Reproductive Medicine: Challenges, Solutions and Breakthroughs Gautam N Allahbadia, Rubina Merchant, Sulbha Arora
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1Gynecological Endoscopy2

Philosophy of Endoscopy in InfertilityCHAPTER 1

Vivek Salunke
Rajesh V Darade
 
OVERVIEW
The tale of evolution of endoscopy is by no means less than an epic by itself. It is in fact, the story of a revolution, the seed of whose philosophy was sowed as far back as 4,600 years ago. This long journey, with many turns and turbulences, has probably reached the grand finale in the present era of state of art minimally invasive surgeries and robotics. This is the fruit of centuries of tedious battles by scientists and doctors and the pioneers of endoscopy, who had the foresight to apply and develop scientific knowledge with the courage to judiciously experiment and evolve, and to challenge the deeply rooted ideology of open surgery.
Infertility affects more than 80 million people worldwide. One in 10 couples experience primary or secondary infertility. Although infertility is not a public health problem, it is indeed, a central issue in the lives of those suffering from it. Though irrational, many societies evaluate the potential of a woman through her reproductive capacity and this attaches the stigmata of barrenhood to those who cannot achieve it. Unstable marriages, peer and social pressures, domestic violence and ostracism mar the suffering of an infertile woman. Developments in the field of infertility through endoscopy and assisted reproductive technique (ART) have infused hopes in such people to resolve their infertility through the most minimally invasive means and coupled with with the maximum chances of success.
The present chapter attempts to trace the journey of development in endoscopy, particularly with reference to infertility that has led to its present position as a method par excellence.
 
INTRODUCTION
How do we categorize ‘Endoscopy’? What is Endoscopy anyways? A revolution or an evolution? A more accurate definition, however, places endoscopy firmly in the category of a new philosophy, one-rooted in what is now referred to as minimally invasive surgery. Interestingly, it is not a modern phenomenon. It dates back to almost 4,600 years.
Hippocrates had specifically instructed physicians to avoid invasive methods as much as possible, allowing instead, the body's own healing process to take effect, as the former approach was certainly influenced by a high mortality rate due to infection and hemorrhage. Nevertheless, in reviewing the history of medicine, we can see that the philosophy of minimally invasive medicine has been an integral part of medicine for thousands of years. The late 19th and the early 20th century, favored a form of surgical intervention dominated by “big incisions”. Open surgical approaches were soon codified as gold standards of “classical surgery,” a point that later served to interfere substantially with the progress of endoscopy. While facing such institutionalized beliefs about classical surgery, the story of endoscopy was related to individuals responsible for its progress, whose courage and tenacity envisioned a path of progress beyond technical limitations.
For these reasons alone, taking a moment to review the endoscopy development process will help us to recognize how dominant ideologies or cultural influences act as such profound forces in shaping the practice of medicine.
 
Ancient Indian Perspective
A strong pro-minimally invasive approach is exemplified in the ancient text Sushruta Samhita in the chapter 25, which states that the surgeon should take care of the patient as his own son and the use of surgical equipment in excess can cause harm and grave injury to the body. Chapter 5 clearly 4states that surgical incisions should be made swiftly and the smaller the incision the better.
 
History of Endoscopy in Infertility
1970: Steptoe and Edwards1 primed the ovaries with gonadotropins and used the laparoscope to recover preovulatory oocytes.
1972: Maathius et al.2 reported that laparoscopic investigation was preferable to hysterosalpingography.
1975: Moghissi and Sim3 found that 19 percent of patients with normal hysterosalpingography had pathology at laparoscopy.
1984: Asch et al.4 reported a pregnancy following translaparoscopic gamete intrafallopian transfer (GIFT).
 
Endometriosis
1983: Keye et al.5 used argon lasers in the treatment of endometriosis.
1986: Carbon dioxide lasers were used to treat endometriosis by Davis. Nezat et al.6 reported encouraging conception rates when treatment was for infertility as well as pain.
1987: Lamaro used the Nd: YAG laser.
 
CLINICAL DISCUSSION
 
Endoscopy in Infertility
Currently, laparoscopy is perceived as a minimally invasive surgical technique that both provides a panoramic and magnified view of the pelvic organs and allows surgery at the time of diagnosis. Endoscopic reproductive surgery, intended to improve fertility, may include surgery on the uterus, ovaries, pelvic peritoneum and on the Fallopian tubes.
 
