Office hydrolaparoscopy for the diagnosis of endometriosis and tubal infertility

Comparison of hysterosalpingography and transvaginal hydrolaparoscopy in patients with tubal factor infertility: a prospective cohort study

Aim

To evaluate the usefulness, diagnostic accuracy, and cost-effectiveness of transvaginal hydrolaparoscopy (THL) in infertile women with abnormal hysterosalpingogram (HSG) results without obvious pelvic pathology.

Material and methods

Thirty infertile women (age: 20–40 years) who had tubal pathology in HSG were enrolled in the study. All patients underwent THL instead of standard laparoscopy. A cost analysis was performed comparing HSG and THL methods.

Results

In comparison of the HSG of cases by considering the chromopertubation results by THL, the sensitivity and specificity of HSG were 85.1% and 56%, respectively. The reasons for preferring standard laparoscopy rather than THL were: failure in accessing of Douglas (n = 3), insufficient monitoring of pelvis (n = 1), hydrosalpinx (n = 1), and intense peritubal adhesion (n = 1), which were 10%, 3%, 3%, and 3%, respectively. The complication rate was 3.8%. Cost analysis of the procedures showed that the total cost of the THL group was 34.8% lower than the HSG group.

Conclusions

In the elective patients group, THL is more feasible than HSG. Transvaginal hydrolaparoscopy is effective, simple and safe, avoiding the cost, possible complications, time and postoperative patient discomfort compared to conventional laparoscopy.

Transvaginal hydrolaparoscopy

The authors conclude that transvaginal hydrolaparoscopy appears to be a safe alternative to hysterosalpingography and laparoscopy for evaluation of tubal patency and pelvic pathology.

Transvaginal hydrolaparoscopy (THL) is being performed regularly in Europe and China, but rarely in the United States. The reasons may be physicians’ unfamiliarity with the procedure and their uneasiness over potential rectal puncturing due to the proximity of the rectum to the vaginal trocar insertion site. THL has the advantage over hysterosalpingography (HSG) in that it allows for direct visualization of the tubal mucosa in addition to determining tubal patency. THL has advantages over traditional laparoscopy in that it does not require an abdominal incision and has the capability of being conducted in an outpatient office setting with local anesthesia. Studies have shown that THL has comparable accuracy to laparoscopy with 96.1% concordance between THL and laparoscopic findings. THL may be combined with chromopertubation and salpingoscopy. In addition to diagnostic purposes, THL may be used for operative intervention including adhesiolysis, endometriosis ablation, and ovarian drilling. Studies from France and China report the occurrence of rectal injury from 0% to1%. Despite the advantages of THL and low reports of rectal injury, THL has not gained popularity in the United States. The purpose of this article is to familiarize gynecologists in the United States with THL.

One stop fertility clinic

The objective of this study was to determine the feasibility and acceptability of out-patient based investigation of infertile couples using a prospective observational study based in a large undergraduate teaching hospital. We studied couples referred to secondary care for investigation of their infertility. Investigations involved pelvic ultrasound, diagnostic hysteroscopy and culdoscopy. The main outcome measures were feasibility of investigations, findings, patient views, and a management plan.

RESULTS

199 of 347 (57.3%) couples referred met our selection criteria, and 162 of this group have attended. Thirty-one (19.1%) were judged to be unsuitable for culdoscopy, and culdoscopy failed in a further 29 (17.9%). The average time for the three procedures was 41.2 (SD 17.2) minutes, and over 1/3 of patients were found to have pelvic pathology. The investigations were well tolerated and there was only one complication necessitating admission to hospital. Most patients appreciated the need for a single hospital visit and the availability of immediate results.

CONCLUSIONS

A One Stop approach to the investigation of infertility is attractive but not suitable for or desired by all infertile couples. Organisational issues were also identified.

Place of transvaginal fertiloscopy in the management of tubal factor disease

In the case of tubal disease, selection of patients is critical to decide whether tubal surgery or IVF should be proposed as the therapeutic option. Selection is based on tubal lesions, including the aspect of tubal mucosa and tuboperitoneal environment. Therefore, non-invasive diagnostic methods have proved to be insufficient, and endoscopy is mandatory. Fertiloscopy represents an attractive alternative. Fertiloscopy is minimally invasive, reproducible, and at least as precise as lap and dye. Moreover, fertiloscopy and not laparoscopy allows the routine practice of salpingoscopy and microsalpingoscopy. On this basis, fertiloscopy should be adopted as the standard procedure for tubal evaluation in the management of tubal disease.

Surgical intervention in infertility management

Despite improvement in the success of IVF, reproductive surgery will remain an important option and complement to assisted reproductive technologies (ART) for many couples. Reproductive surgery should be considered as the first-line treatment when the correction of infertility pathologies is simple and a good result is expected once corrected, when the pathology is causing symptoms such as pain or abnormal bleeding, or if uncorrected will compromise the results or increase the risks of ART. The success of surgical infertility treatment depends on the careful selection of cases using appropriate investigative techniques, with procedures performed in centres with sufficient expertise. For both specialized reproductive and general gynaecological surgery it is crucial to follow microsurgical principles to avoid adhesion formation and conserve normal tissues, especially tubal and ovarian. These aspects of reproductive surgery, and different surgical techniques used for various tubal, peritoneal, uterine and ovarian conditions to achieve the optimal reproductive outcome are discussed in this article.

