Prof.Dr. M. Turan

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Prof.Dr. M. Turan ÇetinÇukurova
University Faculty of Medicine Dept.of
GynObs.Adana-2008
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Causes of female infertility

• Tuboperitoneal factor
• Ovulatory factor
• Cervical factor
• Uterine factor
• Unexplained

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Methods of Infertility Investigation

• Female hormone assessment
• Spermiogram
• Evaluation of uterine cavity, tubes and/or
  ovaries
• Pelvic ex.
• Ultrasonography
• HSG
• SHG
• HyCoSy
• Chlamydia trachomatis antibody testing
• Laparoscopy and Minilaparoscopy
• Transvaginal hydrolaparoscopy (THL)
• Falloposcopy
• Hysteroscopy

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Non-invasive techniques

• Pelvic exam
• Pelvic USG
• Chlamydia antibody test
• HyCoSy
• SHG
• HSG

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Invasive techniques

• Hysteroscopy (evaluation of uterine cavity)
• Falloposcopy (evaluation of tubal lumen)
• Laparoscopy and Minilaparoscopy (evaluation of
  tubes, peritoneum, ovaries)
• THL (evaluation of tubes,peritoneum, ovaries)

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Should laparoscopy be used in the standard
evaluation of infertile women ?
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Optimal initial infertility investigation
protocol should be (Ekerhovd)

• Diagnostically accurate,
• Expeditious
• Cost effective
• Reliable
• As minimally invasive as possible
• providing clinician with useful prognostic
  information regarding possible future treatment

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Pelvic exam

• Should always be the first exam in infertility
  work-up

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Ultrasonography

• Simple,quick and non-invasive
• Valuable information about uterine wall, cavity
  and tubes (hydrosalpinx,ep)
• Correct diagnosis of PCO which is common cause of
  anovulation
• Most common imaging modality for endometriosis.
  Particularily endometrioma.
• Limited role in diagnosis of adhesions or
  superficial peritoneal implants

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Ultrasonography

• Low efficiency in detecting pelvic pathology
  causing infertility. Should be reserved for
  specific indications (Preutthipan et al)

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HyCoSy(Hystero-salpingo-contrast-sonography)

• Similar accuracy in detecting tubal patency as
  HSG
• Better visualization of uterine cavity than HSG
• no radiation exposure

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HyCoSy vs HSG (by Strandell et al.)

• HSG HyCoSy
• Sensitivity 60 50
• Specificity 77 84
• significant agreement between obtained results

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HyCoSy

• So can be offered as a screening test for
  infertile women
• (Shahid et al)

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HSG

• Commonly used for assessment of tubal disease
• Painful procedure
• Has low sensitivity
• Has high specificity
• Less invasive than laparoscopy
• Has presumed ability to induce pregnancies

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HSG vs. Lap (Stewart et al.)

• Estimated ROC curve for diagnosis of peritubal
  adhesions shows HSG to be unreliable test
• HSG has sensitivity of 65 and specificity of 83
  for diagnosis of tubal occlusion compared with
  laparoscopy

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High false positive of HSG thought to be due to

• tubal spasm,
• dissimilar tubal filling pressure,
• too high viscosity of contrast medium and
• faulty technique
• can be lowered when HSG combined with Chlamydia
  titres

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Chlamydia serology

• Simple and inexpensive
• Causes minimal inconvenience to patient
• Provides no information on tubal integrity
• Based on detection of previous infection
• Other possible causative agents are not
  identified
• High titres of Chlamydia IgG antibody associated
  with inflammatory tubal damage, pelvic adhesions
  and increased risk of tubal pregnancy
• But cannot be used as sole test of tubal patency

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• Chlamydia antibodies are seen in 11.6 of the
  normal population
• It is found in 55.6 of women with tubal factor
  infertility
• This shows us that chlamydia antibodies are
  important in tubal infertility
• M.T.ÇETIN et
  al. Indian J.Med Res. 1992.

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Thomas et al.

