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Objective: To determine the rate of uterine synechiae after bipolar hysteroscopic myomectomy in patients suffering from infertility., Design: Retrospective case series study., Setting: University obstetrics gynecologic and assisted reproduction center., Patient(s): A group of 53 patients with primary (n = 30) and secondary (n = 23) infertility., Intervention(s): Patients underwent bipolar hysteroscopic resection of myomas between 2001 and 2006, and an outpatient hysteroscopy was performed 2 months after the fibroid resection., Main Outcome Measure(s): The formation of uterine synechiae and pregnancy rates were collected from the patients' clinical notes., Result(s): The submucosal myomas were intracavitary class 0 (n = 12), intramural class 1 (n = 19), and intramural class 2 (n = 22). The mean age of the women was 35.0 +/- 4.8 years. The mean myoma size was 25 +/- 11 mm. Postoperative office hysteroscopies revealed synechiae in four (7.5%) of 53 patients. Sixteen (32.7%) of the 49 patients not lost to follow-up conceived, and 12 (24.5%) of them delivered at term. Myoma size >or=3.5 cm and age <35 years were associated with a significantly higher pregnancy rate in univariate and multivariate analysis., Conclusion(s): The incidence of uterine synechiae after bipolar hysteroscopic resection of fibroids was 7.5%. This appears to be lower than that reported in previous studies using monopolar energy. Bipolar hysteroscopic myomectomy may be a better option for infertile women.

Objective: To review the current understanding of the role the uterus plays in embryo implantation and to outline congenital anomalies and acquired diseases that impact normal uterine function., Design: The publications related to the embryo implantation, Mullerian anomalies, uterine polyps, uterine synechiae, and myomas were identified through Medline and reviewed., Conclusion(s): Congenital anomalies and acquired diseases of the uterus may negatively impact on the complex processes of embryo implantation. Hysteroscopic surgery to correct uterine septa, intrauterine synechiae, and myomas that distort the uterine cavity may benefit women with infertility or recurrent pregnancy loss. The effect of endometrial polyps on fertility is uncertain, but their removal, once identified, is justifiable. Complex congenital anomalies such as unicornuate uterus and uterus didelphys may negatively affect fertility and pregnancy outcome, and surgical treatment may benefit select patients.

Postoperative adhesion formation is a natural consequence of surgical tissue trauma and healing and may result in infertility, pain, and bowel obstruction. Microsurgical principles and minimally invasive surgery may help decrease adhesion formation, but anti-inflammatory agents and peritoneal instillates have no demonstrable benefit. Although some surgical barriers are effective for reducing postoperative adhesions, none has been shown to improve fertility or to decrease pain or the incidence of postoperative bowel obstruction.

The role of surgery vs. IVF-embryo transfer to improve the potential for conception will vary as enhancements of these interventions occurs. Well-designed and conducted studies, controlling for the complexities of surgical trials are needed.

Objective: To review the relation between adhesions and pelvic pain and the effectiveness of adhesiolysis in pain control., Design: Selective review of the literature., Patient(s): Patients with pelvic pain and/or undergoing adhesiolysis for pain control., Result(s): Intraabdominal adhesions are accepted as etiologic factors for infertility and small bowel obstruction; however, the contribution of adhesions to pelvic pain is less clear. The most common laparoscopic findings in patients with and without pelvic pain were endometriosis and adhesions. Immunohistologic studies also have shown evidence of nerve fibers in adhesions that had been removed from patients with and without pelvic pain. Multiple adhesiolysis techniques have been employed, with outcome of surgical procedures ranging from no pain relief to pain relief in 90% of patients. However, randomized trials have shown that adhesiolysis is ineffective in improving the outcome of the treatment of pelvic pain, possibly because of adhesion reformation. Interestingly, adhesions are usually not described as an etiologic factor for pelvic pain in men; this might be related to a gender difference in pain perception or the possibility that adhesions per se do not cause pain., Conclusion(s): The correlation between pelvic pain and adhesions is uncertain. Adhesiolysis has not been shown to be effective in achieving pain control in randomized clinical studies.

