Global Fertility services

Endoscopy is the gold standard for diagnosis of Tubal pathology, uterine and other intra-abdominal causes of subfertility. Advances in IVF and Endoscopy have changed Infertility to Subfertility implying that now we have treatment options for most if not all causes of subfertility. The current section provides an over view of role Laparoscopy in subfertility, role of hysteroscopy will be discussed in a subsequent edition.

In general, semen analysis, HSG and documentation of ovulation should be done prior to Laparoscopy. It is our practice to start an infertility (female) work up with a semen analysis, HSG and documentation of ovulation. We proceed to Diagnostic Laparoscopy in cases with abnormal HSG or those who don't conceive despite 3-6 months of regular treatment with a normal HSG (all other causes of infertility having been evaluated). In subfertile patients Laparoscopy reveals abnormality in 21-68 % cases after normal hysterosalpingogram (HSG). Depending on the severity of Laparoscopic findings, the initial treatment decision e.g. IUI, can be changed into direct laparoscopic correction of the abnormality followed by IUI, fertility-improving surgery by laparotomy or referral to IVF.

Operative Laparoscopy in infertility

Ovarian drilling for polycystic ovaries
Polycystic Ovaries Ovarian drilling is done for women with PCOD who have not responded to life style management and medical ovulation induction. Electrocautery or laser can be used to drill holes in the ovaries. 4 holes at 40W, 4 mm depth for 4 sec are optimum and it is reported that ovarian drilling results in an 80% ovulation rate and a 50% CPR.

Endometriosis Laparoscopy remains the gold standard for the diagnosis and management of endometriosis. Laparoscopic appearance of endometriosis may include any of the following
•	The classical "powder-burn" or blueberry lesion
•	White lesions that mimic scar tissue
•	Clear or slightly brown-colored papillary lesions
•	Strawberry or flame-like lesions which are hormonally active
•	Peritoneal pockets which contain endometrial implants
•	Ovarian endometriomas or chocolate cysts

Studies ascertain that Laparoscopic ablation of minimal-mild endometriosis relieves pain and improves fertility rates. The aim of the surgery is complete excision of Endometrial implants along with restoration of pelvic anatomy. Chocolate cysts can be excised with preservation of normal ovarian tissue and function, and should be attempted only by an expert. Excision, fulgaration by electrocautery or laser and aqua dissection can be utilized judiciously to attain removal of all visible implants.

Evaluation and excision of ovarian cysts (including chocolate cysts) can be excised with preservation of normal ovarian tissue and function, and should be attempted only by an expert.

Fallopian tube occlusion refinements of instrumentation and techniques allow laparotomy to be avoided for tubal reconstructive surgery in most instances. The advent of salpingoscopy, a new endoscopic technique, has allowed improved patient selection for tubal surgery. Procedures like fimbrioplasty for fimbrial blocks and phimosis, tubal anastamosis for isthimic and ampullary blocks can be dealt with laparoscopically with pregnancy rates similar to microsurgery in expert hands.

Hydrosalphinx Laparoscopic reconstructive surgery (salpingostomy) for mild or moderate (Stage I or II) hydrosalpinges is an effective approach in distal tubal occlusion. Extent and nature of adhesions, thickness of tubal wall and diameter of the hydrosalpinx diameter are useful parameters for predicting the pregnancy outcome in cases with hydrosalpinx. Patients with Stage III and IV disease are best referred for IVF. It has been shown that IVF implantation rate is markedly reduced (about 50%) and the miscarriage rate increased with hydrosalpinx. Hydrosalpinx fluid retained in the tube is embryo toxic and impairs endometrial receptivity.

Enlarged tubes may compromise the blood flow to the ovary causing a poorer response to gonadotropins. Studies have shown that salpingectomy removing the hydrosalpinx improves the subsequent success of IVF. It is now generally recommended to remove or ligate these tubes laparoscopically before IVF.

Removal of uterine fibroids Pedunculated subserous, small and single leiomyomas are managed more easily laparoscopically than multiple and larger tumors.

Sub-serous-fibroid
Uterine size < 14 weeks; no individual myoma larger than 7 cm; no myoma near the uterine artery or tubal cornua and at least 50% of the leiomyoma subserosal are criteria for adequate repair of the myometrium laparoscopically. Most studies have found no significant difference in pregnancy rate after surgery between laparoscopic and abdominal myomectomy, though decreased hospital stay, postoperative recovery time and blood loss; reduced postoperative pain, smaller incisions, better cosmetic results are significant advantages.

Adhesions cause infertility by distorting pelvic anatomy with or without causing tubal blockage. Peritubal adhesions affect ovum pick-up by fimbriae. Periovarian adhesions may also interfere with the normal ovulatory function.

Laparoscopic adhesiolysis is performed as a day care procedure along with the diagnostic laparoscopy. It is associated with shorter hospitalisation and recovery times. There are fewer de novo adhesions associated with laparoscopic surgery compared to laparotomy. Therefore although the overall pregnancy rates after laparoscopic adhesiolysis are similar to those after adhesiolysis at open surgery, laparoscopic adhesiolysis remains an effective procedure for infertile patients with adhesions.

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