Practical Guide in Reproductive Surgery Gita Ganguly Mukherjee, Bhaskar Pal, Gautam Khastgir
INDEX
Page numbers followed by, f refer to figure, fc refer to flow chart, and t refer to table.
A
Adenomyomectomy, role of 63
Adenomyosis 64, 82, 86, 89, 90
diagnosis of 89
Adhesiolysis 70
choice 98
equipment 98
Adhesions
development, pathophysiology of 94
type of 11, 95, 95f
Adipokine 237
Adiponectin 237
Adipose tissue 237
Adnexa 173f
Adnexal mass 121
Airway pressure 228
pulmonary 230
Amenorrhea, risk of 217t
American Association of Gynecologic Laparoscopists 149
American College of Obstetricians and Gynecologists 60
American Fertility Society 127
classification system, revised 76
American Society for Reproductive Medicine 78, 127
American Society of Clinical Oncology 216
Amniotic Membrane Acts 270
Amniotic membrane graft 270
Ampulla 109
Ampullary
adhesions 127
mucosa 98
part 109
Androstenedione 237
Anejaculation 184
Anesthesia
epidural 232
general 172, 194
local 232
opioid-free 231
regional 232
spinal 195
technique, choice of 230
type of 17
Anesthetic management 229
Angiotensin 227
Anovulation disturbance 238
Antagon 16
Antibiotic prophylaxis 15
Anticancer treatments 217t
Anticoagulants 100
Anti-inflammatory agents 101
Anti-Mullerian hormone 61, 108, 147
Antioxidant therapy 210
Anti-progestagens 78
Antral follicle count 62
Apgar's score 267
Aplastic anemia 205
Apoptosis suppression 75
Appendicectomies 97
Aqua dissection 99, 100f
Arrhythmias, hypercarbia-induced 228
Arterial blood
gas 230
pressure 226
Arterial oxygen desaturation 232
Artery forceps 263
Asherman's syndrome 129, 147, 150, 157, 161
Assisted reproductive technology 6, 45, 59, 78, 90, 98, 116, 126, 148, 183, 203, 238, 246, 269
Atrial pressure 225
Autofluorescence 70
Autoimmune diseases 205
Autonomic dysreflexia 187
Azoospermia 183, 184, 249
classification 183
nonobstructive 183, 184, 191, 246, 255, 255t
obstructive 183, 246
pretesticular 183
B
Bariatric surgery 236, 240, 241
assessment of 241
in infertility, role of 240
Beta-human chorionic gonadotropin 122
Bicornuate uterus, metroplasty for 155f
Bicorporeal uterus 163
Biliopancreatic diversion 242
Bladder 172f
catheterization 17
drainage 265f
Bleeding 30, 154, 171, 173f, 176f, 178
Blind vagina 262f
Blood pressure, intermittent noninvasive 229
Blunt dissection 99
Body mass index 139, 236
Bowel overlying uterus 84
Bowel surgery 97
Brachial plexus 225
neuropathy 226
Brain tumors, treatment of 217
Bupivacaine 130
C
Calcium 242
Cancer
cells, reseeding of 211
cryopreservation in 208
loss of ovarian function after
treatment of 216
nongynecological 218
therapy
adverse effects of 204
and fertility 203
regimens 203
Carcinoma
in situ 220
nasopharyngeal 217
Cardiorespiratory collapse 228
Cardiovascular system 226
Carina 225
Catecholamine 227, 231
Cell
ovarian carcinomas 222
signaling 207
types of 207
Central nervous system 184
Cerebral
Atresia
complete 267, 268
congenital 267
isolated 260, 268
cancer 219, 220
dilation 18
edema 30, 168
intraepithelial neoplasia 220
laceration 15, 29
pregnancy, management of 118
restenosis 269
stenosis 15
stent 265f
Cervicovaginal atresia 268
canalization of 259
complete 263f, 269
congenital 259
correction of 260
operative step for 260
Cervicovaginal canal 270
Cervix 263f
cord like 264f
Cesarean scar 116
pregnancy, management of 118
Chemerin 237
Chemotherapy, neoadjuvant 220
Chlamydia 2
Chromotubation 110
Chronic inflammatory reaction 140
Clomiphene citrate 43
Coagulation disorders 178
Coelomic metaplasia 75
Coexistent infertility factors 100
Cold
knife incision 252
loop 23
Colorectal
endometriosis 140
surgeon 69
surgery 71
Colpohematometra 267, 268
Conservative surgery 220
Control postpartum hemorrhage 153
Conventional testicular sperm extraction 197
Cornual pregnancy, management of 119
Cosmesis 69
Cranial irradiation 217
Cruciate incision 267
Cryoinjury 205
Cryopreservation 218, 254
conventional 205
Cryoprotectants 205
efficacy of 207
Cryptozoospermia 189
Crystalloids 101
Cumulus cells 207
Cystectomy 77
D
Dartos fascia 196
Deep vein thrombosis 226
Defense Advanced Research Projects
Agency 134
Dehydroepiandrosterone sulfate 108
Dermoid cysts 129
Diabetes 161
mellitus, gestational 239
Diabetic neuropathy 184
Diagnostic hysteroscopy in infertility, role of 10
Diagnostic laparoscopy, common indications of 1
Dienogest 77, 80
Diethylstilbestrol 161
Dimethyl sulfoxide 206
Domperidone 229
Dorsal lithotomy position 138
Dynamic cell 207
Dysmenorrhea 90
endometriosis-associated 77
Dysmorphic uterus 162, 163
E
Ectocervix 270
Ectopic endometrium, presence of 69
Ectopic pregnancy 97, 116, 120
