Minimally invasive exploration of the female reproductive tract in infertility

An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review

Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.

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.

Prospective evaluation of the learning curve of fertiloscopy with and without ovarian drilling

Fertiloscopy represents an alternative to laparoscopy in the diagnostic evaluation of unexplained infertility or for the purpose of ovarian drilling. The learning curve of fertiloscopy in an experienced laparoscopic surgeon was evaluated in a prospective multicentre observational trial. A total of 110 fertiloscopies were carried out. At Centre 1, a beginner, and at Centre 2, an expert in fertiloscopy, performed the procedures. In three cases in Centre 1, and in 0 cases in Centre 2, the procedure was converted to transabdominal laparoscopy owing to intraoperative complications. Median operating time was longer at Centre 1 during the first 40 procedures (P < 0.001) and equal thereafter. Analyzing fertiloscopies with and without ovarian drilling separately, operating time was only longer for the first 20 procedures in each group (P < 0.001 and P = 0.002). In a multivariate analysis, intraoperative complications and fertiloscopy with ovarian drilling (compared with diagnostic fertiloscopy) were associated with longer duration of surgery (P < 0.001 for both parameters). An increasing consecutive number of fertiloscopies was associated with shorter duration of surgery (P < 0.001). Experienced laparoscopists should consider a transition towards fertiloscopy in the diagnostic workup of unexplained infertility or for the purpose of ovarian drilling.

Transvaginal endoscopic surgery for tubal ectopic pregnancy

Transvaginal endoscopic salpingectomy for tubal ectopic pregnancy appears to be feasible and safe and may result in less postoperative pain compared with a laparoscopic approach.

Objective:

To explore the feasibility, safety, efficacy, and cosmetic outcomes of transvaginal endoscopic salpingectomy for tubal ectopic pregnancy.

Methods:

From May 2009 to May 2012, we prospectively enrolled 40 patients, each of whom had been scheduled for a salpingectomy because of a tubal ectopic pregnancy, and randomized them into two groups: transvaginal endoscopic surgery and laparoscopic approach. We recorded the estimated blood loss, time of anal exhaust, postoperative pain score, length of stay, and scar assessment scale associated with transvaginal endoscopic access (n = 18) (natural orifice transluminal endoscopic surgery) and laparoscopic salpingectomy (n = 20) (control group) for tubal ectopic pregnancy. The transvaginal salpingectomy was performed with a double-channel endoscope through a vaginal puncture. A single surgeon performed the surgical procedures in patients in both groups.

Results:

The group that underwent the transvaginal endoscopic procedure reported lesser pain at all postoperative visits than the group that underwent the laparoscopic approach. The duration of time for transvaginal endoscopic surgery was slightly longer than that for the laparoscopic approach. However, there was no statistically significant difference between the two groups in the duration of operative time. The group that underwent transvaginal endoscopic surgery was more satisfied with the absence of an external scar than the group that underwent the laparoscopic procedure, which left a scar. The estimated blood loss, time of anal exhaust, and length of stay were the same in both groups.

Conclusion:

The safety and efficacy of transvaginal endoscopic salpingectomy for tubal ectopic pregnancy are equivalent to those of the laparoscopic procedure. Lesser postoperative pain and a more satisfactory cosmetic outcome were found with the transvaginal endoscopic procedure, making it the more preferred method and superior to the laparoscopic approach.

[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.

Affordable IVF for developing countries

Worldwide, more than 80 million couples suffer from infertility; the majority are residents of developing countries. Residents of developing countries encounter a lack of facilities at all levels of health care, but especially infertility diagnosis and treatment. Infertility defined as a disease has a much stronger negative consequence in developing countries compared with Western societies. Social isolation, economic deprivation and violence are commonly observed. Tubal infertility due to sexually transmitted diseases, unsafe abortion and post-partum pelvic infections are the main causes of infertility in developing countries. Very often those conditions are only treatable by assisted reproductive technologies. Although preventative measures are undoubtedly the most cost-effective approach, not offering assisted reproduction is not an alternative. This study proposes a specially designed infertility care programme leading to cost-effective simplified assisted reproduction as a valid treatment protocol in developing countries when prevention or alternative methods have failed. Special attention should be given to avoid adverse outcomes such as ovarian hyperstimulation and multiple embryo pregnancy.

Office hysteroscopy and adenomyosis

Adenomyosis, the heterotopic presence of endometrial glands and stroma within the myometrium, has traditionally been diagnosed by the pathologist in hysterectomy specimens. However, the recent development of high-quality non-invasive techniques such as transvaginal sonography (TVS), magnetic resonance imaging (MRI) and hysteroscopy has renewed interest in diagnosing adenomyosis in the office prior to any treatment. Hysteroscopy offers the advantage of direct visualization of the uterine cavity, and since nowadays it is performed in the office, it can be offered as a first-line diagnostic tool for evaluation of uterine abnormalities in patients with abnormal uterine bleeding and/or infertility. The available data clearly indicate that high-quality mini-hysteroscopes, saline as a distension medium, and atraumatic insertion technique are essential for the success of office hysteroscopy. The procedure is indicated in any situation in which an intrauterine anomaly is suspected; it is immediately preceded by a physical exam and a TVS to evaluate uterine characteristics, and it is followed by a second TVS to take advantage of the intracavitary fluid for a contrast image of the uterus. Although diagnostic hysteroscopy does not provide pathognomonic signs for adenomyosis, some evidence suggests that irregular endometrium with endometrial defects, altered vascularization, and cystic haemorrhagic lesion are possibly associated with the entity. In addition to the direct visualization of the uterine cavity, the hysteroscopic approach offers the possibility of obtaining endometrial/myometrial biopsies under visual control. Since they can be performed in the office, the combination of TVS, fluid hysteroscopy and contrast sonography is therefore a powerful screening tool for detecting endometrial and myometrial abnormalities in association with adenomyosis.

Transvaginal laparoscopy

Transvaginal laparoscopy (TvL) offers an alternative to standard diagnostic laparoscopy in subfertile patients without obvious pelvic pathology. With a specially developed needle-trocar system, access to the pouch of Douglas is gained through a needle puncture of the posterior fornix. Performed under local anaesthesia or sedation with the patient in a dorsal decubitus position and using prewarmed Ringer lactate as a distension medium, TvL allows complete exploration of the tubo-ovarian structures without supplementary manipulation. The combination of transvaginal sonography and transvaginal endoscopy, including minihysteroscopy, TvL, salpingoscopy and chromopertubation test, permits the most complete exploration of the reproductive tract and can be used as a first-line investigation of female fertility in a one-stop infertility clinic. As the transvaginal route offers easy access to the tubes, ovaries and fossa ovarica, some operative procedures are possible. However, in the absence of a panoramic view, these will be limited to minor interventions.