Endometriosis: modern surgical management to improve fertility

Endometriosis is a pleiotropic reproductive condition and the lesions visualized at laparoscopy are only one aspect of this disease process. At present, there is no evidence that surgery for endometriosis can cure infertility. The most important surgery in infertility is ovarian surgery. It is generally accepted that, in most cases, the invagination of the cortex results in the formation of an endometriotic pseudocyst. As a consequence, primordial follicles are present at the base of the cyst. Since surgery is of limited value, the utmost care has to be given to conservation of the patient's fertility. Ablative surgery offers advantages over excision of the cyst in terms of less adhesion formation and better preservation of the ovarian reserve. The ablative eversion technique differs from fenestration and drainage by its access through the site of inversion and resection of the fibrotic ring. Using the new technique of transvaginal hydrolaparoscopy, access to the site of pathology in the fossa ovarica is facilitated. Furthermore, the aqueous distension medium keeps the organs afloat and provides a clear delineation between the organs and adhesions allowing atraumatic reconstructive surgery.

Experience with transvaginal hydrolaparoscopy for reconstructive tubo-ovarian surgery

The transvaginal approach to tubo-ovarian surgery allows easy and direct access to the tubo-ovarian structures and the fossa ovarica without additional manipulation. In the absence of a panoramic view, the proximity of the tubo-ovarian structures allows operative procedures for treatment of superficial and cystic ovarian endometriosis, drilling of the ovarian capsule, adhesiolysis and salpingostomy. Operative procedures were performed in 78 patients. No conversion to standard laparoscopy was necessary, and no complications occurred. All procedures were carried out on an ambulatory basis with a very low morbidity.

One-stop endoscopy-based infertility clinic

PURPOSE OF REVIEW

The investigation of the infertile couple is currently a highly debated issue. The purpose is to review whether transvaginal hydrolaparoscopy in combination with mini-hysteroscopy and chromopertubation can be offered as a one-stop infertility investigation.

RECENT FINDINGS

The technique is based on the direct visualization of the reproductive organs and the presence of tubal patency, and has been clinically validated during the past year for its accuracy, safety and patient tolerance.

SUMMARY

Further prospective randomized studies are required to prove the superiority of transvaginal hydrolaparoscopy in comparison with hysterosalpingography as a first-line investigation in predicting the fertility outcome.

Transvaginal hydrolaparoscopy but not standard laparoscopy reveals subtle endometriotic adhesions of the ovary

OBJECTIVE

To determine whether transvaginal hydrolaparoscopy is superior to standard laparoscopy for detection of subtle endometriotic adhesions of the ovary.

DESIGN

Videotapes of standard laparoscopy and transvaginal hydrolaparoscopy were viewed by an independent observer in random order and in a blinded manner.

SETTING

Tertiary referral centers for infertility.

PATIENT(S)

Patients with minimal or mild endometriosis (n = 11) and unexplained infertility (n = 10) on standard laparoscopy from a group of 43 patients with infertility who were undergoing both studies.

INTERVENTION(S)

Transvaginal hydrolaparoscopy followed by standard laparoscopy.

MAIN OUTCOME MEASURE(S)

Detection of unexplained ovarian adhesions.

RESULT(S)

Patients with minimal and mild endometriosis and unexplained infertility had significantly more ovarian adhesions on transvaginal hydrolaparoscopy than on standard laparoscopy. The subtle adhesions seen on transvaginal hydrolaparoscopy but not on standard laparoscopy were filmy, microvascularized, and nonconnecting.

CONCLUSION(S)

Unexplained ovarian adhesions are frequently detected on transvaginal hydrolaparoscopy but not on standard laparoscopy in infertile patients with minimal and mild endometriosis and unexplained infertility.