diagnosis of 116
risk of 162
Edema, pulmonary 30
Ejaculation
neurophysiology of 186f
retrograde 184
Ejaculatory duct 253
obstruction 252
transurethral resection of 252
Ejaculatory failure 184
Electroejaculation 185, 187
procedure 187
Electrosurgical excision procedures 220
Embolization, retrograde 250
Embryo 206
cryopreservation of 203, 204
cryostorage 211
preservation 218
transfer 177
Emphysema, subcutaneous 228
Endometrial
ablation 19
method, second-generation 20
ablation therapy 89
biopsy 11
cancer 219, 220
polyp 12
stem cells, role of 75
tissue 70, 76
vascular disturbances 45
Endometrioma 61, 62
cyst wall, laparoscopic excision of 62f
recurrent 66
Endometriosis 2, 96, 97, 128
deep 63
fertility index 60
minimal 60
moderate 129
resection of 140
severe 63
surgery for 140
surgical treatment in 140
treatment of 80
type of 75
Endometriotic
implants 64, 99
surgery, hallmark of 69
tissue 63
removal of 60
Endometritis, tuberculous 105
Endometrium, cryoablation of 31
Endoscopic developments 148
Epididymis, reconstructive surgery of 253
Epigastric arteries 142
Epinephrine 130
Epithelial ovarian cancer 221, 222
Erection, neurophysiology of 186f
Esophageal
sphincter, lower 227
stethoscope 230
Essure microinserts, placement of 28, 29
Essure sterilization 28, 32
Estradiol 210
Estrogen 237, 238
postoperative 159
supplementation 27
therapy 157
Estrone 237
European Society for Gynaecological Endoscopy 163
European Society of Human Reproduction and Embryology 6, 60, 61, 76, 163
Extrapelvic pathology, diagnosis of 177
Extraperitoneal insufflation 228
F
Fallopian tube 2, 97, 259
Falloposcopy 97
development of 13
Female genital tract anomalies, classification of 163t
Female reproductive organs 219
Female sterilization 114
factors influencing of 105
operative procedure 108
reversal of 104
Ferric hyaluronic acid 101
Fertility
assessment 107, 108
preservation 154, 203
methods 218, 219
options for 204
preserving surgery 221
rate 6
restoration of 104, 208
status of couple 105
Fertilizing matured eggs, technique of 218
Fetal position, abnormal 130
Fibrin glue 101
Fibrinolytic agents 100
Fibroids 16, 28, 45, 86, 90, 130
clinical management of 56
influence infertility 55
management of 56, 87, 87fc, 88fc
medical therapy for 56
morcellation for 47
multiple 150
resection of 27, 29
submucous 11, 16, 20, 21, 57, 148, 153
subserosal 57
surgical removal of 47
treatment strategies 46
with intramural component 23
Fitz-Hugh-Curtis syndrome 2
Fluid control 151
Foley's catheter 27, 142, 265f
Follicle in stroma, absence of 209f
Follicle-stimulating hormone 108, 191f, 247, 255
levels of 210
Follicular
aspiration 179
development 237
puncture, severe complications of 180
Food and Drug Administration 32, 72, 82, 134
Forceps grasps 143f
Freezing cells 203
Freezing oocytes 206
Fresh amniotic membrane 265f
Frozen tissue, thawing of 206
Functional residual capacity 225
Furosemide 30
G
Ganirelix acetate 16
Gastric bypass 240
Gastrointestinal system 227
Gelatin-thrombin matrix 130
Genital
tract, female 130, 161
tuberculosis 2
Germ cell tumors 221
Gestational products, removal of 120
Gestational sac 121
Global infertility prevalence rates 171
Glycine 151
Gonadal damage risk, degrees of 204t
Gonadotropin-releasing hormone 76, 166, 171
Granulosa cell 207
apoptosis 238
Growth hormone 236
Gynecare versapoint bipolar electrosurgery system 21
Gynecological cancer 216, 219
Gynecological surgery 134
H
Harmonic scalpel 41f
use of 42
Hartman's solution 101
Healthy ovarian tissue 61
Hegar's dilators 156
Hematoma
cause of 172
transvaginal ultrasonographic
image of 173f
Hematometra 263f
Hematopoietic stem cell transplantation 204
Hematoporphyrin 70
Hematosalpinx 266
Hemoglobin, borderline 48
Hemoperitoneum 266
management of 179fc
Hemorrhage after surgery 154
Hemostatic sealant 118
Hepatorenal circulation 227
Herniorrhaphy surgery 194
Heterogeneous tissue 206
Heterotopic transplantation 208
Hormonal
contraceptives 78, 80
therapy 190
Hormone binding globulin 236
Horseshoe-shaped kidney 260
Hot flushes 161
Human
beta chorionic gonadotropin 121
chorionic gonadotropin 172
reproductive tissue freezing 206
Hybrid technique 140
Hydraulic energy, use of 99
Hydrosalpingeal fluid 127
Hydrosalpinges 6
effects of 127
Hydrosalpinx 6
Hydrothermablator system 20
Hydrothermal method, second-generation 20
Hyperandrogenemia 237, 238
Hypercapnia 231
Hypercarbia, presence of 231
Hyperosmolar glucose 121
Hyponatremia 151, 152
Hypoplastic uterus, metroplasty for 157
Hypospermatogenesis, biopsy-proven 251
Hypotension, acute 228
Hypotonic solutions 151
Hysterectomy 80
Hysterosalpingo contrast sonography 3