Endoscopic Tubal Surgery
Procedures included under endoscopic tubal surgeries are salpingo-ovariolysis, salpingostomy and tubal reanastomosis. Adhesions involving the Fallopian tubes have been implicated as the cause of infertility. In a control study, examining the role of salpingo-ovariolysis, 69 infertile women were subjected to this procedure and 78 women with a similar degree of adhesions were not treated.7 The cumulative pregnancy rate at 24 months follow-up was significantly higher in the treated women compared to the untreated group, (45% versus 16%, respectively). In one study, 167 patients with pelvic adhesions, suffering from an inability to conceive, underwent operative laparoscopy and adhesiolysis. According to the severity of adhesions, patients were categorized by diagnostic laparoscopy as mild (group 1), moderate (group 2), and severe (group 3). After laparoscopic adhesiolysis, all the patients were followed up for one year. Pregnancies occurred in 51 (70.8%), 28 (48.3%) and 8 (21.6%) patients in groups 1, 2 and 3, respectively.
Salpingo-ovariolysis, as a fertility-enhancing procedure is done by separating adnexal adhesions with laparoscopic scissors, electrocautery, or lasers. Endoscopic surgery is more precise for excision of such adhesions as it avoids damage to the surrounding vital structures. An increased rate of adhesion formations has been reported in patients undergoing reproductive surgery via laparotomy.8, 9 In their study, Nezhet et al.10 demonstrated that endoscopic reproductive surgery was very effective in reducing peritoneal adhesions and was associated with a low frequency of postoperative adhesions recurrence and mostly avoided the formation of de novo adhesions at most surgical sites.10
Hydrosalpinx is a chronic pathological condition of the Fallopian tube and a major cause of infertility, the main caused being pelvic inflammatory disease, previous abdominal operations, history of peritonitis and tuberculosis and endometrioses.11, 12 Laparoscopy provided both the certain diagnoses and treatment of hydrosalpinx at the same sessions. One meta-analysis demonstrated deleterious effects of hydrosalpinx on achieving pregnancy in women undergoing in vitro fertilization (IVF). It was shown that the clinical pregnancy rate was 50 percent lower and the miscarriage rate was more than two-fold higher in patients with hydrosalpinx.13 The proposed mechanism by which embryotoxicity occurs begins with the leakage of fluid from the hydrosalpinx into the uterine cavity. This fluid may not only be harmful to the embryos but may have an adverse effect on the uterine receptivity and implantation mechanisms. A Cochrane review confirmed that the odds of pregnancy were increased with laparoscopic salpingectomy prior to IVF.14 All these data demonstrate that laparoscopic surgery for hydrosalpinges is a preferred procedure for improving pregnancy rates. Proximal tubal obstruction is found in 10 to 25 percent cases of tubal infertility. It is most commonly due to salpingitis isthmica nodosa (SIN). Cornual implantation, done endoscopically, is rarely preformed nowadays except in very specialized centers. Diseases of the distal tube could be secondary to any pelvic inflammatory condition including infection, endometriosis, or may occur postsurgically. Tubal preservation surgery for distal tubal lesions includes salpingostomy and fimbrioplasty. Patency of the distal tube does not necessarily equate with normality of the tubal mucosa. Fimbrioscopy and salpingoscopy are procedures to ascertain the quality of fimbriae and endosalpinx, respectively and determine the prognosis of future fertility.12 Laparoscopic tubo-tubal anastomosis is done for reversal of tubal ligation. The success of the surgery depends on the type of tubal ligation procedure performed, total tubal length before reversal, patient's age and ovarian function.5
 