• Titres should be done before method of tubal
  assessment is selected
• Adnexal adhesions better picked up by laparoscopy
  are more common in women with high titres (higher
  than 1/ 128) so these women should have
  laparoscopy
• Low titres (less than 1/128) can be combined with
  HSG

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Chlamydia antibody testing

• its use will reduce the number of laparoscopies
  performed
• 
  Hum.Repr.15.2000

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• Many studies already demonstrated limits of
  procedures such as HSG in diagnosis of
  tuboperitoneal infertility,
• underlining role of endoscopy in infertility
  assessment (Querleu et al, Cundiff et al, Mol et
  al)

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Laparoscopy

• Advantages
• Panoramic view of pelvic structures
• More on-the- spot interventions

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• Disadvantages
• Requires general anesthesia
• Considered major surgical procedure due to risk
  of complications
• Increased cost
• CO2 pneumoperitoneum provokes patient discomfort
  and acidosis potentially harmful

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• Laparoscopy has traditionally been the final
  diagnostic method in the infertility
  investigation.
• Difficult to convince women with normal HSG of
  the necessity of performing lap. These women
  generally prefer IVF.
• 
  Hovav and Hornstein,1999.

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IUI recommended

• Norm.HSG or susp uni-tp 63
• Lap.confirmation 60
• 3..(4.8)IVF
• Change in original treatment plan of 4.8 for
  normal or suspected unilateral tubal pathology on
  HSG
• Lavy et al. ObsGyn. 2004

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IVF recommended

• susp bi tp 23
• Lap confirmation 16..IVF(69.6)
• 6..(26) IUI
• 1..(4.3)IUI
• Change in original treatment plan of 30 for
  suspected bilateral tubal pathology on HSG
• Lavy et al. ObsGyn.
  2004

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Laparoscopy may be omitted in women with

• normal HSG or
• suspected unilateral distal tubal pahology on HSG
  
• since it was not shown to change original
  treatment plan indicated by HSG in 95 of
  patients.
• Lavy et al

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Laparoscopy should be recommended in cases

• with suspected bilateral tubal occlusion on HSG
• since it altered the original treatment plan in
  30 of patients from IVF to IUI
• Lavy
  et al.

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In bilateral visible hydrosalpinges

• Laparoscopy may be option for evaluation of the
  tubes and treatment with salpingectomy or
  salpingoneostomy in order to enhance chance of
  pregnancy (Erel et al)

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Hydrosalpinx

• Two randomized controlled trials have revealed
  increased implantation and PR in IVF cycles
  following salpingectomy (Dechaud et al, Strandell
  et al)
• Increased PR and IR after cauterization or
  ligation of hydrosalpinx (Murray et al,
  Stradtmauer et al)

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Endometriosis

• Stage I-II surgical treatment by lap ablation
  followed by expectant management seems to be
  controversial (Marcoux et al, Parazzini et al)
• Stage III-IV no data regarding effect of
  surgical treatment

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Endometriomas

• Should be considered an exceptional issue
• Theoretically may have some harmful effects on
  ART cycle (may interfere with ovarian
  stimulation, difficulies during opu, be toxic to
  maturing oocytes)
• However removal of them may destroy adjacent
  normal ovarian tissue and may reduce ovarian
  reserve
• Some studies reported no change on ovarian
  response (Donnez et al, Canis et al) but many
  reported lower ovarian response, lower FR, and
  reduced Ir and PR

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PCOS

• Laparoscopic ovarian drilling before ART may be
  considered (Erel et al)

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PCOS

• LOD is thought to have beneficial effects on IVF
  outcome and reduce rates of treatment
  cancellation and OHSS (Rimington et al, Hum
  Reprod, 1997)

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Adhesions

• Case controlled studies usually claim that
  adhesiolysis increases the pregnancy rate in a
  certain period of time
• However randomized controlled trials have shown
  that laparoscopic adhesiolysis following pelvic
  reprod surgery does not have a significant impact
  on pregnancy, live birth, EP and miscarriage.

