During this webinar session, Dr Elias Tsakos, FRCOG, Medical Director at Embryoclinic – Assisted Reproduction Clinic in Thessaloniki, Greece, has explained robotic surgery methods, their indications, and outcomes.
The fact is that commercial drive has favoured IVF over the last 30 years or so, and there’s a medical drive that has made fertility surgery a little obsolete in the last couple of decades. Most patients prefer to have IVF as opposed to having surgery, and this is a bit of an issue because it doesn’t allow us to make a complete and valid diagnosis. It’s quick to diagnose unexplained infertility without performing a laparoscopy or hysteroscopy, and just based on history and sometimes just an HSG without a hysteroscopy and all that.
According to Dr Tsakos, there are a lot of reasons why fertility surgery has lost its place in infertility care, especially for younger female patients, this is not entirely beneficial. Another reason is the fact that in the 90s, the doctors were trained simultaneously in fertility medicine and fertility surgery, while the younger generation of fertility specialists are solely trained in fertility medicine or generally in IUIs, IVF, and endocrinology, and all that and fertility surgery has lost its niche. This is moved outside the scope of a fertility specialist. It is moved on to a minimally invasive surgeon speciality, which is all okay, except for the fact that sometimes the point of view of the minimally invasive surgeon or the oncology surgeon is not the same as that of the fertility specialist. There are a lot of reasons why fertility surgery has gone out of vogue, and there should be a balance based on evidence and the best interests of the patients. At the end of the day, a fertility clinic should be able to offer the expertise of both medicine and surgery in fertility care.
What are the indications of fertility surgery? In general, most fertility diagnoses could be managed by surgery, at least partly. We cannot diagnose unexplained infertility unless a very careful laparoscopy hysteroscopy is performed, which is often missed or not performed. When there is a mild male factor, we need to ensure that the diagnostic laparoscopy has been performed and that we have excluded a mild, surgically potentially correctable female factor. If we want to explore further the tubal factors, we need to do a laparoscopy. Endometriosis is suspected or obvious, and there’s a high percentage of possible endometriosis infertile patients, and more often than not, we don’t make the diagnosis until quite a few years down the line.
When it comes to fibroids, nowadays, we mostly rely on the ultrasound scan to diagnose fibroids sometimes, the diagnosis can be a bit in the grey zone, so there may be a fibroid of 2 to 3 centimetres intramural, which doesn’t distort the cavity and we may judge that this is fine and we may be missing another fibroid that may be hiding behind this, that may be affecting the uterine cavity. Also, sometimes it’s virtually impossible with the 2D scan, which is the majority of the scanning technology that is used in the IVF clinics, very few clinics use a high-resolution 3D vaginal scanning to diagnose correctly and accurately fibroids, polyps, uterine malformations and so forth.
Conventional laparoscopy is done with a scope down the abdomen using the conventional technology, it is a minimally invasive procedure. There has been an evolution over the last 30 years or so and we now have better optics, technology, instruments, monitors, lights, and energy, which we use, and it can be an outpatient procedure. It is associated with a very quick and short recovery, however, it does have limitations. The majority of fertility surgery can be performed by standard conventional laparoscopy, although it has limitations, which include the 2D image, we don’t have a sense of depth, this could be bypassed with the 3D laparoscopy. There is a limited range of motions because we’re using straight stick instruments. Even if it’s performed by a very experienced laparoscopist, whose done thousands of procedures, the accuracy is not of robotic surgery, and it is assistant dependent, especially for lengthy operations with lots of adhesions, big fibroids, big complex endometriosis cases. There is the element of fatigue for both the surgeon and the assistant, which can be challenging for that surgery, and the ergonomics of the surgeon.
The history of robotics started in 1998, which was called ZEUS, it has evolved with the latest Da Vinci system, which has been used in the last 5 years or so, this is the newest Da Vinci system, which consists of the surgeon’s console, so the surgeon operates the masters by sitting in this console and also using the foot pedals and looking down a 3D magnified set of lenses, there is a patient car, there are the robotic arms which are operating under the direction of the surgeon within the body with very high accuracy. There is also a control system with all the software, energy supplies and high definition monitor.
What are the advantages of the latest robotic technology, Da Vinci? We work with up to 10-fold magnification, we use 3D imaging, we have high definition, and we have a stable camera, which is controlled by the surgeon. There is the ability to use 4 limbs, it’s possible to use both feet and hands, and it’s possible to control the camera and the assistant port at the same time, therefore, there is no need for a very experienced assistant as we can move the 4 robotic arms. One of the biggest advantages is the 7-degree movement and the dexterity that is much better than the human hand because the degree of freedom of the wristed instruments is much better than the human hand. We also don’t need an experienced assistant surgeon, which means that we spare one person for the rest of the team to look into the patients from a different perspective, and it is suitable for operating deep into the pelvis or in restricted areas. Last but not least, ergonomics ensure that we can do difficult, long operations without the strain on the doctors.