Objective: To determine whether the accuracy of transvaginal hydrolaparoscopy is comparable to that of standard laparoscopy for the diagnosis of infertility., Design: Prospective, comparative study., Setting: General hospital in Belgium., Patient(s): Ten infertile patients without obvious pelvic pathology., Intervention(s): Two gynecologists independently performed transvaginal hydrolaparoscopy and standard laparoscopy and reported the observations in a confidential manner to a third person., Main Outcome Measure(s): Endometriosis, adhesions, and other pelvic pathology related to infertility., Result(s): Minimal or mild endometriosis was diagnosed in seven patients and sequelae of pelvic inflammatory disease in one patient at both procedures. The interobserver agreement for tuboovarian adhesions was 95% at transvaginal hydrolaparoscopy and 74% at standard laparoscopy. Ovarian adhesions were detected in 63% at transvaginal hydrolaparoscopy and in 37% at standard laparoscopy., Conclusion(s): Transvaginal hydrolaparoscopy is comparable in accuracy to standard laparoscopy for the diagnosis of adhesions and endometriosis in infertile patients without obvious pathology.

Objective: To compare the prognostic value of salpingoscopy with a current classification system of adnexal adhesions and distal tubal occlusion in patients with tubal infertility undergoing reconstructive tubal surgery., Design: Prospective clinical study., Setting: Department of Obstetrics and Gynecology of the Catholic University, a tertiary care University Center in Rome, Italy., Patients: Fifty-five infertile patients with either adnexal adhesions (29 patients) or hydrosalpinx (26 patients) undergoing reconstructive tubal surgery., Interventions: Salpingoscopy performed concomitantly to salpingo-ovariolysis or salpingoneostomy at the time of either operative laparoscopy or laparotomy using microsurgical techniques., Main Outcome Measures: Salpingoscopic findings were compared with a current classification system of adnexal adhesions and distal tubal occlusion. The patients were followed for a mean follow-up of 49 months; the pregnancy rates achieved were correlated with the salpingoscopic findings and the classification system used., Results: There was a significant correlation between the salpingoscopic grade and the occurrence of a term pregnancy for both the salpingo-ovariolysis and salpingoneostomy groups of patients. There was no significant correlation between the classification system used and the occurrence of a term pregnancy for both groups of patients., Conclusion: Salpingoscopy plays an important role in selecting the patients who may benefit the most from reconstructive tubal surgery.

Objective: To correlate the presence and extent of peritubal and mucosal adhesions in hydrosalpinges., Design: Comparative study., Setting: Tertiary centers with experience in tubal microsurgery., Patients: Infertile women with complete distal tubal block., Intervention: Salpingoneostomy., Main Outcome Measure: Presence and extent of adhesions., Results: Peritubal adhesions occur more frequently than mucosal adhesions in hydrosalpinges. Of 7 hydrosalpinges without peritubal adhesions, 1 showed mucosal adhesions but of 83 hydrosalpinges with peritubal adhesions, 31 (37%) showed no mucosal adhesions., Conclusion: Accurate endoscopic assessment of the ampullary mucosa is recommended in hydrosalpinx to select the appropriate patient for surgery.

