The advent of endoscopy and improvement in technique and technology has had a great impact on the management of infertility. Laparoscopy has enabled a detailed and repeatable visualization of the pelvis. Addition of hysteroscopy to the endoscopic armamentarium allowed direct visualization of the endometrial cavity, tubal ostia and cervical canal. This has improved our ability to understand, diagnose and treat the various causes of infertility.
This chapter will focus on the efficacy and limitations of some of the important fertility promoting endoscopic procedures, restriction of space precludes detailing of technique.
Endoscopy can be used for both diagnosis and therapy.
As a diagnostic tool a combined laparoscopic and hysteroscopic examination is the gold standard for the evaluation of infertility. Direct visual examination is superior to hysterosalpingography1 justifying use of the more invasive procedure.
Laparoscopy allows an assessment of tubal patency and also identifies pelvic pathology while hysteroscopy diagnosis intracavitary lesions.
Development of smaller diameter endoscopies has further simplified the procedure. Microlaparoscopy and minihysteroscopy, performed under local anesthesia or mild sedation have a high degree of diagnostic acuracy despite a smaller visual field, and have been proposed as the first line diagnostic procedures.2
Salpingoscopy and falloposcopy allow evaluation of the tubal lumen. The former is a transfimbrial approach allowing visualization from the ampullary-isthmic junction to the fimbriae. The latter is a transcervical approach allowing assessment of the tubal lumen from the uterotubal ostium to the fimbria. Falloposcopy has the potential to become a standard investigation for infertility since tubes that look normal externally can have lesions of the endosalpinx.3 High cost of equipment has been a major deterrent. Transvaginal hydrolaparoscopy was introduced to assess the tubo-ovarian relationship. Since it can only view the Pouch of Douglas its use is limited.
The decreased morbidity and shortened hospital stay, an opportunity to diagnose and treat at the same time and a reduction in postoperative adhesion formation has led to the immense popularity of operative endoscopy.
Surgery’s performed include:
• Polycystic ovary
Ovarian drilling syndrome
• Ovarian cysts
• Distal tubal occlusion
• Proximal tubal obstruction
Transcervical tubal recannalization
• Asherman’s syndrome
• Congenital anomalies
Metroplasty Excision of rudimentary horn
• Adnexal adhesions
Polycystic Ovary Syndrome (PCOS)
Infertility in PCOS is related to anovulation. Surgical induction of ovulation was achieved by wedge resection of the ovary. This fell into disrepute because of increased morbidity and postoperative adhesion formation. Endoscopy revived this surgical option in the form of ovarian drilling. Ovulation occurs presumably because of a decrease in stromal mass or disruption of parenchymal blood flow leading to reduction in ovarian androgen production and luteinizing hormone levels.
Ovarian drilling can be performed using unipolar needle cautery or laser.
The ovarian surface is fulgurated at evenly spaced points. Cautery is maintained until the ovarian capsule and cortex is penetrated, 5 to 6 seconds at each point using a current of 300 to 400 watts.4 With cautery 4 to 8 punctures are enough. For laser the number of punctures is higher 20 to 40.5 Restraint must be used as premature ovarian failure has been reported after too generous a drilling of the ovarian cortex.6 The peritoneal cavity should be lavaged to reduce risk of adhesions.
To date there is no standardization of the technique. Ovulation rates ranging between 70 to 90 percent and pregnancy rates of 70 percent7 have been reported. The minimum ‘dose’ of diathermy that is required and the modification for each patient needs to be determined.
Duration of infertility < 3 years
Use of diathermy rather than laser8
Pretreatment LH levels > 10 IU/L
As effective as gonadotrophin therapy
One time procedure
Intensive ultrasound monitoring not required
Reduces risk of multiple pregnancy and OHSS
Increases sensitivity of ovary to stimulation.
Possibility of inducing premature ovarian failure.
Cochrane database review states that the value of laparoscopic ovarian drilling as a primary treatment is undetermined. There is insufficient evidence to determine a difference in ovulation or pregnancy rates when compared to gonadotrophin therapy in clomiphene resistant women. Multiple pregnancy rates are reduced. None of the modalities of drilling have any obvious advantages.9
Twenty to forty percent of subfertile women have endometriosis. The cause of infertility in endometriosis is debatable. In severe endometriosis distortion of the tubo-ovarian relationship may lead to infertility. In the absence of a mechanical factor, infertility is attributed to ectopic implants inducing a peritoneal inflammatory reaction, an autoimmune response or to related endocrine abnormalities.
Ablation/resection of implants
Correction of abnormal pelvic anatomy
Management of endometriomas.
Ablation of Implants
Ablation of implants is done by coagulation, vaporization and excision. Coagulation can be achieved by using the unipolar or bipolar electrocautery, the endocoagulator or various surgical lasers. Laser is a more precise delivery system and causes less damage to the adjacent tissues. Results with all the techniques are comparable.