Laparoscopic Myomectomy
Uterine fibroids can affect 30 to 40 percent of reproductive aged women. It has been observed that pregnancy rates are lower in patients presenting with myomas. Approximately 50 percent of women with myomas conceive after myomectomy.15 Depending on the locations of myomas, a hysteroscopic or laparoscopic approach is used to remove them. As fertility preservation is the primary goal of myomectomy, laparoscopy gives a distinct advantage over laparotomy. The incidence of adhesions following open myomectomy is 100 percent as compared to 36 to 67 percent following laparoscopic myomectomy.1620 Dubuisson et al.20 studied the risk of adhesions after laparoscopic myomectomy. Second-look procedures were performed in 45 of 271 laparoscopic myomectomy patients. Additional laparoscopy procedures were performed at the time of laparoscopic myomectomy in 19 patients (42.2%). Overall, the postoperative adhesion rate was 35.6 percent, with 16.7 percent of the myomectomy sites affected. Most importantly, the adnexal adhesions rate was 24.4 percent, with 11 percent being bilateral. In patients without associated laparoscopic procedures, the adhesion rates were even lower with an overall adhesions rate of 26.9 percent and an adnexal adhesions rate of 11.5 percent, none of which was bilateral. One of the concerns regarding laparoscopic myomectomy has been adequate reconstruction and healing of the uterine defect, with subsequent ability of the uterus to withstand pregnancy and labor. The excessive use of electrocautery contributes to myometrial necrosis and impaired wound healing. Few studies have evaluated the effect of myomas on pregnancy rates after assisted reproductive technique (ART). Elder Geva et al.21 compared 106 ART cycles in patients with uterine fibroids and 318 ART cycles in patients without uterine fibroids and concluded that implantation and pregnancy rates were significantly lower in patients with intramural and submucosal fibroids, even those with no deformation in the uterine cavity.21 Stovall et al.22 showed that even after patients with submucosal fibroids are excluded, the presence of fibroids reduces the efficacy of ART.22 Therefore, infertile women with intramural fibroids should be subjected for myomectomies earlier.
 
Endoscopy in Endometriosis
About 30 to 70 percent of infertile women have been reported to have endometriosis.23 Severe endometriosis, associated with pelvic adhesions and distortion of the pelvic anatomy, would result in infertility. However, the impact of mild to moderate endometriosis on fertility could be explained by ovulatory dysfunction, endocrine abnormality, inflammatory and immunological abnormalities. Laparoscopy is the best surgical approach for treating endometriosis. Superficial peritoneal endometriosis is fulgurated or excised. For larger lesions more than 5 mm, excision is a better option. For endometriomas, drainage and removal of the cyst wall should be tried. The IVF success rates in infertile patients with endometriosis are lower compared to women undergoing IVF for other indications. Barnhart, et al.24 investigated the IVF outcome in patients with endometriosis.24 It was demonstrated that patients with endometriosis have more than a 50 percent reduction in pregnancy rate after IVF compared with women with tubal factor infertility. Data suggest that the presence of endometriosis affects multiple aspects of the reproductive cycle, including oocyte quality, embryogensis and endometrial receptivity, which may result in lower implantation rates.2527 The Practice Committee of ASRM developed a report in May 2004. According to their recommendations, when laparoscopy is performed, the surgeon should consider safely ablating or excising visible lesions of endometriosis. In women with stage I and II endometriosis-associated infertility, expectant management or superovulation with intrauterine insemination (IUI) can be considered for younger patients. Older patients, more than 35 years, should be treated with superovulation /IUI or in vitro fertilization-embryo transfer (IVF-ET). In women, with stage III and IV endometriosis-associated infertility, conservative surgical therapy with laparoscopy and possible laparotomy are indicated.
Advances in endoscopic surgery have revolutionized our approaches to gynecological surgery. Endoscopic surgery for infertile patients has a major role to play, and if performed by an endoscopic surgeon experienced in fertility-enhancing surgeries, better results can be obtained.28
 