Experience with 109 cases of transvaginal hydrolaparoscopy

We conducted a prospective review of our experience with 109 transvaginal hydrolaparoscopies (THLs) performed in 97 women. The THL was considered complete in 101 procedures (93%) and adequate for management in 105 (96%). Two complications occurred (1.8%), one failed entry and one perforation of a retroflexed uterus. Diagnoses for 67 infertile patients were normal pelvis in 34 (51%), endometriosis in 14 (21%), adhesions in 6 (9%), and tubal obstruction in 10 (15%); 3 THLs (4%) were considered incomplete. Of 17 women with dysmenorrhea, a normal pelvis was found in 8 (47%) and endometriosis in 9 (53%). In 11 patients with pelvic pain endometriosis was found in 4 (36%), normal pelvis in 3 (27%), and adhesions in 3 (27%); THL was incomplete in 1 (9%). Six infertile patients (9%) had operative laparoscopy and 10 (15%) operative THL; 6 (9%) were counseled to seek in vitro fertilization. Pregnancy occurred in 16 patients (24%). Analog pain scores (0 = no pain, 10 = worst pain) were tracked in 39 consecutive patients. Pain during trocar insertion averaged 4.2 +/- 0.5, 2.2 +/- 0.2 at midprocedure, and 1.1 +/- 0.1 at the end of THL. We believe that THL should be considered instead of hysterosalpingogram and laparoscopy in selected patients.

Transvaginal hydrolaparoscopy: a new diagnostic tool in infertility investigation

BACKGROUND

To establish the value of a new technique called transvaginal hydrolaparoscopy for exploration of the tubo-ovarian structures in the management of patients with unexplained infertility.

METHODS

A total of 120 women with primary or secondary infertility, and without obvious pelvic pathology, were included in the study. The first 14 patients received general anesthesia and underwent transvaginal laparoscopy immediately before standard laparoscopy. The remaining 106 patients had transvaginal laparoscopy performed under local anesthesia, with standard laparoscopy performed only on those with pathology, which required operative intervention. Information on pathology, complications, and successful access to the pouch of Douglas were recorded.

RESULTS

The successful rate of access was 93%. Pathology was found in 29 patients, of whom 15 required operative laparoscopy. Also, out of 19 patients with adhesions, 11 (58%) had normal dye test bilateral, and only two (11%) had bilateral occlusion of the tubes. No complications were observed.

CONCLUSION

Transvaginal hydrolaparoscopy is a safe and well-tolerated method for investigating the tubo-ovarian structures in unexplained infertility. It is superior to hysterosalpingography for diagnosis of adhesions.

Transvaginal hydrolaparoscopy

Transvaginal hydrolaparoscopy (THL) correlates well with standard laparoscopy for evaluation of the cul-de-sac in women with unexplained infertility. Office THL, chromopertubation, and hysteroscopy appear well tolerated, safe, and suitable for most patients, and may be more cost effective than hysterosalpingogram in the infertility work-up. Gynecologic and operative THLs are applicable for selected indications.

Ultrasonographic guided ovarian stroma hydrocoagulation for ovarian stimulation in polycystic ovary syndrome

OBJECTIVE

To evaluate the safety and effectiveness of transvaginal ultrasound guided injection of hot saline into the ovarian stroma in polycystic ovary syndrome (PCOS) cases in an office based gynecology practice under local anesthesia.

SETTING

Outpatient gynecologic clinic.

STUDY DESIGN

Pilot study.

PARTICIPANTS

Fifty-two anovulatory infertile females diagnosed as PCOS by clinical, chemical and ultrasound criteria were recruited for the study. All cases were resistant to clomiphene citrate for more than 6 months.

INTERVENTION

Injection of warm sterile saline (75C) into the ovarian stroma under transvaginal monitoring using ovum pickup needle.

OUTCOME MEASURES

Cycle regularity, ovulation rate and safety were primary outcomes. Pregnancy rate and patient convenience were our secondary outcomes.

RESULTS

Ovulation has been achieved in 73.1% of clomiphene citrate resistant PCOS cases and resulted in pregnancy in 26.9% of these cases. No adverse effects were recorded and the procedure was tolerable in most cases.

CONCLUSION

Transvaginal ultrasound guided ovarian stroma hydrocoagulation (TOSH) in an office setting seems to be a safe, economic and practical procedure that is acceptable by the patients. If larger studies confirm its effectiveness it may be an attractive alternative to conventional ovarian drilling.

Office transvaginal hydrolaparoscopy for early diagnosis of pelvic endometriosis and adhesions

STUDY OBJECTIVE. To evaluate the feasibility of a new endoscopic technique, transvaginal hydrolaparoscopy, for early office screening of subfertile women. DESIGN. Retrospective, descriptive feasibility study (Canadian Task Force classification II-2).

SETTING

Office in an infertility center.

PATIENTS

One hundred fifty-seven continuous women with primary or secondary subfertility.

INTERVENTION

Under local anesthesia, a Veress needle-cannula system was inserted into the posterior fornix with peritoneal distention by saline.

MEASUREMENTS AND MAIN RESULTS

Access was achieved in 95% of patients. In 58.5% the findings were normal and in 28% an explorative or operative laparoscopy was indicated. No major complication occurred. Patients' pain scores were similar to those for office hysteroscopy.

CONCLUSION

Transvaginal hydrolaparoscopy was successfully performed in the office. The technique allows early and complete endoscopic screening of subfertile women.