Hysterosalpingography 3, 10, 12, 27, 97, 130, 148, 165f
role of 13
Hysteroscope placing 17
Hysteroscopic
adhesiolysis 129
lateral metroplasty 167f
management 11, 147
metroplasty 155, 161, 165, 166f, 57, 130
resection, technique of 23, 153
surgery 12, 46, 129
Hysteroscopy 12, 147
complications of 28
diagnostic 18
mechanical complications 28
role of 148
techniques 18
treatment 15
I
Ice crystal formation 206
Iliac fossa 177
Immature oocytes, collection of 219
In vitro fertilization 3, 6, 13, 61, 67, 78, 89, 106, 126, 171, 195, 205, 246
after recurrent disease 66
embryo transfer 79, 80
failure 147
Infection 154
Inferior vena cava, compression of 226
Infertility 45, 12, 241
causes of 10
hysteroscopy 10, 13, 13t
investigations 13t
mechanism resulting in 97
primary 11, 171
Infundibulopelvic ligaments 220
Inguinal approaches, microsurgical 249
Insulin 237
International Federation of Gynecology and Obstetrics 60
International Obesity Task Force 236
Interstitial pregnancy, management of 119
Intra-abdominal
infection 95
instillates 101
pressure 226, 230
Intracranial pressure 227
Intracytoplasmic sperm injection 89, 183, 246, 255
Intragastric pressure 227
Intramural fibroids 45, 56, 57
large 45, 136
management of 56
Intraocular pressure 227
Intraperitoneal normal saline infusions 232
Intratubal adhesions 100
Intratubular germ cell neoplasma 255
Intrauterine
adhesiolysis 26
adhesions 24, 154, 157
classification 158
diagnosis 158
mild 158
moderate 158
severe 158
treatment 158
contraceptive device 130
role of 167
device 25
removal 25
insemination 1, 5, 48, 60
morcellator 22
pathology, management of 147
pregnancy 120, 121
pressure 155
synechiae, hysteroscopic resection of 158f
Intravaginal misoprostol 15
Iodine 242
Iron 242
Ischemic optic neuropathy 226
Isoflurane 231
K
Kallmann syndrome 190
Ketorolac tromethamine 26
Klinefelter syndrome 246
Knowles-Eccersley-Scott-Symptom scores 72
L
Labial stitches 264, 265f
Landon's retractors 263
Laparoscopic
adhesiolysis 98
infertility 94
adjustable gastric banding 241
assisted bowel resection 72
gynecological operations 229
gynecology surgery, anesthesia for 225
myomectomy 138
robotically-assisted 136, 138, 139t
operation 139
ovarian
cystectomy 61
diathermy 4
drilling 4, 39, 40f, 41f, 43
procedures, abdominal 232
repair 248
surgery 67, 129, 225, 229
robotically-assisted 140
technique 120
tubal anastomosis 141
tubal reanastomosis,
robotically-assisted 143
uterosacral nerve ablation 77
Laparoscopy 4, 6, 230, 250
before intrauterine insemination 5
Laryngeal
edema 151, 225
mask airway 230
Laser ablation 22
Lasmar's classification 149, 150t
Leimyosarcoma 47
Leiomyoma 55, 87
submucous 147, 148, 149f
Leptin 237
levels 237
Leukocytospermia, intractable 189
Levonorgestrel intrauterine system 80, 221
use of 77
Lipid metabolism 237
Lithotomy position 226
Luteinizing hormone 16, 108, 210
levels of 237
M
Male infertility 174
treatment of 183
Malecot catheter 27
Malignant tumors 221
Mayer-Rokitansky-Küster-Hauser syndrome 260, 268
Medroxyprogesterone 27
acetate 16, 269
Megestrol tablets 221
Menorrhagia, management of 87, 87fc
Menstrual
bleeding 90
cycles 242
disturbance 238
Mesenteric circulation 227
Mesosalpinx 110
defect of 142
Messenger ribonucleic acid 45
Metabolic syndrome 240
Methotrexate 118, 122
Methylene blue 2, 54f
dye, injection of 142
Metroplasty 154
hysteroscopy for 154
knife, incision of 167f
Metzenbaum scissors, use of 25
Michelin test 71
Microbipolar forceps 142
Microdissection testicular sperm extraction 197, 198f
Microdissector forceps 142
Microsurgical biopsy technique 199
Microsurgical epididymal sperm aspiration 193, 195, 196f, 254, 254f, 256, 257f
Microsurgical technique 142
Microtesticular sperm extraction 251
Midsacral vessels 78
Miliary tubercles 2
Mini-gastric bypass 240
Minimal testicular damage 198
Miscarriage 130, 162
Misoprostol 130
Monoclonal uterine myometrial tumors 45
Monopolar drilling needle 40f, 43
Morcellated specimen
bits of 53f
strips of 53f
Morcellation controversy 48
Müllerian anomalies 163
Müllerian bulbs 259
Müllerian duct 161, 268
influence of 268
malformations 270
Müllerian malformations 260
Multiload CU-250 263
Multimodal analgesia 232
Multiquadrant testicular tissue aspiration 194
Myoma
large 139t
morcellation of 52f
resection 151
submucous 149, 150
Myomectomy 57, 97, 131
indications for 46
route of 151
Myometrial trauma 29
Myometrium
hyperplastic 89
normal 150
N
Nasogastric tube 230
National Aeronautics and Space Administration 134
National Institute for Health and Care Excellence 242
Neocervix
cord edges of 263
inside vagina 265f
junction of 270
