Laparoscopy in Infertility

7/29/2019 Laparoscopy in Infertility

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Dr. Mohamed El SherbinyMD Ob.& Gyn. Senior Consultant

Damietta, Egypt

Laparoscopy in

InfertilityAn Evidence Based View


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Sources of Evidences

National Guideline Clearinghouse 2000National Institute of Clinical

Excellence(NICE)Guideline. Fertility2004

ESHRE guideline(2005)

Royal College of Obstetricians and Gynaecologists(RCOG) infertility , 1999 & Endometriosis ,2006

Society of Obstetricians and

Gynaecologists of Canada (SOGC) 244- 2010Cochrane Library

Up To Date 2-19 May 2011

PubMed


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The availability of assisted reproductive

technology (ART) has reduced the needfor laparoscopic reconstructive surgery

in infertile women.However, there are still many

important indications for laparoscopy.

Is There Still a Role for Laparoscopy

in Female Infertility?


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When fertility surgery is indicated, operative

laparoscopy results in outcome are as good

as those performed via open laparotomy.

However laparoscopy is associated with

Shorter Hospital Stay

Lower Incidence Of Ileus

Faster Recovery

Less Morbidities

Lower Postoperative Adhesion Formation

Laparoscopy Versus Laparotomy?

Togas Tulandi., Up to Date 19.2: May 2011


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Less contamination of the surgical field with

glove powder or lint

Bleeding is reduced due to tamponade of

small vessels by the pneumoperitoneum

Drying of tissues is minimal because surgery

occurs in a closed environment

Why Does Laparoscopy Have Lower

Postoperative Adhesion Formation?

Togas Tulandi., UpToDate 19.2: May 2011


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Laparoscopy in Infertility

Diagnostic Laparoscopy

Operative Laparoscopy


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Female Infertility Workup

P4 /HSG

IVF/ ICSI

Laparoscopy

Laparoscopicablation

Minimal

or Mild

Moderate /Severe Mild Moderate

or Severe

AnovulationDysovulation :

Induction

Endometriosis

Obstruction or

Adhesion: traumatic or

inflammatory

AdhesiolysisResection ? /Fenestration ? Laparoscopic

Adhesiolysis

Laparoscopic

UnexplainedP4=Mid luteal phase progesterone

COH + IUI

Laparoscopy

LaparoscopicDrilling

El Sherbiny

f


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Indications of Laparoscopy

in Female InfertilityI. Diagnostic LaparoscopyII. Operative Laparoscopy

Adhesiolysis

Fimbrioplasty

Cornual Obstruction: Laparoscopic guided catheterization

Endometriosis:

Implant: ablation (electro-surgery or Laser)

Endometriomas: Excision, Fenestration & ablation

PCOS: Ovarian Drilling

Hydrosalpinx before IVF:

Salpingectomy

Proximal tubal occlusion & salpingostomy


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Diagnostic

Laparoscopy


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ESHRE Capri workshop 2000

Basic Routine Infertility Investigation

National Guideline Clearinghouse 2000

RCOG Guidelines: Grade B Recommendation 1999

Tests which have an establishedcorrelation with pregnancy are:

Semen analysis

Tubal patency by HSG or laparoscopy

Mid luteal progesterone for the diagnosis of

ovulation

?


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What Are The Tubal Patency Testing?

Transcervical Media:

HSG

Laparoscopy

HyCoSy

(Hysterosalpingo-Contrast Synography)

Direct cannulation of the fallopian tubes:Radiological: Selective Salpingography

Hysteroscopic Guided by Laparoscopy


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Women who are not known to have co-morbidities (such as PID, previous ectopic

pregnancy or endometriosis) should be

offered HSG to screen for tubal occlusion.This is a reliable test for ruling out tubal

occlusion, it is less invasive and makes

more efficient use of resources thanlaparoscopy.

National Institute of Clinical Excellence(NICE)Guideline.Fertility2004

Grade B

When HSG and When Laparoscopy?


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Women who are thought to have

co-morbidities should be offered

laparoscopyand dyeso that tubal andother pelvic pathology can be assessed at

the same time.

National Institute of Clinical Excellence(NICE)Guideline. Fertility2004

Grade B

When HSG and When Laparoscopy?