One of the disadvantages is the costs, there’s a debate about this because it depends on how we factor all those costs, there’s a bigger upfront cost compared to laparotomy or conventional laparoscopy. We’re waiting for the evidence to come out that this can be counterbalanced by the benefits of fewer complications and less chance of conversion into laparotomy. Especially for challenging complex cases, obese patients, patients with multiple surgeries in the past, complex pathology, severe endometriosis, big fibroids, etc.
If we compare that to IVF and if we managed to achieve spontaneous conception through surgery, then that cost would be balanced by avoiding IVF and drugs or the complications of IVF, and so forth. One other main disadvantage is that there’s limited availability, at the moment, in terms of hospitals offering this service, systems in various hospitals and trained surgeons.
In summary, we’re talking about advanced technology, multi-arm system and precise surgery. What are the indications? Its tubal reanastomosis, IVF, was partly discovered because of our inability to restore the tubes, especially after tubal ligation, which has been a method and is still a fairly recognized method of family planning. If somebody changes their mind and a good proportion of females change their mind etc., and so tubal reanastomosis with the Da Vinci system could be a viable option.
Robotic myomectomy, when there are challenging big fibroids, or multiple fibroids. It can also be indicated for patients with morbid obesity, perhaps or with previous multiple surgeries, endometriosis, especially severe complex endometriosis, which can be better managed by robotic surgery. In ovarian cysts, big ovarian cysts where it is important to ensure not only that we remove the ovarian cyst effectively, but that we also preserve the ovarian reserve. Pelvic adhesions can be challenging sometimes, we don’t have access to the ovaries for IVF, and therefore we need to do adhesiolysis to move an ovary into an area that would be accessible with the vaginal scanning to do the egg collection. Cervical cerclage, abdominal cervical cerclage, in case of cervical insufficiency. Finally, fertility preservation and ovarian transplantation could be indications for robotic surgery.
This is a very challenging new area, perhaps a niche area for the application of the robotic system since 25 to 35%, possibly 1/3 of the patients have tubal factor infertility, although not all tubal factor infertility can be surgically corrected. Another figure is that 20-30% of the patients regret having a tubal ligation, and those patients should be consulted and offered the option of robotic reanastomosis, that decision would be made based on various factors.
The first robotic tubal reanastomosis was performed in 1999, and in 2000, that was also performed, and in 2013, there was a paper on human reproduction showing that it is safe and effective. There is another publication in 2014 showing that just with 1 Da Vinci stitch technique, we could achieve a roughly 6% pregnancy rate, which is quite high.
One more publication from 2017 involving more than 10 000 women showed that in sterilized women, surgical anastomosis is an effective treatment, and with robotic surgery, a new era is rising.
Fibroids are very common, usually benign tumours, although a tiny proportion could be malignant, so be aware. They could grow on the surface of the uterus, they could grow deep inside the muscular layer, they could grow in the cavity, and their importance depends on their position and also on the size.
Myomectomy is widely performed in fertility care for various reasons if there are symptomatic fibroids or fibroids impinging the cavity or growing fibroids or multiple fibroids or big fibroids, and so forth, and laparoscopy has been proven to be superior to laparotomy overall, and that has been established.
Regarding robotic myomectomy, there has been evidence, and there are a lot of studies proving that there’s less blood loss and shorter hospital state versus laparoscopy, although a good proportion is still performed by laparotomy.
Laparoscopy is perhaps the gold standard at the moment, and if laparoscopy is not possible because of various complexities, then robotics should be another viable option. We wouldn’t do a robotic myomectomy for a 4-centimetre fibroid that’s touching a bit of cavity perhaps, but if we have multiple 4 sentimental fibroids or larger fibroids or complex patients with a medical history of obesity, previous surgery, in my opinion, robotic myomectomy is superior as it is to laparoscopy as it is associated with less blood loss and shorter hospital stay.
Endometriosis is very common, it affects up to 50% of infertile women. Practice Committees state that it’s a chronic disease, and requires lifelong management. Overall it affects 1 in 10 women, and some are undiagnosed.
Fertility sparing surgery are still rare cases, we’re talking about the cancer patients and patients who are aiming to preserve their fertility. Robotic surgery has a very valid place, at the moment, we get similar results, although the trend is towards robotics as it has been in urology, for example. Da Vinci is efficient during oncology surgery, and there are some rare cases of ovarian transplantation and its outcome, it’s still an experimental method, but the trend is positive. In 2016, there was a very important publication on the first live birth after ovarian transplantation, and uterine transplantation will become more and more common in the next decade or so. Robotics may play an important part in either returning the specimen or in transplanting the specimen or both. Single Port Robotics is becoming more and more popular for various reasons. We are also waiting for the next generation of robotic platforms with the use of haptic feedback, 3D vision and artificial intelligence assistance.
