Surgery, Assisted Reproductive Technology and Infertility PDF

Preface

Infertility evaluations and treatments have undergone remarkable and very positive evolutions over the past decade. Improvements have been made in virtually every way we diagnose and treat our patients. Innovations in imaging techniques and endoscopic procedures and markedly improved success rates with in vitro fertilization (IVF) have led to both subtle and dramatic improvements in care for our patients. Detailed information of structure and function of the reproductive tract has expanded what we do, and when we do it, to maximize the chances for pregnancy in an ever-expanding group of patients. Sensitive two- and three-dimensional ultrasound and magnetic resonance imaging techniques provide structural information. Microarray technology will refine our ability to evaluate function and genomic expression in an increasing number of settings. This technique is already providing insight into the pathophysiology of endometriosis and polycystic ovary syndrome.

Surgery, for so long the stand-alone treatment for infertility, has yielded in many circumstances to assisted reproductive technologies. The evolution of in vitro fertilization to a highly successful process has reduced the number of settings in which surgery is appropriate. Surgery has a continued, though redefined, role in infertility therapies. Though its role has been minimized in some settings, surgical intervention has expanded in two critical areas: in preparation for IVF in patients with factors possibly impacting outcomes negatively and as a conservative, organ-sparing procedure in patients for whom reproduction prior to ART was either not an option or a highly unsuccessful proposition at best. The challenge has been to match the most efficacious and cost-effective technique to that clinical setting where success is most likely. Careful patient selection is the order of the day.

The corollary to these improvements is the critical analysis of outcomes and better definition of populations most likely to benefit from these procedures. Success is improved not only by technical innovations but our ability to define who will and will not benefit. Decision trees guiding patient selection have evolved and matured. Our basis for making decisions has increasingly become data driven. Reliance on results of well-designed clinical trials has emerged as the contemporary paradigm of evidence-based medicine. The overall result of this reliance has been a remarkable improvement in clinical care, and improvements in the quality and cost-effectiveness of care.