Laparoscopy in Infertility

An Evidence Based View

Dr. Mohamed El Sherbiny
MD Ob.& Gyn. Senior Consultant Damietta, Egypt

Sources of Evidences
National Guideline Clearinghouse 2000 National 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- 2010 Cochrane Library Up To Date 2-19 May 2011 PubMed

Is There Still a Role for Laparoscopy in Female Infertility?

The availability of assisted reproductive
technology (ART) has reduced the need

for laparoscopic reconstructive surgery

in infertile women.

However, there are still many

important indications for laparoscopy.

Laparoscopy Versus Laparotomy?

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
Togas Tulandi., Up to Date 19.2: May 2011

Why Does Laparoscopy Have Lower Postoperative Adhesion Formation?

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
Togas Tulandi., UpToDate 19.2: May 2011

Laparoscopy in Infertility

Diagnostic Laparoscopy
Operative Laparoscopy

Female Infertility Workup

Unexplained
Anovulation Dysovulation : Induction

P4 /HSG

P4=Mid luteal phase progesterone

Laparoscopy
Obstruction or Adhesion: traumatic or inflammatory

Laparoscopic Drilling

Endometriosis

Laparoscopy

Moderate / Mild Moderate Severe Minimal or Severe or Mild Adhesiolysis Resection ? / Adhesiolysis
Laparoscopic ablation Fenestration ? Laparoscopic

Laparoscopic

COH + IUI

El Sherbiny

IVF/ ICSI

Indications of Laparoscopy in Female Infertility

I. Diagnostic Laparoscopy II. 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

Diagnostic

Laparoscopy

Basic Routine Infertility Investigation

Tests which have an established correlation with pregnancy are:
Semen analysis Tubal patency by HSG or laparoscopy Mid luteal progesterone for the diagnosis of ovulation
RCOG Guidelines: Grade B Recommendation 1999
ESHRE Capri workshop 2000

National Guideline Clearinghouse 2000

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

When HSG and When Laparoscopy?

Women who are not known to have comorbidities (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 than laparoscopy.
Grade B National Institute of Clinical Excellence(NICE)Guideline.Fertility2004

When HSG and When Laparoscopy?

Women who are thought to have co-morbidities should be offered laparoscopy and dye so that tubal and other pelvic pathology can be assessed at the same time.
Grade B

National Institute of Clinical Excellence(NICE)Guideline. Fertility2004

Test for Tubal Patency

No co-morbidities

Co-morbidities

HSG
Or
Grade B

HyCoSy
Grade A

Laparoscopy & Dye

Grade B

National Institute of Clinical Excellence(NICE)Guideline.Fertility2004

Unexplained Infertility
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.

Semen
Fertile semen Volume :4 ml

Motility: 55% progressive

Normal forms:50%

Count: 48 million/mL

HSG: OK

ML Phase progesterone 12ng/ml

She received empirical 6 cycles CC, then 2 cycles HMG

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

Unexplained Infertility A Place for Laparoscopy?

There is still a considerable debate regarding the place of laparoscopy for cases of unexplained infertility.

Unexplained Infertility A Place for Laparoscopy?

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) .

Unexplained Infertility A Place for Laparoscopy?

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 Steril 2003; 80:1450-1453. Nakagawa et al 2007).. J. Obstet. Gynaecol. 2007; 33; 665-670

Which of The Following is Recommended?

1. Laparoscopy to exclude
endometriosis or adhesion

2. IUI 3 cycles
3. IUI + HMG, for 3 cycles.

4. IVF/ICSI As this patient is young and the period of infertility is not to long, laparoscopy may be a good choice.

Diagnostic laparoscopy can be avoided in:

Older women Those with multiple infertility factors
These women are better served by IVF, instead of a surgical approach to treatment. The presence of endometriosis and adhesions does not markedly influence the effectiveness of IVF.
Togas Tulandi., Up to Date 19.2: May 2011

The following images are examples of possible findings during laparoscopy that include:
Normal laparoscopic findings Mild fimbrial adhesions Moderate adhesions Severe adhesions Hydrosalpinx

Normal left adnxa

Positive methyline blue test

Normal left adnxa and Douglas pouch

Positive methyline blue test

Normal Laparoscopic Findings

Fine adhesion

Fimbria

Fine band of adhesion

Mild fimbrial adhesion

Broad band of adhesion

Fimbria

Douglas Pouch

Fimbria

Moderate adhesion

Severe Adhesions

Dr.Sherbiny

Hydrosalpinx

Operative Laparoscopy for Female Infertility

Tubal Laparoscopic Procedures

Adhesiolysis Fimbrioplasty Cornual Obstruction: Laparoscopic guided catheterization

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

National Institute of Clinical Excellence(NICE)Guideline.Fertility2004

Uterus

L. Ovary

L. Tube

Adhesiolysis of the left tube with micro- scissor

Cutting band of adhesion

R .Ovary

What is Recommended for Moderate to Severe Tubal Disease?

IVF should be considered as the first line treatment for moderate to severe distal tubal disease.
RCOG Guidelines : Grade B Recommendation

Phimosis: delayed methyline blue spill

Phimosis with methyline Blue jet

Dilatation with Maryland forceps

Dr.Sherbiny

Free methyline blue spill

Phimosis of the fimbrial end: Dilatation with Maryland forceps

Cornual Obstruction
If the fallopian tubes are not visualized on HSG, a repeat procedure should be done to exclude the possibility of tubal spasm.