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• Although no previous studies have shown
  beneficial effects of adhesiolysis prior to IVF,
  laparoscopic adhesiolysis may have role in
  assuring initial access to ovaries during OPU

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Unexplained Infertility

• Laparoscopy should be strongly considered for
  examining women with unexplained infertility.
• In the case of the 26-30 years old group, the
  pregnancy rate after laparoscopy was
  significantly higher than that in the ART
  treatment group (33.3 plt0.05) .
• Nagakawa K
  et al., J Obstet Gynecol Res 2007.

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Lap should be considered

• PID and/or chronic pelvic pain
• Patients having undergone pelvic surgery (Ectopic
  pregnancy,)
• Abnormal HSG
• High titres of Chlamydia IgG antibody (1/128)
• In cases of tubal and/or ovarian pathology or
  unexplained infertility
• if it diagnoses and treats a pelvic pathology at
  the same time and if it increases the chance of
  pregnancy

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the introduction of a new approach for endoscopic
diagnosis (THL) was promted by

• The improvement in optical quality of small
  diameter scopes
• The use of distension media other than CO2
• New technical developments in video camera
  equipment and photo documentation

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Transvaginal hydrolaparoscopy(THL)

• Advantages
• Requires local anesthesia
• better visualization of pelvic organs
• Vaginal access allows inspection of tubo-ovarian
  structures in normal position
• Reduced cost
• Patient can follow procedure on screen
• Opportunity to perform dye hydrotubation and
  salpingoscopy

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• Less risk of trauma to major blood vessels
• Provides opportunity to demonstrate fine peri
  ovarian and peritubal adhesions not easily
  detected by lap. (Brosens et al)
• Minor operative procedures such as biopsy and
  adhesiolysis can be performed
• Because of high magnification used greater degree
  of accuracy in evaluation of ovaries and distal
  region of tubes
• Hysteroscopy can be performed with same optic as
  transvaginal hydrolaparoscopy
• Salpingoscopy, microsalpingoscopy and
  hysteroscopy can be combined to it (fertiloscopy)

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• Disadvantages
• View limited to posterior part of true pelvis
• Range of interventions limited
• Not all pathologies are seen without manipulating
  the adnexa
• Cannot be performed on retroverted uterus
• Contraindicated in obstruction of pouch of
  douglas by rectum or prolapsed tumor

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THL vs. HSG

• THL combined with mini-hysteroscopy better
  tolerated by patient than HSG (Cicinelli et al)
• Both techniques equally efficient in determining
  tubal patency but THL superior for diagnosis of
  peritubal adhesions (Shibahara et al.)
• THL provokes less discomfort (Tur Kaspa et al)
  and has higher diagnostic accuracy(Glatstein et
  al) than HSG

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THL (fertiloscopy) vs Lap (international
multicenter prospective trial) Watrelot et al

• Sensitivity of THL and lap 86 and 87
• Negative predictive value 64 and 67
• High degree of concordance between 2 techniques.
• THL can allow laparoscopy to be avoided in 93 of
  women as relevant info can be obtained by this
  less invasive procedure
• In remaining 7 findings at THL indicated need
  for laparoscopic evaluation
• THL should replace diagn lap in routine
  assessment of infertile women without obvious
  lesions of ovary or pouch of douglas

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Conclusion

• Diagnostic accuracy, safety and cost-benefit
  analysis suggest THL should replace HSG as first
  line exploration technique
• Standard lap remains first choice when panoramic
  view of pelvis is required like in extensive
  adhesions,intra-abdominal bleeding or acute
  pelvic pain

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• Generally,L/S is considered the GOLD STANDARD in
  the diagnosis of tubal pathologies and other
  intra-abdominal infertilities

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Hysteroscopy
THL
NOS
Minimal Access
Laparoscopy
Axilloscopy
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minimal invasive surgery
Minimal access
Organ preservation
Reconstruction