retrograde dilatation of 266
Neodymium-doped yttrium aluminium garnet 20, 165
Neovagina 263, 265f, 269, 270
Neural edema, risk of 231
Neurectomy, presacral 77, 80
Nitrous oxide 231
Nodules, removal of 140
Nonexcisional technique 63
Non-Hodgkin's lymphoma 80
Nonhysteroscopic instruments 31
Nonobstructive azoospermia, diagnosis of 184
Nonsteroidal anti-inflammatory drugs 229
Nutritional supplementation 240
O
Obesity 236, 238
and infertility 238
and miscarriage 238
and reproductive functions 237
and treatment in infertility 239
hyperandrogenemia 238
medical therapy in 239
Oligoasthenoteratozoospermia, severe 189
Omental grafts 101
Omentin 237
Oncofertility 204
Oocyte 207
analyzed 208
cryopreservation of 219
normal 210
pickup 6
retrieval, complication of 171
Oophorectomy 80
Oophoropexy 218
preserves ovarian function, strategy of 218
Open conventional biopsy technique 199
Open testicular biopsy 199
Operative office hysteroscopy 26
Oral contraceptive 76
Orthotopic transplantation 208
Ovarian
adhesion score 76
autografts 208
cancer 221
cortical tissue vitrification-thawing,
method for 206
cystectomy 76, 97
drilling 43
ectopic pregnancy 120
endocrine function, loss of 217
endometrioma 6, 77
ablation for 62
excision for 62, 67
endometriotic cysts 6
failure, cause of 41f
function transplantation 210
hyperstimulation 1, 60
syndrome 4
pregnancies, laparoscopic
management of 122
reserve, surgery for 62
stimulation 66
stroma of twins discordant 209f
suppressive effect 59
surface bleeder, laparoscopic
cauterization of 176f
tissue
cryopreservation 205, 206
freezing 203, 205
transplantation 208
cryopreservation of 204, 207, 219
transplantation 209
tumors, borderline 221
Ovariopexy, bilateral 64
Ovary 127
freezing 207
Ovulation 4
induction 4
Oxidative stress 75
P
Pampiniform plexus 248
Paracervical block, use of 22
Paracolic gutter 138, 218
Paramesonephric ducts 161
Parkinson disease 184
Pediatric endotracheal tube 270
Pelvic
abscess 171
adhesions 2, 94
cause of 96, 96f
risk factors in 95
hematoma 175f, 179fc
infections 96
inflammatory disease 3, 64, 96, 97, 105,
kidney 260
pain, nonmenstrual 77
robotic-assisted surgery 226
ultrasonography 1
vessels 171
vibratory stimulation 184, 185
Pentoxifylline 77
Percutaneous epididymal sperm aspiration 193, 193f, 254, 254f, 254, 257f
advantages of 194t
disadvantages of 194t
Percutaneous vasal sperm aspiration 194
Periadnexal adhesions, cases of 98
Pericervical tourniquet 130
Periovarian adhesion, formation of 42
Peripheral nerve stimulation 230
Peritoneal
adhesions 102
grafts 101
irritation 232
Persistent intractable pain 66
Pleuroperitoneal canal 228
Pneumomediastinum 228
Pneumopericardium 228
Pneumoperitoneum 226, 227, 230
Pneumothorax 228
Polycystic ovarian
disease 4
syndrome 4, 39, 39f, 174, 237
Polytetrafluoroethylene 101
Port insertion sites 138f
Postcoital test, unsatisfactory 105
Posthysteroscopy care 26
Post-laparoscopic ovarian drilling adhesion formation 41f
Post-testicular obstruction 184
Potassium chloride 121
Pouch of Douglas 4
peritoneum of 262f
Prader orchidometer 247
Preeclampsia 161
Pregnancy 12
abdominal 120
advanced abdominal 120
heterotopic 116, 120
incidence of 269
rate 3, 61
Premature ovarian failure 204, 209f
Progestagene 78, 80, 210
Prolactin 108
Propanediol 205
Prophylactic antibiotics 159
Prostatic
abscess 252
cysts 253
hyperplasia, benign 82
Protein 242
Proximal tubal cannulation 25
Pulmonary capillary wedge pressure 226
R
Radical surgery 80
Radical trachelectomy 220
Rapid fluid absorption 154
Rate teslis aspiration 257f
Real-time thermometry 84f
Recanalization operation, applications for 113
Reconstructive
surgery 259
tubal surgery 97
Rectal function sparing techniques 72
Rectal injuries 73
Rectovaginal
endometriosis 140
septum 140
Recurrent endometriosis 76
management of 77
Recurrent implantation failure 147
hysteroscopy in 147
Reproductive function, resumption of 210
Reproductive tissue
applications for 203
cryopreservation 205
Resection method 19
Respiratory
acidosis 228
system 227
Restenosis 269, 270
Resuscitation, cardiopulmonary 46
Retroperitoneal repair 248
Ring sign 121
Robot-assisted
laparoscopic surgery 140
surgery, positioning in 226
Robotic instruments 136
Robotic myomectomy 136
Robotic setup 135
Robotic skills 135f
Robotic surgery 72, 139, 141
Robotic tubal reanastomosis 143f
Rokitansky-Küster-Hauser syndrome 259
Rollerbarrel method 19
Routine semen analysis 199
Roux-en-Y gastric bypass surgery 240
S
Saline infusion sonography 149
Salpingectomy 117, 122, 126
Salpingo-ovariolysis 109
Salpingoscopy 97, 98
use of 98
Salpingostomy 117
Salpingotomy 117