CONCLUSION
Advances in endoscopy have revolutionized our approach to gynecological surgery. Surgery, pertaining to the reproductive organs, can and should be approached laparoscopically, especially in the context of infertility. It is evident that endoscopic surgery, when performed by an expert endoscopist, is efficacious and produces as good and probably, better results when compared to open surgery.
Laparoscopy is not merely a technological advancement but a paradigm shift in the way of looking at ‘treatment’. The shift towards minimal invasion reflects a deeper, philosophical commitment to minimal pain in all aspects—physical, mental and social. An exemplary case in point is the laparoscopic approach to infertility treatment. In most societies, where womanhood is synonymous to motherhood, infertility is accompanied by enormous psychological and social pressures, which are exacerbated by the physical trauma of open surgery. In such a context, laparoscopy comes as a much awaited change by virtue of being a more holistic and humane approach to treatment.6
REFERENCES
  1. Steptoe PC, Edwards RG. Laparoscopic recovery of preovulatory human oocytes after priming of ovaries with gonadotrophins. Lancet 1970; l: 683–9.
  1. Maathuis JB, Horbach JG, van Hall EV. A comparison of the results of hysterosalpingography and laparoscopy in the diagnosis of fallopian tube dysfunction. Fertil Steril 1972; 23: 428–31.
  1. Moghissi KS, Sim GS. Correlation between hysterosalpingography and pelvic endoscopy for the evaluation of tubal factor. Fertil Steril 1975; 26: 1178–81.
  1. Asch RH, Ellsworth LR, Balmaceda JP, Wong PC. Pregnancy after translaparoscopic gamete intrafallopian transfer. Lancet 1984; 2: 1034–5.
  1. Keye WR Jr, Matson GA, Dixon J. The use of the argon laser in the treatment of experimental endometriosis. Fertil Steril 1983; 39: 26–9.
  1. Nezhat C, Crowgey SR, Garrison CP. Surgical treatment of endometriosis via laser laparoscopy. Fertil Steril 1986; 45: 778–83.
  1. Tulandi T, Collins JA, Burrows E, et al. Treatment dependent and treatment independent pregnancy among women with periadnexal adhesions. Am J Obstet Gynecol 1990; 162: 354.
  1. Risberg B. Adhesions: preventive strategies. Eur J Surg 1997; 577(suppl): 32–9.
  1. Brill AI, Nezhat F, Nezhat CH, Nezhat C. The incidence of adhesions after prior laparotomy: a laparoscopic appraisal. Obstet Gynecol 1995; 85: 269–72.
  1. Nezhat CR, Nezhat FR, Metzget DA, Luciano AA. Adhesion reformation after reproductive surgery by videolaseroscopy. Fertill Steril 1990; 53: 1008–11.
  1. Bontis JN, Dinas KD. Management of Hydrosalpinx; reconstructive surgery of IVF. Ann NY Acad Sci 2000; 900: 260–71.
  1. Nezhat F, Winer WK, Nezhat C. Fimbrioscopy and salpingoscopy in patients with minimal to moderate pelvic endometriosis. Obstet Gynecol 1990; 75: 15–7.
  1. Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization – embryo transfer. Fertil Steril 1998; 70: 492.
  1. Johnson NP, Mak W, Sowter MC. Laparoscopic salpingectomy for women with hydrosalpinges enhances the success of IVF: a Cochrane review. Hum Reprod 2002; 17: 543.
  1. Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril 1992; 58: 1–15.
  1. Tulandi T, Murray C, Guralnick M. Adhesion formation and reproductive outcome after myomectomy and second-look laparoscopy. Obstet Gynecol 1993; 82: 213–5.
  1. Nezhat C, Nezhat F, Silfen SL. Laproscopic myomectomy. Int J Fertil 1991; 36: 275–80.
  1. Hasson HM, Rotman C, Rana N. Laproscopic myomectomy. Obstet Gynecol 1992; 80: 884–8.
  1. Mais V, Agossa S, Guerriero S, Mascia M, Solla E, Melis GB. Laproscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 1996; 174: 654–8.
  1. Dubuisson JB, Fauconnier A, Chapron C, Krieker G, Norgaard C. Second look after laparoscopic myomectomy. Hum Reprod 1998; 13: 2102–6.
  1. Elder-Geva T, Meagher S, Healy DL, MacLachlan V, Breheny S, Wood C. Effect of intramural, subserosal and submucosal uterine fibroids on the outcome of assisted reproductive technology treatment. Fertil Steril 1998; 70: 687–91.
  1. Stovall DW, Parrish SB, Van Voorish BJ, Hahn SJ, Sparks AET, Syrop CH. Uterine leiomyomata reduce the efficacy of assisted reproduction cycles:results of matched follow-up study. Hum Reprod 1998; 13: 192–7.
  1. Donnez J, Wyns C, Nisolle M. Does ovarian surgery for endometriomas impair the ovarian response to gonadotropin. Fertil Steril 2001; 76: 662–5.
  1. Bernhart K, Dunsmoor-Su R, Coutifaris C. Effect of endometriosis on in vitro fertilization. Fertil Steril 2002; 77: 1148–55.
  1. Elsheikh A, Milingos S, Loutradis D, Kallipolitis G, Michalas S. Endometrosis and reproductive disorders. Ann N Y Acad Sci 2003; 997: 247–54.
  1. Buyalos RP, Agarwal SK. Endometriosis - associated infertility. Curr Opin Obstet Gynecol 2000; 12: 377–81.
  1. Winkle CA. Evaluation and management of women with endometriosis, Obstet Gynecol 2003; 102: 397–408.
  1. Bulent B, Mahdavi A, Shahmohamady B, Nezhat C. Role of laparoscopic surgery in infertility. MEFSJ 2005; 10: 94–104.