Laparoscopy has become an integral part of gynecologic surgery for the diagnosis and treatment of abdominal and pelvic disorders of the female reproductive organs. Endoscopic reproductive surgery intended to improve fertility may include surgery on the uterus, ovaries, pelvic peritoneum, and the Fallopian tubes.
ENDOSCOPIC TUBAL SURGERY
A variety of procedures is collectively known as tubal surgery; salpingo-ovariolysis is division of adhesions involving Fallopian tube and ovary; salpingostomy is the refashioning of a distal tubal ostium for distal tubal occlusion and is designed to keep the Fallopian tube open; tubal reanastomosis is the rejoining of Fallopian tubes typically performed for reversal of sterilization; cornual anastomosis and utero-tubal implantation are recognized surgical treatments for corneal occlusion . All these procedures can be easily and effectively performed by laparoscopic surgery.
The traditional surgical treatment for cervical insufficiency consists of vaginal placement of cervical stitches, known as transvaginal cervical cerclage or Mc Donald’s Stitch. Compared to the outcomes if no treatment is done, prophylactic cervical cerclage reduces the incidence of preterm birth in selected women at risk of recurrent preterm delivery .
Laparoscopic Cerclage (a.ka. Bionic Cervix) is a highly specialised procedure involving the laparoscopic placement of mersilene tape in patients with repeated vaginal cervical stitch failures.
Adhesions involving the fallopian tube are implicated as a cause of infertility. The decision to treat such disease to increase fertility rates may be based on certain prognostic factors associated with future fecundity. Regardless of whether performed via microsurgical techniques or via laparoscopy, data show that the removal of filmy adhesions is associated with improved fecundity.
As a fertility-enhancing procedure is done by separating periadnexal adhesions with laparoscopic scissors, electrocautery or the laser. Before being divided, the adhesions can be stretched with laparoscopic forceps and an intrauterine canula. Vascular adhesions should be coagulated before being separated. Endoscopic surgery is precise enough that adhesions can be excised without destroying surrounding tissue or damaging vital structures such as the ureters, bladder and bowel. Removal of all adhesions and restoration of the normal anatomic relationship of the pelvic organs will certainly enhance the fertility.
Hydrosalpinx is a chronic pathological condition of the Fallopian tube, and is a major cause of infertility. In most patients, the fimbriated end of the tube adjacent to the ovary is occluded and the distal half of the tube is distended with fluid . The main causes of hydrosalpinx are pelvic inflammatory disease, ectopic pregnancy, previous abdominal operations, and a history of peritonitis and tuberculosis . Distal occlusion may also result from endometriosis . The presence of hydrosalpinx can be diagnosed by hysterosalpingogram or by laparoscopy with or without chromopertubation.
Indications for tubal anastomosis include reversal of sterilization, midtubal block secondary to pathology, tubal occlusion from ectopic pregnancy, and salpingitis isthmica nodosa. The goal is to remove abnormal tissue and reapproximate the healthy tubal segments with as little adhesion formation as possible. Although not always successful, sterilization reversal is the most successful surgical reconstructive procedure for improving fertility.
Laparoscopic Myomectomy and Pregnancy Outcome:
Uterine leiomyomas are the most common tumor of the female reproductive tract and affect 30-40% of reproductive-age women. Although they are seldom the sole cause of infertility, myomas have been linked to fetal wastage and premature delivery. Several elements indicate that myomas are responsible for infertility. For example, pregnancy rate is lower in patients with myomas, and in cases of medically assisted procreation, the implantation rate is lower in patients presenting interstitial myomas. There are other indirect evidences supporting a negative impact, including lengthy infertility before surgery (unexplained by other factors), and rapid conception after myomectomy . Approximately 50% of women who have not previously conceived become pregnant after myomectomy . Because medically treated fibroids tend to grow back or recur, most fibroids that cause symptoms are managed surgically. Depending on their number and their location myomas with mostly intracavitary development should be dealt with by hysteroscopy. Interstitial and subserosal myomas can be operated either by laparotomy or by laparoscopy.
Endoscopic Surgery in Endometriosis Associated Infertility
Endometriosis is a heterogeneous disease with typical and atypical morphology and spans a spectrum from a single 1-mm peritoneal implant to 10-cm or larger endometriomas with cul-de-sac obliteration. The American Society for Reproductive Medicine revised classification system for endometriosis (ASRM 1996) is the most widely accepted staging system. Endometriosis is frequently associated with infertility. Indeed, 30% to 70% of infertile women have been reported to have endometriosis. Fecundity rates in women with endometriosis tend to be lower than normal, and despite extensive research, no agreement has been reached concerning the mechanism of infertility. Severe endometriosis is associated with pelvic adhesions and a distortion of pelvic anatomy leading to a possible mechanic or anatomic disturbance of fertility. However, the impact of mild and moderate endometriosis on fertility is less obvious, so many putative mechanisms have been suggested. These fall into three broad groups: disorders of folliculogenesis or endocrine abnormality, inflammatory or immunological abnormality, and increased miscarriage rate. The exact relationship between infertility and endometriosis, in the absence of pelvic distortion, is unknown.