Sampson's retrograde menstruation theory 75
Scar tissue 140
formation of 129
Sclerosis, multiple 184
Sclerotherapy
antegrade 250
retrograde 250
Scrotal
approach 248
operation 250
skin 248
Semen
evaluation of 108
poor 100
Sepsis 29
Septate uterus 163
Septum
complete 130
transection of 28
Sertoli cell-only syndrome 184, 251
Sevoflurane 231
Sibutramine 240
Sickle cell anemia 205
Sigmoid colon endometriosis 66
Silicone gastric banding 240
Simultaneous nonhysteroscopic endometrial ablation 32
Sinovaginal bulb 268
end of 268
Sleeve gastectomy 240
Society of Obstetricians and Gynaecologists 56
Sodium osmolality 30
Solid Müllerian bulbs 270
Sonography 155
Sperm
chromatin dispersion test 200
cryopreservation of 203
retrieval 191, 192
method 191
prognostic factors for 191
rate 192t, 198t
surgical 189
techniques 253, 257f
Spermatocele aspiration 257f
Spermatogenesis 247, 252
absence of 183
Sterilization
contraindications of 105
procedure 106
reasons for demanding, reversal of 105
reversal 112
procedure 105
Stripping technique 62f, 63
Subdiaphragmatic instillation 232
Subfertility 122
Subinguinal approaches, microsurgical 249
Submucous fibroids
multiple 150
resection of 22
Submucous myomas
presurgical classification of 149
removal of 150
Superficial transient skin burns 83
Superoxide dismutase 189
Surgery, abdominal 117
Surgical knots 101
Surgical sperm retrieval 183, 192, 195, 254f
procedures 183
types of 193
Swedish obesity study 240
Sympathicotonia, hypercapnia-induced 227
Systemic lupus erythematosus 205
Systemic vascular resistance 226
T
Testicular
failure 183, 193
function 247
histopathology 251
spectrum of 253
sperm 195, 254
extraction 192, 193, 196, 197f, 198t,
use of 199
sperm aspiration 193, 194f, 254, 254f, 256
advantages of 195t
disadvantages of 195t
tissue 198
volume assessment 247
Testis biopsy 247
Testosterone 190
Thalassemia 205
Theca cells 207
Thermachoice endometrial ablation 32
Thiopentone sodium 230
Thromboembolism 227
Thromboprophylaxis, postpartum 240
Thyroid-stimulating hormone 108
Tidal volume 227
Tissue
extraction 151
hypoxia 95
removal 153
Total body irradiation 203, 204
Total peritoneal resection 64
Totipotential germ cells 129
Toto enucleation 23
Trachelectomy, abdominal 220
Transcervical
chromotubation 110f
tubal sterilization 25
Transrectal sonography 252
Transvaginal
endoscopic technique 97
follicular aspiration 171
follicular puncture 174
oocyte retrieval 171, 179fc
sonography 116, 175f
ultrasonography 3, 149
Transverse septum 260
Trendelenburg's position 138, 225
reverse 226
Triglycerides 237
True endometriotic lesion, visualization of 141
T-shaped uterus 161, 162, 164f
cause of 161
diagnosis 163, 164, 165f
Tubal anastomosis 110, 111f, 142
Tubal blockage 97
Tubal cornual anastomosis 126
Tubal disease 126
Tubal ectopic pregnancy 122, 141
management of 122
Tubal factor 3
Tubal lesions, cause of 96, 96f
Tubal patency 112f
Tubal pregnancy, management of 117
Tubal reanastomosis 134, 141
advantages 144
disadvantages 144
microsurgical technique 142
technique 142
use of 141
Tubal sterilization 110f
Tubal surgery 104
Tuberculosis 171
Tubo-peritoneal factor 3
Tubotubal anastomosis 109, 112
Tumors
benign 55, 130
necrosis factor-alpha 237
Tunica vaginalis 196
Tunical incision, large 198
U
Ulipristal acetate 54, 57
Ultrasonography, abdominal 172
Umbilical cannula 50f
United State Food and Drugs Administration 47
Ureteric
double-J stent in situ 175f
injury 171, 172, 177
diagnosis of 172
Urinary infection 252
Urogenital sinus origin 268
Uroretroperitoneum ureteral stenting 178
Uterine
abnormalities 10
anomalies 162f
congenital 161
architecture 154
artery embolization 85, 118
bleeding, abnormal 12
cavity 11, 157
evaluation of 10
visualization of 18
chromopertubation 142
contractions 23
dimensions, measurements of 16
distension, poor 154
endoscopy 10
expansion 10
factor 148
fibroids 55
reduce symptoms 57
fluids 76
malformations, congenital 164
metroplasty surgery 164
perforation 29, 154
septa, metroplasty for 147, 154
septum 129
resection of 24
transection of 24
submucous fibroid, case of 11
surgery 129
Uterocervicovaginal atresia, congenital 259
Uterotubal ostium 97
Uterus
hypoplastic 147, 157
large 16
lateral wall of 167f
leiomyoma of 45
normal 163
robot and mobilization of 142
V
Vagal tone 226
Vagina
complete absence of 260
lower part of 268
Vaginal
approach 260
bleeding 15
cord invaginates 268
mold covered 265f
reconstruction 270
vault 172f
Vaginoplasty 259
Vaporization 21
Varicocele
repair 247
retroperitoneal repair of 249f
surgical treatment of 250
treatment 257
Varicocelectomy
subinguinal 249