Objective: To assess the predictive value of preoperative endometrial sonography in the diagnosis and surgical treatment of women with amenorrhea due to severe Asherman's syndrome., Design: Patient series., Setting: Academic clinical practice., Patients: Seven women with severe Asherman's syndrome characterized by amenorrhea despite normal ovulatory function and complete obstruction of the uterine cavity at the level of the cervix or lower uterine segment at hysterosalpingogram., Main Outcome: Ability of vaginal sonography to predict successful hysteroscopic treatment as assessed by resumption of menstrual cyclicity and normalization of the uterine cavity., Results: Transvaginal sonography demonstrated a well-developed endometrial stripe in three of seven women, while three others had virtually no endometrium seen. All women with well-developed endometrium were found to have adhesions occluding the lower uterine segment and had resumption of normal menses and normalization of the cavity after hysteroscopy. The women with minimal endometrium had no cavity identified and derived no benefit from surgery. A seventh woman with endometrium seen only on one side of the cavity had patency successfully established only on that side., Conclusion: The endometrial pattern seen with transvaginal sonography is highly predictive of surgical and clinical outcome in women with severe Asherman's syndrome characterized by complete obstruction of the cavity at hysterosalpingogram.

A 28-year-old married, Korean woman was diagnosed with a right unicornuate uterus, a left hypoplastic tube, and a right ovarian necrotic corpus luteal cyst. We performed a right oophorectomy and an excision of the left hypoplastic tube and then transferred the left ovary to the right broad ligament with intact vascular pedicles. Thus the remaining left ovary and right fallopian tube were placed in proximity. The patient conceived 2 months after the operation and delivered a living male infant.

There are no reports on the subsequent anatomic findings in women with intrauterine adhesions who conceived and delivered after therapy, but our experience indicates that most of these women menstruate and conceive normally. The recurrence of intrauterine adhesions, together with preserved fertility in this patient, suggest that fertility, while usually correlated with subsequent resumption of normal menstruation and anatomy, may sometimes be independent of these features.

Objective: To further elucidate the origin and significance of serum CA-125 in pelvic endometriosis., Design: Retrospective., Patients: Ninety-seven women with endometriosis who participated in two trials: (1) open-label study on buserelin acetate (n = 51) and (2) comparative, placebo-controlled study on nafarelin (n = 31) versus danazol (n = 15) (2:1 ratio)., Interventions: (1) Buserelin acetate 900 micrograms/d intranasally (IN); (2) nafarelin 400 micrograms/d IN versus danazol 400 mg/d orally during 6 months., Main Outcome Measure(s): Serum CA-125 and estradiol concentrations; severity of endometriosis-related symptoms; scores according to The American Fertility Society (AFS) classification for endometriosis and/or adhesions (before and on last day of therapy)., Results: Menstruation and adhesions appeared major factors influencing pretreatment serum CA-125 concentrations. Compared with nonmenstruating women without adhesions, both menses and adhesions induced a slight increase tending to significancy, whereas the elevating effect of adhesions and menses together was highly significant and more than expected. All three treatment regimens reduced CA-125 concentrations to the same extent; cessation of therapy was followed by restoration to pretreatment concentrations. Of the AFS scores for implants and/or adhesions, only pretreatment scores for adhesions correlated significantly with CA-125 concentrations. Severity scores for endometriosis-related complaints did not correlate., Conclusions: The findings indicate that adhesions play a major role in the presence of CA-125 in the systemic circulation and suggest that reductions of serum CA-125 concentrations during gonadotropin-releasing hormone agonist and danazol therapy are hormonally determined.

Objective: To present the technique and assess the efficacy of operative laparoscopy to manage ovarian remnant syndrome., Design: Observational with a follow-up of 6 to 32 months., Setting: Private subspecialty practice with a large referral base., Patients: Thirteen women, 9 with previous bilateral salpingo-oophorectomy and 4 with previous unilateral salpingo-oophorectomy and pain on the ipsilateral side., Interventions: Multipuncture advanced operative laparoscopy., Main Outcome Measures: Patient pain relief was assessed through return examinations, telephone interviews, or contact with referring physicians., Results: Nine patients reported complete pain relief. One reported incomplete but satisfactory pain relief. Two required bowel resection by laparotomy to obtain pain relief, and one, despite subsequent laparotomy, had persistent pain. No intraoperative or postoperative complications were noted., Conclusion: Laparoscopy can be effective in managing ovarian remnant syndrome when performed by an experienced laparoscopist.