Technique of Endoscopic Surgery in Endometriosis:
Since laparotomy does not seem to have any advantages in terms of pregnancy rate or recurrence rate in the surgical treatment of ovarian endometrioma , laparoscopy can be considered to be the best surgical approach for ovarian endometriotic cysts. Although details can be found somewhere else , here, we want to summarize our practice in the treatment of endometriosis. The goal of treating of peritoneal endometriosis is to destroy the implants in the most effective and the least traumatic way to minimize the formation of postoperative adhesions. Hydrodissection and CO2 laser are the best choices for treatment. Superficial peritoneal endometriosis is vaporized with the laser, coagulated with monopolar or bipolar current or excised. Implants less than 2 mm can be coagulated, vaporized, or excised. When lesion is greater that 3 mm, vaporization or excision is needed. Lesions greater than 5 mm must be excised or deeply vaporized. For the treatment of endometriomas the cyst wall is opened, halved and dissected. Mainly, there are two different surgical techniques to treat the endometrioma: (i) cystectomy with excision of the endometriotic cyst; and (ii) drainage/ aspiration of the cyst content and ablation of the cyst capsule with laser or electrocoagulation. After the capsule is stripped from the ovary, the base is cauterized to seal tiny blood vessels and help ensure that the entire endometrioma has been removed. Draining endometrioma or partially removing its wall is inadequate because the cyst lining remains functional leading to reoccurrence of the symptoms. If possible sutures should not be used since they can cause adhesion formation. However, when necessary, suture is placed within ovarian stroma, and the knot is tied inside the ovary, to minimize adhesion formation.
Laparoscopic ovarian drilling in PCOS patients
About 20% of all patients diagnosed with polycystic ovarian disease (PCOS) and infertility, will not ovulate after ovulation induction treatment with clomiphene citrate. Even today, the effective treatment of clomipheneresistant PCOS remains a challenge for the medical profession. More than 20 years ago, Gjonnaess (1994)described that laparoscopic electrocoagulation of the ovarian capsule in 62 clomiphene resistant PCOS patients resulted in an ovulation rate of 92% and a pregnancy rate of 69%.
In a recent Cochrane review (Farquhar et al., 2005), the efficacy of laparoscopic drilling of the ovarian capsule (laparoscopic ovarian diathermy, LOD) by diathermy or laser in clomipheneresistant PCOS has been compared to gonadotrophin treatment based on a total of 15 RCTs. Only six trials were included for further analysis. The primary outcome parameters were the live birth rate, ovulation rate and ongoing pregnancy rate. Secondary outcome parameters included the rate of miscarriage, multiple pregnancy rate, ovarian hyperstimulation syndrome and the total cost of the respective treatments.
However, the multiple pregnancy rates were lower with ovarian drilling than with gonadotrophins. There was no evidence of difference in miscarriage rates between both treatment modalities (OR 0.8; 95% CI 0.36–1.86). Approximately 50% of all treated patients will have a live birth and 16% will have a miscarriage with either treatment. The reviewer’s conclusion is that there is no difference in the live birth rate and the miscarriage rate in women with clomipheneresistant PCOS undergoing LOD when compared with gonadotrophin treatment (Farquhar et al., 2005). However, the reduction in multiple pregnancy rate in women undergoing LOD makes this option attractive.
Disadvantages of the LOD procedure include the risks related to laparoscopic surgery, the need for general anaesthesia, the possible risk of thermal damage to adjacent organs and ovarian adhesion formation, and as clearly mentioned in the Cochrane review, the lack of knowledge concerning the possible negative long-term effects of this procedure on the ovarian reproductive function (Farquhar et al., 2005). Moreover it has been pointed out that the effects observed are usually temporary and the signs and symptoms of PCOS may return within months following the LOD (Insler and Lunenfeld, 1993).
Advantages of LOD included the opportunity to treat concomitant pelvic pathology such as peritubal adhesions and endometriosis that can be associated with female infertility. Furthermore, during the same endoscopic procedure, tubal patency can be tested, and a hysteroscopy can be performed as part of the infertility work-up.
In summary, the position of diagnostic laparoscopy in the setting of ovulation induction is at present not clear due to the lack of sound scientific evidence provided by good-quality studies. The routine use of diagnostic laparoscopy to evaluate all cases of female anovulatory infertility cannot be advocated, but laparoscopy can offer the opportunity to assess tuboperitoneal status, to treat pelvic pathology that may limit conception (endometriosis, adhesions), and to perform LOD. Laparoscopic ovarian diathermia is a good option when compared with gonadotrophin treatment in the clomiphene citrate resistant PCOS patient, but counselling should be offered with regard to the unknown long-term effects of this procedure on the ovarian function.
Advances in endoscopic surgery have revolutionized our approaches to gynecological surgery. Among reproductive operations, most of them could and should be done by laparoscopy. The variety of conditions indicative of surgery demonstrates the importance of maintaining surgical skills in the reproductive medicine practice, so that patients can be offered the most appropriate treatment. It appears that endoscopic surgery for infertility patients, when performed by an experienced endoscopist, is efficacious and can produce as good or better results than traditional procedures.