technique of 247t
Vas deferens
absence of 253
reconstructive surgery of 253
Vascular resistance, pulmonary 226
Vascularity near pelvic collection 175f
Vasoepididymostomy 253
Vasopressin 17, 227
use of 130
Vasovasostomy 253
Venous gas embolism 228
Versapoint system 24
Vertical banded gastroplasty 240
Vibrators, types of 187
Violin-string adhesions 2
Visfatin 237
Vital capacity 225
Vitamin
A 242
D 242
Vitrification 206
emergence of 207
W
Wamsteker's classification 149
World Endometriosis Society 60
World Health Organization 12
Z
Zinc 242
Zygote 254
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Chapter Notes

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Diagnostic Laparoscopy in InfertilityCHAPTER 1

Gita Ganguly Mukherjee,
Mausumi De Banerjee,
Siddhartha Chatterjee
 
INTRODUCTION
Infertility is defined as a failure to conceive during 1 year of frequent unprotected intercourse. Apart from male factors, the main causes of female infertility include tubal pathology, ovarian disorders, uterine or cervical factors, endometriosis, infection pelvic tuberculosis, etc. In recent past, diagnostic laparoscopy (DL) was the gold standard for diagnosis as well as management of female infertility. This view was supported by the World Health Organization (WHO) guidelines,1 and also American Fertility Society recommendations. It was a custom to perform DL as an essential infertility workup by about 90% of infertility specialists in the United States of America (USA) during late 90s. The main advantage of laparoscopy is that on one hand, diagnosis can be made about anatomic pelvic defect and on the other hand, corrective surgery can be performed at the same time, along with performing hysteroscopy at the same sitting. DL also termed as exploratory laparoscopy, is usually established as the most perfect and accurate procedure to detect pelvic organ pathologies likes tubal pathology, endometriosis, fibroids, ovarian cysts and other conditions influencing fertility.29
 
COMMON INDICATIONS OF DIAGNOSTIC LAPAROSCOPY
  • Patients with unexplained infertility following standard infertility screening tests usually undergo timed intercourse (TI) that coordinates the time of ovulation and coitus, controlled ovarian hyperstimulation (COH), or intrauterine insemination (IUI). If the treatment is unsuccessful, DL is performed.
  • Infertility with suspected pelvic pathology detected during clinical examination or pelvic ultrasonography (USG)
  • Infertile women with chronic pelvic pain
  • Past history of pelvic surgery involving pelvic organs
  • Women with secondary infertility.2
 
PROCEDURE IN A NUTSHELL
Laparoscopy patients are admitted 8–12 hours before the surgery and kept in fasting. The procedure is performed in postmenstrual phase. DL is performed by standard technique under general anesthesia in lithotomy position.
The laparoscope is introduced through subumbilical incision and after CO2 insufflations. Thorough assessment is performed and findings are recorded. Methylene blue is used to check the tubal patency. The patients are discharged on next day morning.
During laparoscopy, all the pelvic organs are examined very carefully by manipulating through the second puncture instrument. A third puncture may be necessary to push the bowels upward and backward, to examine the pelvic organs thoroughly, particularly the ovarian fossa, which is a very common site of endometriotic involvement which is often missed.
 
COMMON APPEARANCES OF VARIOUS LESIONS IN LAPAROSCOPY
  • Genital tuberculosis:
    • Congestion, edema, pelvic adhesions, loculated collections of fluid in subacute stages
    • Miliary tubercles, white, yellow or opaque plaques
    • Chronic stages—tubo-ovarian mass, caseous nodules, encysted ascites, various types of adhesions—both flimsy, dense, perihepatic adhesions
    • The fallopian tubes—normal, tubercles, retort-shaped, hydrosalpinx, caseous granuloma, beaded, tobacco pouch appearance (exudative or productive adhesive type of tubercular salpingitis).
  • Chlamydia and gonococcus:
    • Normal (75%)
    • Violin-string adhesions and perihepatic adhesions (Fitz-Hugh-Curtis syndrome).
  • Endometriosis:
    • Typical black/dark blue or deep red spots or peritoneal surface
    • Scarring, red flame like lesions, yellow patches, clear “bubble” like lesions, peritoneal defects and adhesions
    • Chocolate cysts.
  • Other lesions—fibroid, adenomyosis, uterine structural anomalies, ovarian cysts can be diagnosed well with laparoscopy.
The role of diagnostic laparoscopy in modern day fertility practice is under debate.