Correction of Tubo-ovarian Relationship
The range of adhesions encountered varies from fine avascular adhesions to extremely dense adhesions that completely obliterate tissue planes. Lysis of adhesions must be meticulous, causing minimal tissue trauma and maintaining complete hemostasis.
Adhesions may be lysed by delicate pressure with scissors, aquadissection or blunt and sharp dissection. Vital structures must be clearly identified before dissection.
Management of Endometrioma
Cysts < 3 cm are usually vaporized/coagulated. Cysts > 3 cm are dealt with by cystectomy or drainage, stripping of the cyst wall and coagulation of the base and any remnant endometriotic tissue. Simple incision and drainage of the cyst leads to increased rate of recurrence.10 Extraovarian endometriotic cysts are formed by invagination of the ovarian cortex therefore ablation should be limited. Drainage of the cyst with eversion of the cyst wall gives good results.11
Results and Recommendation
Meta-analysis of literature suggests that in mild and moderate endometriosis laparoscopic ablation is superior to no treatment or medical treatment for infertility management.12 Restoration of the tubo-ovarian relationship improves pregnancy rates with a cumulative pregnancy rate of 70 percent.
Pregnancy outcome with laparoscopy or laparotomy for severe endometriosis does not differ significantly13 therefore choice of technique should be based on surgical expertise.
Occlusion may be fimbrial or cornual.
Fimbrial agglutination, fimbrial encapsulation and prefimbrial phimosis are sequlae of infection. Collection of fluid within the tubal lumen leads to the formation of hydrosalpinx.
Fimbrioplasty Distension of the fallopian tube with methylene blue dye facilitates surgery. The tube is stabilized holding the serosa with an atraumatic forceps. A 3 mm alligator forceps is introduced into the tubal ostium. Deagglutination of the fimbria is achieved by opening the jaws of the forceps inside the lumen and gently withdrawing it from the tube a number of times in different directions.14
Correction of prefimbrial phimosis is done by incising the fibrous bands constricting the infundibulum using blended current. Radial incisions are made along avascular points starting at the fimbrial end and going beyond the region of the constriction.
Results Success rates range from 20 to 50 percent.15 Ectopic pregnancy rate is 5 percent.
Neosalpingostomy After distending the tube with dye the tube is inspected to locate site of scarring. The tube is stabilized and an incision is made extending from the ostium towards the ovary. Two to three radial incisions may be required to expose the fimbria.
Electrocautery, laser or microscissor can be used. Meticulous hemostasis using bipolar cautery and peritoneal lavage are essential to optimize outcome.
Results of reconstructive surgery are optimal when the tubal mucosa shows minimal damage, varying between 58 to 77 percent.16
Prognostic factors for surgery are:
Extent of adhesions
Nature of adhesions
Diameter of the hydrosalpinx < or > 1 cm
Macroscopic condition of endosalpinx
Tubal wall thickness.
Cornual block occurs in approximately 15 percent of patients with tubal infertility. The technique of transcervical tubal cannulation was developed by Novy17 and it transformed the treatment of cornual occlusion.
A coaxial catheter system is used to access the tubal ostia under direct hysteroscopic vision. The block is removed by moving the catheter with the wire guide in and out of the tubal lumen. Laparoscopic control is maintained to avoid risk of tubal perforation and to facilitate passage of the cannula.
Results Recanalization is achieved in 80 to 90 percent of tubes, and pregnancy rates are in the range of 40 percent. Compared to tubal microsurgery the procedure gives better results and is minimally invasive, the ectopic pregnancy rates are also much lower. Pregnancy rates are poor when the wire guide is required to open the block.
Laparoscopic myomectomy for intramural fibroids in the infertile patient was not encouraged because endoscopic suturing did not give a sound uterine scar. Currently this view is being opposed. Laparoscopic myomectomy for infertility should be attempted by an experienced surgeon.
Hysteroscopic polypectomy and myomectomy enhance fertility and should be the procedures of choice18 for intrauterine lesions.
An inverse relationship exists between the grade of adhesions and the pregnancy rate. Before commencing dissection a careful identification oof intra-abdominal structures is essential. Adhesions should be coagulated before division. Thick adhesions should be divided one layer at a time to prevent trauma to underlying structures.
The incidence of infertility due to uterine structural abnormalities and endometrial pathology is approximately 5 to 10 percent. Hysteroscopic surgical procedures for intrauterine pathology became popular as they avoided cutting through uterine musculature to enter the cavity.
Asherman’s syndrome is found in approximately 5 percent of infertile women. The sine qua non for the development of intrauterine adhesions is endometrial trauma, especially to the basalis layer. The simple movement of the hysteroscope can break mild or minimal adhesions. Thicker lesions require use of scissors or electrocautery. Laparoscopic control is advocated. Balloon catheter can be used to provide tamponade. The use of IUD’s and catheters is not recommended. Conjugated estrogen should be administered after surgery.