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Test for Tubal Patency

No co-morbidities


Co-morbidities

Laparoscopy

& DyeHSG

Or

HyCoSy

Grade B

Grade B

Grade A

l i d f ili


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Case presentation A 27 year old woman, BMI 26

Primary infertility 4 years

No history of pelvic pain, infection or

ectopic pregnancy or pelvic surgery.

SemenFertile semen

Volume :4 ml

Count: 48 million/mL

Unexplained Infertility

Motility: 55% progressive

Normal forms:50%


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She received empirical 6 cycles CC,

then 2 cycles HMG

ML Phase progesterone 12ng/ml

HSG: OK


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Which of The Following is

Recommended for Our Patient?

1. Laparoscopy to exclude

endometriosis or adhesion

2. IUI 3 cycles

3. IUI + HMG, for 3 cycles

4. IVF/ICSI


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There is still a considerable debate

regarding the place of laparoscopy

for cases of unexplained infertility.


A Place for Laparoscopy?

U l i d I f tilit


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There has been a growing tendency for

bypassing diagnostic laparoscopy in

unexplained infertility.In their opinion this approach would

probably prove to be the most cost

effective and efficient treatment protocol.

Fatum, et al . (2002) Hum. Reprod.,17;1-3

Balasch (2000) Hum. Reprod., 15, 22512257

Badawy et al (BJOG 2008) .



U l i d I f tilit


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However, there were several reports indicating that in

infertile couples, laparoscopy revealed abnormal

findings in 21-78% with normal HSG.

After the treatment of these abnormal findings, higher

pregnancy rates can often be achieved by timing

intercourse or an IUI.

Cundiff et al. J Reprod Med 1995;40:1924. couples,.

Tanahatoe et al (2003) Hum Reprod 18,811.

Capelo et al(2003) Fertil Steril2003; 80:1450-1453.Nakagawa et al 2007).. J. Obstet. Gynaecol. 2007; 33; 665-670




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Which of The Following is

Recommended?

1. Laparoscopy to exclude

endometriosis or adhesion2. IUI 3 cycles

3. IUI + HMG, for 3 cycles.

4. IVF/ICSIAs this patient is young and the period of infertility is not

to long, laparoscopy may be a good choice.


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Diagnostic laparoscopy can beavoided in:

Older women

Those with multiple infertility factors

These women are better served by IVF, instead ofa surgical approach to treatment.

The presence of endometriosis and adhesionsdoes not markedly influence the effectiveness ofIVF.



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The following images are

examples of possible findingsduring laparoscopy that include:

Normal laparoscopic findings Mild fimbrial adhesions

Moderate adhesions

Severe adhesions Hydrosalpinx


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Positive methyline blue test

Positive methyline blue test

Normal left adnxa

Normal left adnxa and Douglas pouch


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Mild fimbrial adhesionFimbria

Fine band of

adhesion

FimbriaFine

adhesion

Fimbria

Broad band

of adhesion

Moderate adhesion

DouglasPouch


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Severe Adhesions

Dr.Sherbiny


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Hydrosalpinx


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Operative Laparoscopy for

Female Infertility


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Adhesiolysis

Fimbrioplasty

Cornual Obstruction: Laparoscopicguided catheterization

Tubal Laparoscopic Procedures

Wh i T b l S


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When is Tubal Surgery

Recommended ?For women with mild tubal disease, tubal

surgery may be more effective than no

treatment.

In centres where appropriate expertise is

available it may be considered as a treatment

option.


Grade D


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Adhesiolysis of the left tube with micro- scissor

Uterus

L. Ovary

L. Tube


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R .Ovary

Cutting band of adhesion

What is Recommended for


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What is Recommended forModerate to Severe Tubal Disease?

IVF should be considered as the first

line treatment for moderate to severedistal tubal disease.

RCOG Guidelines : Grade B Recommendation


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Phimosis of the fimbrial end: Dilatation with Maryland forceps

Dr.Sherbiny

Phimosis with

methyline Blue jetPhimosis: delayed

methyline blue spill

Free methyline

blue spill

Dilatation with

Maryland forceps


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Cornual ObstructionIf the fallopian tubes are not

visualized on HSG, a repeat

procedure should be done to

exclude the possibility of tubal

spasm.


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Bilateral Cornual Obstruction

Tubal Catheterization


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Tubal Catheterization

or Cannulation

For women with proximal tubal obstructionselective salpingography plus tubal

catheterization, or Hysteroscopic tubal

cannulation (laparoscopic guided), may betreatment options because these

treatments improve the chance of

pregnancy.