In mid-90s indicated that DL is not an ideal predictor of infertility. Moreover with this view, some authorities declined the need for this procedure as an essential workup of infertility.10,11 Consequently, with increase in popularity of 3in vitro fertilization (IVF) and it is cost-effectively, DL is increasingly bypassed. Moreover, DL is an invasive procedure requiring general anesthesia, patient anxiety, surgical accident like hollow viscus injury, and postoperative adhesion formation. A large Finnish follow-up study has concluded the complication rate of DL to be 0.6/1,000.12
If we want to avoid laparoscopy, we have to explore other alternative procedure which helps us to investigate infertility.
 
TUBAL FACTOR
Hysterosalpingography (HSG) and sonosalpingography (SSG) are the two alternative procedures to evaluate the tubal status. As the patient is exposed to radiation in HSG, many people want to avoid it and prefer to do hysterosalpingo contrast sonography (HyCoSy). It is an attractive alternative to HSG, because the patient is not exposed to X-rays or iodinated contrast media. Fallopian tubal patency is assessed using transvaginal ultrasonography (TVS) and a galactose microbubble contrast medium. The concordance rates on the assessment of tubal patency between HyCoSy and HSG are similar, making this ultrasound (US)-diagnostic tool an attractive option for the outpatient screening for tubal patency. The accuracy of HSG or HyCoSy so far pregnancy rate (PR) is concerned, are similar.13 The other disadvantages of HSG are abdominal pain and discomfort, pelvic abscess, and peritonitis. The technique of HSG has several possible adverse effects. Lower abdominal pain and discomfort are commonly experienced by patients undergoing HSG, and can be remembered for years afterward as one of the most painful outpatient examinations in gynecology. An HSG can induce or exacerbate pelvic inflammatory disease (PID), leading to peritonitis, pelvic abscess and very exceptionally, even to death.14 Uterine perforation and post-examination hemorrhage are a possibility. Other complications include granuloma formation and vascular intravasation. Hypersensitivity reactions to iodine exist with any of the HSG media, but allergic reactions are rare. Finally, the ionizing radiation used for HSG can be detrimental to an undiagnosed early pregnancy. A multicentre randomized controlled trial (RCT) comparing cumulative PRs (CPRs) in a group where HSG was followed by DL versus a group where DL alone was performed, showed no significant difference in CPR at 18 months.15 HSG can detect luminal problem of tube and uterus. But peritubal adhesion and other mild pelvic adhesion can only be detected by laparoscopy.
 
TUBO-PERITONEAL FACTOR
Minimal and mild endometriosis are better diagnosed by laparoscopy. According to a meta-analysis by Jacobson and coworkers,16 the ablation of endometriotic lesions with adhesiolysis to improve fertility in minimal and mild endometriosis is effective compared to DL alone. This recommendation is based upon a systematic review of two similar but contradictory RCTs 4performed in Italy17 and in Canada,18 comparing laparoscopic ablation or excision and adhesiolysis of endometriotic lesions versus DL alone. The fact that these two RCTs have been assembled into one meta-analysis has been criticized,19 because the Italian study had some methodological limitations.19 Some authorities have used TVS to detect mild to moderate endometriosis in the pouch of Douglas (POD), by detecting thickening of POD. This procedure is not popularized yet.20
Minor tubal defects may pass unnoticed during laparoscopic procedure. Six types of minor tubal defects had been presented by Chatterjee et al.21 Correction of these problems at the same sitting resulted in improvement of PRs in case of unexplained infertility, which is comparable to IVF PR for same type of problems.
 
LAPAROSCOPY AND OVULATION
During performing DL, ovulatory stigma may be visible. In matured preovulatory follicle or Graafian follicle with some straw-colored fluid collection in POD might indicate the ovulatory status. This is not a routine practice and USG-folliculometry and serum progesterone estimation are the standard practices for detecting ovulation. Laparoscopy before ovulation induction (OI) is not an essential step, but finding endometriosis or minimal adhesion (peritubal and periovarian) might indicate that OI may be useless to achieve a pregnancy unless the adnexae are made free. Whether minimal or mild endometriosis must be treated before OI is an unresolved question but proper OI with or without gonadotropin, IUI may be a proper step to treat ovulatory infertility.
 
LAPAROSCOPIC OVARIAN DRILLING
Laparoscopic ovarian drilling (LOD) is another way of treating polycystic ovarian disease (PCOD) particularly for clomiphene-resistant cases (20% of PCOD cases). In a recent Cochrane review,22 the efficacy of laparoscopic drilling of the ovarian capsule (laparoscopic ovarian diathermy, LOD) by diathermy or laser in clomiphene-resistant polycystic ovarian syndrome (PCOS) has been compared to gonadotropin treatment based on a total of 15 RCTs. Only six trials were included for further analysis. The primary outcome parameters were live birth rate, ovulation rate and ongoing PR. The secondary outcome parameters included rate of miscarriage, multiple PR, ovarian hyperstimulation syndrome (OHSS) and the total cost of the respective treatments. There was no evidence of difference in the live birth rate or ongoing PR or miscarriage rate between LOD and the gonadotropin. However, the multiple PRs were lower with ovarian drilling than with gonadotropin. The reviewer's conclusion is that there is no difference in the live birth rate and the miscarriage rate in women with clomiphene-resistant PCOS undergoing LOD, when compared with gonadotropin treatment.22 However, the reduction in multiple PRs in women undergoing LOD makes this option attractive.5
 
LAPAROSCOPY BEFORE INTRAUTERINE INSEMINATION
Intrauterine insemination is an effective fertility enhancement treatment in cases of cervical factor, unexplained infertility and mild male factor infertility. The role of laparoscopy before IUI is not yet specified23 and studies also could not conclude whether laparoscopy before IUI influences the success rate. Scientific evidence suggests that minimal and mild endometriosis, treated surgically before starting COH (COH and IUI may increase the cycle PR and reduce the time to pregnancy).24 Indeed, in a retrospective cohort study, D'Hooghe and coworkers24 recently showed data suggesting that it is useful to treat minimal and mild endometriosis before starting COH and IUI.25 The study observed that surgical treatment prior to IUI restores the clinical PR after COH and IUI in women with minimal to mild endometriosis to the same level, as that in women with unexplained infertility. This is in contrast with previous studies where the cycle PR and CPR seemed to be lower in patients with surgically untreated minimal to mild endometriosis than those with unexplained infertility.24 Randomized trials are needed to verify this conclusion, which might have important implications.
