, not asked by a question on that that at spouses, shall admit or allow, there are no uterine pipes, and colleagues gynecologists in a similar situation forcing the woman to take basal temperature and so forth pr. pr. By the way the most favourite diagnosis of gynecologists-endocrinologists is giperprolaktinemija without dependence from a level of Prolactinum and according to its or her treatment without dependence from soputsvujushchih diagnoses.





I not casually considered or examined;surveyed a question of TREATMENT of STERILITY or BARRENNESS (not tactics of the surgeon at presence of one uterine pipe and ectopic pregnancy) and from positions cost-efficiency *quot;.



Prim. Care Update Ob Gyns. 1998 Jul 1; 5(4) :168. Tubal surgery vs in vitro fertilization for the treatment of infertility due todistal tubal occlusion. Nichols KP, Steinkampf MP.

The University of Alabama at Birmingham, USA

Background: The optimal treatment of infertility due to tubal occlusion has notbeen established. Many practitioners feel that the success of tubal repairexceeds that of in vitro fertilization (IVF); however, previous studies ofpregnancy after tubal surgery have been limited by bias in patient selection, follow-up, or surgical expertise. The purpose of the present study was todetermine the outcome after repair of distal tubal occlusion performed byexperienced surgeons in an unselected patient population with consistentfollow-up.

Design: Chart review with telephone contact of patients lost tofollow-up.

Methods: The records of all tubal surgery performed between 1989 and1996 at the University of Alabama Hospital and The Kirklin Clinic outpatientsurgery facility were reviewed. All women with infertility due to distal tubalocclusion, with or without pelvic adhesions, who had no other significantinfertility factors were included for study. Details of the infertility history, operative procedure, and postoperative course were recorded. Patients lost tofollow-up within 1 year after surgery were contacted by telephone forinformation regarding subsequent testing and treatment and pregnancyoutcome. Results: Eighty-three women aged 19-39 years met the entry criteria forthis study. Follow-up of at least 1 year was obtained in all but 11 patients. Tubal surgery was accomplished by laparotomy in 19 women; 64 women underwenttubal repair by laparoscopy. Within 1 year of surgery, 9 hysterosalpingograms, 51 clomiphene cycles, and 20 gonadotropin cycles wereperformed on the studygroup. Pregnancy was achieved within 1 year in 13 women; of these, there were 6live births (9.6 % birth rate per surgery), 2 spontaneous abortions, and 3ectopic pregnancies. There were no live births among women who underwent tubalrepair by laparotomy. None of the postoperative gonadotropin cycles resulted inpregnancy. Seven women underwent IVF within 1 year after surgery because ofextensive tubal damage noted at surgery. Based on current charges for theinfertility treatments performed, the cost of a live birth with tubal surgeryexceeded $120,000, versus less than $50,000 per live birth with IVF usingresults obtained nationally or at UAB.

Conclusions: The cost-effectiveness ofreconstructive surgery in unselected patients with distal tubal occlusion isless than that of IVF. Empiric use of gonadotropins for ovarian stimulation doesnot improve pregnancy rates after tubal surgery. In our series, laparoscopictubal repair seemed to give results superior to that of laparotomy.



The similar information will force to think of a choice of a method of treatment.



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[boris]

By the way and in the report of the patient it is spoken about the reference of application of methods VRT.



Pipe have saved (she at me unique), but to become pregnant in the natural way did not recommend. How you believe, from what it is the surgeon spent an intervention, does not recommend the woman to try to become pregnant natural by????



Apparently, he also is afraid of offensive or approach of the subsequent ectopic pregnancy in the changed and operated uterine pipe, though does not assume (as follows from the report), that



Carrying out eko at the saved uterine pipes does not exclude offensive or approach of ectopic pregnancy.



Why he leaves it or her??



Only therefore, that in case of occurrence of claims to not be engaged in explanations about expediency of the similar decision. I.e. over it or him (and not only this separately taken surgeon) in the given situation the clinical thinking supervises not, and existing stereotypes and phobia of a potential opportunity to give the given reason explanations of the decision.



Naturally from two decisions he accepts most idle time.



Not a secret, as today at presence of much more objective methods of inspection (hormonal research, ultrasonic research) are used archaic methods (measurement of basal temperature). In overwhelming majority the similar approach is connected not with absence of a material resources, and with the developed stereotypes.







In the conclusion I can tell or say only, that









It is impossible to consider or examine;survey TREATMENT of STERILITY or BARRENNESS from positions uzkoprofessionalnyh

The patient at planning treatment HAS the right And SHOULD receive the FULL information concerning prospects of treatment and possible or probable complications.

C uv. A moderator of a forum

B.Kamenetsky



PS: By the way not harmfully to esteem Beloborodova S.M.'s review about physiology of uterine pipes which lays here: http: // forums./showthread.php? t=1274*amp; highlight = % E1%E5%EB%EE%E1%EE%F0%EE%E4%EE%E2

[dr_medvedev]

Dear Boris Aleksandrovich!

Thanks for detailed answers. The matter is that I completely with you agree:



1. Reconstructive surgery of pipes - history of medicine and, naturally, repeated operations in occasion of peritoneal sterility or barrenness can be treated as a medical mistake or error. I shall make a reservation, that there are cases of the mixed sterility or barrenness when along with solderings we have SPKJA and the cauterization of ovaries really is useful action.

2. I also stay in a shock from domination BADov and dreadful algorithms of treatment of sterility or barrenness which are applied by gynecologists (for -urologists I do not collide or face).

3. In treatment of sterility or barrenness as, however, and many other things diseases, are not present cleanly surgical or medicamental methods of treatment. There are the references based or founded;established on demonstrative researches which consider including *quot; cost-effectiveness*quot;. The Same concerns or touches methods of diagnostics.

4. *quot; the patient at planning treatment HAS the right And SHOULD receive the FULL information concerning prospects of treatment and possible or probable ????N??*quot; - your citation.



Why the doctor advises EKO and leaves thus a pipe? Here there is an obvious divergence. Was certainly inexpedient to leave a pipe, recommending EKO. But, with trudoj it is possible to try to do without the party or side if a pipe have left EKO (even any time) considering, that EKO in our countries will manage obviously more expensively expectant or waiting tactics (if she, certainly, will give result).



I think, that the reasons on which have left a pipe, you have noticed correctly.



And still will agree, what we yet did not manage to find researches, whether which would finish in a question it is necessary to save a unique pipe at the first extrauterine pregnancy or salpingocuesis and normal sorts or labors in the anamnesis or it or her it is necessary to clean or remove and direct at once the woman on EKO?



I still especially did not look the information in this occasion. Can be to me it will be possible to something to find.

[boris]

And still will agree, what we yet did not manage to find researches, whether which would finish in a question it is necessary to save a unique pipe at the first extrauterine pregnancy or salpingocuesis and normal sorts or labors in the anamnesis or it or her it is necessary to clean or remove and direct at once the woman on EKO? Naturally is not present.

If operation scheduled, ectopic pregnancy the first, there are no previous surgical interventions, age of the patient no more than 35 plus a real estimation of a status of a uterine pipe, I would recommend a pipe to save.



With uv. B.Kamenetsky