Feasibility and clinical significance of endoluminal assessment by transvaginal salpingoscopy during transvaginal hydrolaparoscopy in infertile women

Tubal flushing with oil-based contrast during transvaginal hydro laparoscopy, a case report

Background: Oil-based contrast has been shown to have a fertility-enhancing effect during hysterosalpingography (HSG) but is not yet used during transvaginal hydro laparoscopy (THL). Objective: To asses if additional tubal flushing with oil-based contrast during THL is feasible. Materials and methods: Case report with video assessment. A healthy 29-year-old woman with primary unexplained subfertility, underwent a THL under local anaesthesia. First, chromopertubation was performed by methylene blue. Afterwards, tubal flushing with 3mL oil-based contrast (Lipiodol® UltraFluid, Guerbet) was performed. Main outcome measures: In this case report we evaluated the feasibility of additional tubal flushing with oil- based contrast during THL, in terms of; the visibility of the oil-based contrast at the tubal fimbriae, the pain and acceptability scores. Results: Both fallopian tubes were patent to methylene-blue as well as to oil-based contrast. Interestingly, the oil-based contrast came out of the fallopian tube in the form of free droplets with strong internal bonding. Furthermore, some residue of the droplets was visible on the surface of the peritoneal wall in the form of oily micro-droplets. Conclusions: We present the first sub-fertile woman, in which additional tubal flushing with oil-based contrast during THL was performed. It is likely, that the residue of oily micro-droplets is also present inside the fallopian tube, where it may enhance the cilia movement by introducing lubrication. These lubricating characteristics of the oil-based contrast may be important for its fertility-enhancing effect. More research is necessary to confirm this hypothesis and the feasibility of tubal flushing with oil-based contrast during THL in more women.

Systematic use of transvaginal hydrolaparoscopy as a minimally invasive procedure in the exploration of the infertile patient: results and reflections

Background

The aim of this study was to evaluate the added value of transvaginal hydrolaparoscopy (THL) in the investigation of the infertile patient.

Methods

A retrospective cohort study, based on records from 01/09/2006 to 30/12/2019 was undertaken in a tertiary care infertility centre. THL was performed in 2288 patients. These were patients who were referred for endoscopic exploration of the female pelvis as part of their infertility investigation. In 374 patients with clomiphene- resistant polycystic ovary syndrome (PCOS), ovarian capsule drilling was also performed. The outcome objectives of this study included the evaluation of the added diagnostic value of THL as well as the feasibility and safety of the visual inspection of the female pelvis using this technique.

Results

Of the 2288 procedures failed access to the pouch of Douglas occurred in in 23 patients (1%). The complication rate was 0.74%, due to bowel perforations (n= 13) and bleeding (n= 4) requiring laparoscopy. All bowel perforations were treated conservatively, with 6 days of antibiotics, and no further complications occurred. Findings were normal in 49.8% of patients. Endometriosis was diagnosed in 366 patients (15.9%); adhesions were present in 144 patients.

Conclusions

THL is a minimally invasive procedure, with a low complication and failure rate, providing an accurate visual exploration of the female pelvis in a one-day hospital setting. When indicated, minimally invasive surgery is possible in the early stages of endometriosis and for ovarian capsule drilling in patients with clomiphene- resistant PCOS.

[Comparison of fertiloscopy versus laparoscopy in the exploration of the infertility: analysis of the literature]

BACKGROUND

Fertiloscopy is a recent technique designed to explore the tubo-ovarian axis in unexplained infertility. It is a simple outpatient technique, allowing to perform operative procedures, but its position relative to laparoscopy is yet to be defined.

MATERIAL AND METHODS

A thorough and extensive bibliographical search was undertaken to fully embrace the question, challenging Medline at the National Library of Medicine, Cochrane Library, National Guideline Clearinghouse, Health Technology Assessment Database. All the retrieved articles were classified as either descriptive or comparative studies and evaluated on a set of criteria.

RESULTS

Most of the papers described case series coming from a few teams, focusing mainly on the technical aspect of the procedure, like the access rate to the posterior cul-de-sac, the success rate in visualizing the pelvis, the complications rate (mainly rectal perforation), and its operative performance in drilling ovaries for resistant polycystic ovarian syndrome. Comparative studies numbered six trials. They all followed the same design, fertiloscopy preceding conventional laparoscopy in patients taken as their own control. The concordance rate between the two modalities reaches 80% in terms of tubal pathology, adherences and endometriosis, with an estimated reduction of laparoscopies varying from 40% to 93%.

CONCLUSION

The current literature shows a concordance between fertiloscopy and conventional laparoscopic findings for certain parameters in cases of tubal pathology, adherences and endometriosis. The relative positions of these two modalities in unexplained infertility still remain elusive.

Major complications and outcome of diagnostic and operative transvaginal hydrolaparoscopy

AIM

Transvaginal hydrolaparoscopy (THL) has recently been developed as a less invasive alternative to conventional laparoscopy. There are some reports that described the usefulness and prognostic value of diagnostic THL in infertile women. Moreover, operative THL such as ovarian drilling for unovulatory women with polycystic ovarian syndrome (PCOS) to induce ovulation has also been found to be as effective as that by conventional laparoscopy. The risk of bowel injury and sepsis by transvaginal access with culdoscopy was higher than that with laparoscopy in the previous reports. The purpose of the present study was to examine the risk of diagnostic and operative THL according to two case studies with a literature review.

METHODS

The authors carried out diagnostic or operative THL in 177 infertile women, aged 22-43 years. Major complications during THL and a review of the literature were analyzed.

RESULTS

Two cases of bowel injury were diagnosed during diagnostic THL. No complication occurred during operative THL. In total, the incidence of bowel injury was 1.1%. The injuries were diagnosed during THL and treated expectantly under strict conditions in both cases. Ten studies in the literature reported a total of 4232 procedures, including 26 bowel injuries (0.61%) and one perforation of a retroflexed uterus (0.02%).

CONCLUSIONS

The usefulness of THL for diagnostic and operative purposes is in no doubt. However, informed consent should be obtained and vigilance before and during THL should be maintained, although it can be done on an outpatient clinic basis.