The noncontrolled retrospective evidence in this study stresses the importance of referring patients with severe endometriosis to a center with the necessary expertise,26 in which case even after several failed IVF cycles, radical and appropriate surgery may still be beneficial to their reproductive outcome. It is clear that further randomized controlled studies are needed to support this view on laparoscopic treatment of severe endometriosis after failed IVF cycles.
 
LAPAROSCOPY IN ADVANCED ENDOMETRIOSIS
Laparoscopy can diagnose advanced endometriosis and sometimes, some definitive surgery is added to it in anticipated cases, mostly to alleviate pain. Adnexal endometriotic involvement like endometrioma may need laparoscopic procedure even before IVF treatment. The restoration of pelvic anatomy may increase spontaneous PR but in India, this rise is negligible because of presence of associated adenomyosis.27 No definite data regarding the benefit of laparoscopy in endometriosis is available. There seems to be a negative correlation between the stage of endometriosis and the spontaneous CPR after surgical removal of endometriosis based upon the evidence of three studies,28,29 but statistical significance for this statement was only reached in one study.27 Laparoscopic surgery for advanced endometriosis may technically be very demanding, time consuming, and high risk with significant post TI morbidities and needs tremendous expertise. Laparoscopy for the treatment of endometriosis in failed IVF patients if performed by very experienced surgeon might increase a PR. A non-controlled retrospective study stressed the importance of such procedure in very experienced hand.266
 
DEBATE OF LAPAROSCOPY AND IN VITRO FERTILIZATION
This is true that the progresses of IVF technology have made the need for laparoscopic procedures less important in the treatment of infertility. However, there is a fair degree of consensus that in selected adnexal pathologies, such as hydrosalpinx and ovarian endometriotic cysts, still have to be treated by laparoscopic surgery prior to IVF.
With respect to hydrosalpinx, two RCTs have demonstrated increased implantation and PRs in IVF cycles after salpingectomy for ultrasonically visible hydrosalpinges.30,31 Both these trials have been included in a recent Cochrane review.32 The Scandinavian trial31 reports a delivery rate per started cycle of 27% in IVF patients undergoing salpingectomy prior to IVF treatment versus 17% in the control group without salpingectomy. The adverse effect of hydrosalpinx on assisted reproductive technology (ART) success rates can be explained by several mechanisms: the direct toxic effect of tubal fluid on the embryos, the negative effect of tubal fluid on the endometrium by flushing out embryos, dilution of implantation factors and prevention of normal embryonic-endometrial apposition.33 Some authors like Puttemans et al. have warned against the indiscriminate and blind victimization of the fallopian tube and have advocated selective salpingostomy in selected cases.34 A RCT of reconstructive tubal surgery versus salpingectomy and IVF in women with hydrosalpinx is needed to define the position of both treatment strategies in everyday clinical practice, but can only be done in countries with a high prevalence of PID.25 Ovarian endometrioma or chocolate cyst should be considered crucially. Small endometrioma of less than 3 cm may not hinder IVF result and treating them may kill the time as well as inappropriate surgery may reduce ovarian function. Larger symptomatic endometrioma if removed, improves fertility rate, oocyte pickup (OPU) rate and reduces the recurrence rate.3537 With respect to endometriosis and ART, the recent European Society of Human Reproduction and Embryology (ESHRE) guidelines state that IVF is appropriate treatment especially if tubal function is compromised, if there is also male factor infertility and if other treatments have failed.26
The IVF PR is lower in patient with advanced endometriosis as compared to other factors.
 
CONCLUSION
Diagnostic laparoscopy, which was at one time essential step for evaluation and treatment of infertility, is gradually losing ground due to more and more advancement of ART procedures. The routine use of diagnostic laparoscopy for evaluation of all cases of female infertility is currently under debate. Laparoscopy performed after several failed cycles of OI in unexplained infertility cases may detect significant proportion of pelvic pathology amenable to treatment, but many authorities deny that because they think correction of those pathologies 7like mild and minimal endometriosis do not increase PR. LOD in clomiphene citrate-resistant PCOS is at least as effective as gonadotropin treatment, and the only advantage being reduction of multiple PRs. The role of diagnostic laparoscopy before IUI is controversial. In case of definite tubal pathology like hydrosalpinx or large ovarian endometrioma, laparoscopy improves the PR through IVF. The evidence of benefit of laparoscopic surgery in moderate and severe endometriosis is still lacking. Though its role has generally been accepted, the use of laparoscopy should be individualized and should not be used randomly in the treatment of infertility.
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