Grade B

Hysteroscopic tubal catheterization or


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Hysteroscopic tubal catheterization orCannulation laparoscopic guided

Dr.SherbinyDr.Sherbiny

Laparoscopic guided

Catheterization

Hysteroscopic catheterization

Guide wire

Passage of inspissated material with M.blue at injection through the catheter


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Alternatively and

much cheaper, is to

use a pediatric

ureteric catheter

Passage of inspissated material with M.

blue at injection through the catheter

Laparoscopic guided

Catheterization

Hysteroscopic catheterization


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Tubal Surgery Versus IVF

At present, the available research is not

adequate to determine the effectiveness.

More research is needed, including informationabout adverse outcomes and costs.

Pandian et al The Cochrane review 2007 revised 2009Issue 1, 2009

Dr.Sherbiny

Wikimedia
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Endometrioses

Associated Infertility:

The Role of Laparoscopy

Diagnostic

Operative

S i l Vi li ti f L i


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Typical Endometriosis:

Black Endometriosis

Blue Endometriosis

Atypical (subtle) Endometriosis: Red Endometriosis: Red pink, flam-like & clear

White Endometriosis

White Yellow Brown

Peritoneal Defect

American Society For Reproductive Medicine (ASRM)

Surgical Visualization of Lesions

Typical Endometriosis


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Classic bluish black endometriotic implants

Typical Endometriosis

Black Endometriosis

Blue Endometriosis

Black Blue


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Typical EndometriosisIn the majority of instances, the

laparoscopic appearances ofendometriosis lesions are quitecharacteristic: black-blue, powder-burnappearance.

Diagnosis in most cases is simple, withoutthe need for a biopsy.



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Atypical Endometriosis= Subtle Endometriosis

= Non-pigmented EndometriosisEndometriotic lesions that lack the

typical black-blue, powder-burnappearanceJansen & Russel,1986


American Society For Reproductive Medicine (ASRM) 1996


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Red Endometriosis (Pink)

Yellow Brown Endometriosis

Clear Endometriosis

ASRM Classification


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ASRM ClassificationThe most widely used system was introduced by

the American Society for ReproductiveMedicine (ASRM) in 1979 and revised in 1996 .

This system assigns a point score based upon the

size, depth, and location of endometriotic

implants and associated adhesions. The system

was revised for women with infertility to help

predict success in achieving pregnancy following

treatment of endometriosis.

Robert S Schenken, UpToDate 2-19 May 2011



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Stage I: Minimal (score 1-5)

Stage II: Mild (score 6-15)

Stage III: Moderate (score 16-40)

Stage IV: Severe (score >40)


Endometriosis


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Endometriotic Cyst

=

Endometrioma

Endometriosis


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Implant:

Diagnosis

Ablation (electro-surgery or Laser )

Endometriomas:

Excision

Fenestration & ablation

EndometriosisAssociated Infertility


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Laparoscopic Surgery

1. Laparoscopic treatment of minimal or mild

endometriosis improves pregnancy rates

regardless of the treatment modality. (I)

SOGC Clinical Practice Guidelines 244, 2010

Jacobson et al , Cochrane Library Review, 20 JAN 2010

Laparoscopic treatment: Ablation or excision of implants and

adhesions via Mechanical, electro-surgery or LASER surgery


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Monoplar Ablation

of Endometriotic

Implant


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Laparoscopic Treatment

2. The effect on fertility of surgical

treatment of deeply infiltrating

endometriosis is controversial. (II)

3. Laparoscopic excision of ovarian

endometriomas more than 3 cmin diameter may improve fertility. (II)

SOGC Clinical Practice Guidelines 244, 2010

O l i Di d 20%


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Ovulation Disorders - 20%

The WHO classification is three groups:

Group I: hypothalamic pituitary failure

(hypothalamic amenorrhoea or

hypogonadotrophic hypogonadism)

Group II: hypothalamic pituitary dysfunction

predominately polycystic ovary syndrome (PCOS)Group III: ovarian failure

National Institute for Clinical Excellence (NICE) 2004


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Polycystic Ovary

Syndrome

(PCOS)

Rotterdam Diagnostic


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When 2 out of 3 features are present:

Oligomenorrhoea and/or Anovulation

Clinical Hyperandrogenism and/or

hyperandrogenemia

Polycystic ovaries (U/S)

After exclusion of other etiologies.