Congenital Uterine Anomalies
Incidence is 0.1 to 1.5 percent. Prevalence in women with recurrent pregnancy loss is significantly higher (1-12%). Among congenital anomalies, septate uterus is associated with the highest incidence of reproductive failure.
The septum can be cut with scissors, electrocautery or a bipolar vaporizer (Versapoint).
‘Shortening’ technique (thin septa) Incision starts from the apex.
‘Thinning technique ’ (wide septa) Incisions are made along each side of the septum alternately, thinning the septum.
The dissection is complete when the hysteroscope can be moved freely from one cornual recess to the other without intervening obstruction and when both ostia can be visualized simultaneoously.19 A small residual septum of < 1 cm does not impair reproductive outcome.20 Incision of cervical septum does not lead to cervical incompetence.21
Results Results of hysteroscopic metroplasty for recurrent pregnancy loss are excellent and superior to those obtained by transabdominal approach. Cumulative pregnancy rate is 80 to 89 percent at 36 months and overall miscarriage rate is 15 percent. Results are not as good when surgery is performed primarily for primary infertility.
Complications Perforation, uterine rupture in subsequent pregnancy though rare has been reported.
The minimal invasiveness, the reduced morbidity and excellent results have assigned endoscopic surgery the central role in infertility management.
- Golan A Eilat E Ron-El R Herman A Soffer Y Bukovsky I. Hysteroscopy is superior to hysterosalpingography in infertility investigation. Acta Obstet Gynecol Scand 1996; 75 (7): 654–56
- Campo R Van Belle Y Brosens I Gordts S. Office minihysteroscopy. Hum Reprod Update 1999; 5: 73–81.
- Antony M Slangen T van Herendael BJ. Salpingoscopy is an important part of the infertility work-up. J Am Assoc Gynecol Laparosc 1996; 3 (3): 369–74
- Gjoannaess H. Polycystic ovarian syndrome treated by electrocautery through the laparoscope. Fertil Steril 1984; 41: 20–25.
- Daniell JF Miller W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril 1989; 51: 232–36.
- Balen A. Polycystic ovary syndrome: mode of treatment. In Female Infertility Therapy Current Practice. Z Shoham CM Howles HS Jacobs (eds), pg. 45–67.
- Tulandi T al Took S. Surgical management of polycystic ovarian syndrome. Baillieres Clin Obstet Gynaecol 1998; 12 (4): 541–53
- Li TC Saravelos H Chow MS Chisabingo R Cooke ID. Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility. Br J Obstet Gynaecol 1998; 105 (3): 338–44.
- Farquhar C Vandekerckhove P Arnot M ilford R. LLaparoscopic “drilling” by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 2000; (2): CD001122
- Reich H McGlynn F. Treatment of ovarian endometriomas using laparoscopic surgical techniques. J Reprod Med 1986; 31: 577.
- Brosens IA Van Ballaer P Puttemans PJ Deprest J. Reconstruction of the ovary containing large endometriomas by an extraovarian endosurgical technique. Fertil Steril 1996; 66: 517–21.
- Adamson DG Pasta DJ. Surgical treatment of endometriosis- associated infertility: meta analysis compared with survival analysis. Am J Obstet Gynaecol 1994; 171: 1488–505
- Adamson GD Hurd SJ Pasta DJ Rodriguez BD. Laaparoscopic endometriosis treatment: is it better? Fertil Steril 1993; 59: 35–44.
- Gomel V. Salpingo-ovariolysis by laparoscopy in infertility. Fertil Steril 1983; 40: 607–11.
- Fayez JA. An assessment of the role of operative laparoscopy in tuboplasty. Fertil Steril 1983; 39: 476–79.
- Mage G Pouly JL Bouquet de Jolinier J et al. A preoperative classification to predict the intrauterine and ectopic pregnancy rates after distal tubal microsurgery. Fertil Steril 1988; 46: 807–10.
- Novy MJ Thurmond AS Patton P Uehida BT Rosch J. Diagnosis of cornual obstruction by transcervical fallopian tube cannulation. Fertil Steril 1988; 50: 434–40.
- Varasteh NN Neuwirth RS Levin B Keltz MD. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstet Gynaecol 1999; 94: 168–71.
- Homer HA Li T Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril 2000; 73: 1–14.
- Fedle L Arcaini L Parazzini F Vercellini P Di Nola G. Reproductive prognosis after hysteroscopic metroplasty in 102 women: lifetable analysis. Fertil Steril 1993; 59: 768–72.
- Nisolle M Donnez J. Endoscopic treatment of uterine malformations. Gynaecol Endosc 1996; 5: 155–60.