Bilateral Cornual Obstruction

Tubal Catheterization or Cannulation

For women with proximal tubal obstruction selective salpingography plus tubal catheterization, or Hysteroscopic tubal cannulation (laparoscopic guided), may be treatment options because these treatments improve the chance of pregnancy.
Grade B

National Institute of Clinical Excellence(NICE)Guideline.Fertility2004

Hysteroscopic tubal catheterization or Cannulation laparoscopic guided

Guide wire

Laparoscopic guided Catheterization

Hysteroscopic catheterization

Dr.Sherbiny

Dr.Sherbiny

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

Hysteroscopic catheterization

Laparoscopic guided Catheterization

Alternatively and much cheaper, is to use a pediatric ureteric catheter

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

Tubal Surgery Versus IVF

Wikimedia

Dr.Sherbiny

At present, the available research is not adequate to determine the effectiveness. More research is needed, including information about adverse outcomes and costs.
Pandian et al The Cochrane review 2007 revised 2009 Issue 1, 2009

Endometrioses Associated Infertility: The Role of Laparoscopy

Diagnostic Operative

Surgical Visualization of Lesions

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)

Typical Endometriosis
Black Endometriosis Blue Endometriosis

Black

Blue

Classic bluish black endometriotic implants

Surgical Visualization of Lesions Typical Endometriosis

In the majority of instances, the laparoscopic appearances of endometriosis lesions are quite characteristic: black-blue, powder-burn appearance. Diagnosis in most cases is simple, without the need for a biopsy.

Surgical Visualization of Lesions

Atypical Endometriosis

= Subtle Endometriosis
= Non-pigmented Endometriosis Endometriotic lesions that lack the typical black-blue, powder-burn appearance
Jansen & Russel,1986 American Society For Reproductive Medicine (ASRM) 1996

Atypical Endometriosis
Red Endometriosis(Flam-like) Yellow Brown Endometriosis

Peritoneal Defect

White Endometriosis

Yellow Brown Endometriosis

Clear Endometriosis

Red Endometriosis (Pink)

ASRM Classification
The most widely used system was introduced by the American Society for Reproductive Medicine (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.
American Society For Reproductive Medicine (ASRM) Robert S Schenken, UpToDate 2-19 May 2011

Endometriosis
Stage I: Minimal (score 1-5)

Stage II: Mild

Stage IV: Severe

(score 6-15)

Stage III: Moderate (score 16-40) (score >40)

51
American Society For Reproductive Medicine (ASRM)

Endometriotic Cyst = Endometrioma

Endometriosis Associated Infertility

Implant:
Diagnosis

Ablation (electro-surgery or Laser )

Endometriomas:

Excision
Fenestration & ablation

Laparoscopic Surgery
1. Laparoscopic treatment of minimal or mild endometriosis improves pregnancy rates regardless of the treatment modality. (I)

Jacobson et al , Cochrane Library Review, 20 JAN 2010 SOGC Clinical Practice Guidelines 244, 2010

Laparoscopic treatment: Ablation or excision of implants and adhesions via Mechanical, electro-surgery or LASER surgery

Monoplar Ablation of Endometriotic Implant

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 cm in diameter may improve fertility. (II)
SOGC Clinical Practice Guidelines 244, 2010

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

Polycystic Ovary Syndrome

(PCOS)

Rotterdam Diagnostic Criteria Of PCOS May 2003

What are?
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 U/S Criteria of PCO 2003

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.

PCO

Management of PCOS
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 Intrauterine insemination Fifth Step: IVF /ICSI

PCOS: Laparoscopic Drilling

Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS.

RCOG Guidelines : Grade A National Institute of Clinical Excellency (NICE) 2004

58

PCOS Drilling Optimization

A strategy of minimizing the number of diathermy points to: 4/ovary For 4 s At 40 W

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

Complications of Laparoscopic Drilling

Tubo-ovarian adhesions can occur, but tend to be milder than with the classic wedge resection.

Ovarian drilling is the commonest cause of pelvic adhesion in Egypt.

The ovaries can undergo irreparable damage and atrophy.
Naether, 1993; Greenblatt, 1993 Dabirashrafi, 1989).

Laparoscopic Ovarian Drilling

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%.
Togas Tulandi., Up to Date 19.2: May 2011

Laparoscopic Ovarian Drilling

Techniques:
Electrocautery Laser "drilling" Multiple biopsy Each 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

Laparoscopic Ovarian Drilling

Laparoscopic ovarian drilling is recommended in those women who meet the following criteria: Failure of ovulation despite an adequate trial of clomiphene citrate and metformin Body mass index 30 kg/m2 An elevated serum luteinizing hormone concentration (>10 IU/L) Absence of other causes of infertility
Togas Tulandi., Up to Date 19.2: May 2011

Advantage of Drilling Over Gonadotropin Therapy

No cyclic monitoring of ovulation More cost-effective as results in several ovulatory cycles No increased risk of multiple gestation or ovarian hyperstimulation Pregnancy rates are similar to gonadotropin therapy Lower spontaneous abortion rate in some studies
Barry W Donesky., UpToDate 19.2: May 2011

Laparoscopic Management of Hydrosalpinges Prior to IVF

Hydrosalpnex

Incomplete septation

Dr.Sherbiny

Hydrosalpnex (Ultrasonography ) : Oblong shape with incomplete septations

Laparoscopic Management of Hydrosalpinges Prior to IVF

Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment as it improves IVF pregnancy rates.
NICE Guideline 2004 Infertility Johnson et al (2004 ) Cochrane Systematic Reviews 2009 Issue 4

Laparoscopic Management of Hydrosalpinges Prior to IVF

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. A more recent evidence
Johnson et al (2010 ) Cochrane Systematic Reviews Issue 1, 2010

Tubal bipolar coagulation

Cutting of the medial part of the tube

Salpingostomy

Salpingostomy

Laparoscopic tubal occlusion & salpingostomy of Hydrosalpinges prior to IVF to improve pregnancy rate

Thank You

Egypt