Rotterdam DiagnosticCriteria Of PCOS May 2003

What are?

Rotterdam

U/S Criteria


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At least one of the following:

12 or more follicles measuring 29 mm in diameter

Increased ovarian volume (>10 cm3

) The distribution of follicles and a description of the stroma are

not required for diagnosis.

The presence of a single PCO is sufficient to provide the

diagnosis.

Rotterdam U/S Criteriaof PCO 2003


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PCO

Management of PCOS


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First Step:

Lifestyle modification: Weight loss 10%Second Step:

Clomiphene citrate (CC) or Tamoxifen

Third Step:Improving the CC Resistant: Metformin

Fourth Step:

Gonadotropin Versus Drilling Intrauterineinsemination

Fifth Step:

IVF /ICSI

Management of PCOS

PCOS: Laparoscopic Drilling


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Laparoscopic ovarian drilling with either

diathermy or laser is an effectivetreatment for anovulation in women with

clomiphene-resistant PCOS.

PCOS: Laparoscopic Drilling

RCOG Guidelines : Grade A

58National Institute of Clinical Excellency(NICE) 2004


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PCOS Drilling Optimization

A strategy of minimizing the number ofdiathermy points to:

4/ovary

For 4 s

At 40 W

Armar et al. Fertil Steril 1990;53:459.

Complications of


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Tubo-ovarian adhesions can occur, buttend to be milder than with the classic

wedge resection.

Ovarian drilling is the commonest cause of

pelvic adhesion in Egypt.

The ovaries can undergo irreparabledamage and atrophy.

Naether, 1993; Greenblatt, 1993

Dabirashrafi, 1989).

Complications of

Laparoscopic Drilling

Laparoscopic Ovarian Drilling


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Multiple holes are made on the surface of

the ovary using either laser or

electrocautery.

This results in a decrease in circulating

androgen levels, with resumption of

cyclic ovulation.

Ovulation rate: 80 %

Pregnancy rates at 12 m: 54 to 68%.





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Techniques:ElectrocauteryLaser "drilling"

Multiple biopsyEach share a common goal of creating

focal areas of damage in the ovarian

cortex and stroma.There is no evidence that one method

consistently produces superior clinical

results.


Barry W Donesky., Up to Date 19.2: May 2011



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Laparoscopic ovarian drilling is recommended

in those women who meet the followingcriteria:

Failure of ovulation despite an adequate trialof clomiphene citrate and metformin

Body mass index 30 kg/m2

An elevated serum luteinizing hormoneconcentration (>10 IU/L)

Absence of other causes of infertility



Advantage of Drilling


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No cyclic monitoring of ovulationMore cost-effective as results in several

ovulatory cycles

No increased risk of multiple gestationor ovarian hyperstimulation

Pregnancy rates are similar to

gonadotropin therapyLower spontaneous abortion rate in

some studies

Advantage of DrillingOver Gonadotropin Therapy

Barry W Donesky., UpToDate 19.2: May 2011


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Laparoscopic

Management ofHydrosalpinges

Prior to IVF


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Hydrosalpnex


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Dr.Sherbiny

Incomplete

septation

Hydrosalpnex (Ultrasonography ) : Oblong shape with incomplete

septations

Laparoscopic Management of


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Laparoscopic Management ofHydrosalpinges Prior to IVF

Laparoscopic salpingectomy should be

considered for all women with

hydrosalpinges prior to IVF treatment

as it improves IVF pregnancy rates.

Johnson et al (2004 ) Cochrane Systematic Reviews 2009 Issue 4

NICE Guideline 2004 Infertility


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Laparoscopic tubal occlusion is an alternative to

laparoscopic salpingectomy in improving IVF

pregnancy rates in women with hydrosalpinges.

Further research is required to assess the value of

aspiration of hydrosalpinges prior to or during

IVF procedures.

Johnson et al (2010 ) Cochrane Systematic Reviews Issue 1, 2010

A more recent evidence


Hydrosalpinges Prior to IVF


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Tubal bipolar coagulation Cutting of the medial

part of the tube

SalpingostomySalpingostomy

Laparoscopic tubal occlusion & salpingostomy of

Hydrosalpinges prior to IVF to improve pregnancy rate

Thank You


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Thank You

Documents

Laparoscopy in Infertility