Overall 10 million robotic procedures have been performed globally at the moment, not just in gynaecology, but overall, so robotics is here to stay. That’s another challenge for fertility specialists and also for minimally invasive gynaecological surgeons.
My general advice is that if you trust your doctor, just go on with his advice, if you don’t, find someone you trust. However, in general, if I were to give my general opinion in regard to breast cancer, at the moment, there’s enough evidence that IVF or a short course of HRT is not associated with increased breast cancer risk provided that you have been fully checked. I don’t put anyone on HRT unless I have a recent, within a maximum 1 year, a full assessment of their breasts, so mammography breast, ultrasound, and then do HRT or IVF if that’s the case, then there’s absolutely no risk in taking the HRT for a short period before IVF. The second comment is that if there is indeed a family breast cancer history that has to be thoroughly evaluated, the specific algorithms, which would tell us if you qualify for genetic screening or not. If your mother had breast cancer at the age of 60, probably you’re not at higher risk because of genetics, if your grandmother had breast cancer at the age of 50 or 70 probably, you don’t have any risk, however, if you have 1 or 2 members of your family, your immediate family with breast cancer, colonic cancer, ovarian cancer that has developed before 50, then you may be at high risk because of genetics.
Remember that only 5%, 1 in 20 breast cancers are genetically linked, and the other 95% are not associated with genetics. The bottom line is if you’re concerned about family history, have a proper assessment by a geneticist or by a breast specialist to identify if you are indeed at a higher risk, you may find that you’re not, but if you’re on the grey zone or if you’re at a higher risk for familial breast cancer due to the history then go on and have genetic screening with BRCA1 in the first instance.
The answer is easy, absolutely. Women have an amazing self-healing mechanism in place, and this is called the menstrual period, so 4 to 5 weeks is absolutely fine. If the polyp is too big, if there’s any concern on the hysteroscopy, if there’s any reason to worry about whether the healing is complete or not or if there’s any adhesion formation or if there’s a bit leftover of the polyp and so forth, then maybe an office diagnostic hysteroscopy may be a good idea before you proceed with first embryo transfer. However, in my opinion, that is an exception.
I would probably agree with your doctor 100%, to be honest, you’ve done the treatment, the EMMA test is highly accurate, and I’m sure you took the right antibiotics based on the profile of the results that would suffice plus an extra drug, those before the transfer would do the trick and you’ll get pregnant.
I can’t really answer this. Usually, we don’t expect this huge variation from 1 year to the other, however, there may be some factors that I’m not aware of, for example, some general health issues, some other associated factors, sometimes a COVID-19 infection or some sort of hidden endocrinology disease, maybe some hidden thyroid disease and all that, so I don’t think that I can answer this. I would look into the protocols that they have followed, in general, any clinic, in my opinion, looks into the previous stimulation and if we’re happy with the outcome of the stimulation compared to the profile of the patient, if the outcome was good, we typically don’t change it.
I would probably agree with your doctor. If this was once a day, I’m a little sceptical if this can be increased so highly. The standard dose is 2 to 3 times a day, but for a shorter time, so I would probably agree with your doctor. Although I have to confess that I invariably do not test for DHEA levels because it’s very difficult to interpret and associate this with any benefit or any alteration of the management, and also I invariably do not give DHEA for longer than maybe 6 or 8 weeks before stimulation, we have a lot to learn about DHEA, quite a few projects are going on at the moment, we’re hoping that in ESHRE meeting in July, we should be able to listen to some results about the optimum duration, dosage and the optimum type of androgen priming before stimulation whether it’s going to be DHEA or testosterone. I would probably agree with your doctor and just hang in there until we have some more evidence as to what is the best way to prime your ovaries before stimulation.
Probably yes is the answer, but again, to be honest, I’m a big fan of hysteroscopy. I think that hysteroscopy is not a big deal, we can do it without anaesthetic, we can do it with mild sedation, and I think that it should be part of a standard baseline fertility workup. Thirty years ago, laparoscopy and hysteroscopy put together used to be the norm, used to be the gold standard for the workup, now we don’t do that much diagnostic laparoscopy anymore. I think we’re losing a lot of endometriosis by not doing it. What is the effect on our success rate and our complications? I don’t know, but there may be a small component in miscarriages, so yes, if you had a failed transfer, I think it would be indicated to have a hysteroscopy and microbiome check-up.