Objectives: To lay down the criteria to clearly define whether conservative or radical laparoscopic treatment should be adopted in cases of ectopic pregnancies (EP)., Design: Retrospective, noncomparative., Setting: At the University Hospital of Clermont Ferrand and the La Pergola Clinic at Vichy from July 1974 to December 1987., Patients: This study was carried out in 223 patients who had been treated laparoscopically for EP and who desired future childbearing and who were not lost to follow-up., Main Outcome Measures: The measures chosen to achieve the objective included age, parity, size of hematosalpinx, volume of hemoperitoneum, tubal rupture, location, intrauterine device, ipsilateral and contralateral adhesions, and patient's previous history of salpingitis, EP, solitary tube, and tubal infertility., Results: The general intrauterine pregnancy rate was 67% (149 patients) and the recurrence rate 12% (27 patients). The results according to the studied factors demonstrated that age, parity, and the type of the EP have no influence on the postectopic fertility. The history of the patient, ipsilateral adhesions, or contralateral tubal status significantly reduce the future fertility prognosis and risk of recurrence., Conclusions: From a multivariable analysis, the authors propose a scoring system to choose the most suitable treatment to preserve fertility and to reduce the risk of recurrence ranging from laparoscopic conservative treatment to laparoscopic salpingectomy with contralateral sterilization.

This study indicates that SP occur in a higher percentage than theoretically expected after IVE-ET treatment, but it is not conclusive as to whether the SP is independent or a result of the treatment or operative laparoscopy. Our results are in agreement with those of previous studies that have shown that SP occur with almost all kinds of infertility. We therefore reject the previous suggestion of Steptoe, who argued that to prevent ectopic pregnancy from complicating embryo replacement, preparatory electrocauterization of diseased tube should be performed. We also suggest that as long as the results of treatment are below the normal monthly spontaneous conception rate, there is justification for a prospective random study that includes all diagnoses other than BTB. Such a study might help make any future selection of patients for treatment more appropriate.

The effectiveness of macrosurgical and microsurgical techniques for adhesion management was evaluated in nonpregnant female baboons that had significant pelvic adhesions as a sequela of previous surgery. Two weeks after the initial laparotomy the animals were reoperated upon and adhesion reformation assessed. Mean adhesion scores were not significantly different between the macrosurgery and microsurgery groups before or after lysis. However, the reduction in the mean adhesion score following lysis approached significance (P less than 0.1) in the microsurgical group, whereas it did not in the macrosurgical group. This study does not confirm that the use of microsurgery in adhesion management is clearly superior but does suggest it may be slightly more effective in reducing adhesion reformation.

To elucidate the etiology of infertility due to endometriosis, we autografted endometrial or adipose tissue to the pelvic peritoneum of 21 cynomolgus monkeys. These primates were divided into five groups: control animals with adipose tissue autografts (n = 5), animals with microscopic endometriosis (n = 5), animals with mild endometriosis (n = 5), animals with moderate endometriosis (n = 4), and animals with severe endometriosis (n = 2). During three subsequent menstrual cycles, each animal underwent (1) serial assay of peripheral serum gonadotropins and steroids; (2) mating timed according to daily serum 17 beta-estradiol; and (3) laparotomy to document an ovulatory stigma. The chemical and term pregnancy rates were lower among monkeys with moderate or severe endometriosis, as compared with control animals. The impaired fertility in monkeys with endometriosis appeared to be mediated primarily by failure of follicular rupture and/or pelvic adhesions.

The outcome of 93 consecutive cycles of in vitro fertilization (IVF) and embryo transfer (ET) treatment in 52 women with "frozen pelvis" is reported. The treatment termination rate due to inadequate ovarian stimulation was 20%. The mean +/- standard deviation of the number of follicles of mean diameter greater than or equal to 15 mm, oocytes recovered and fertilized per operation, and embryos replaced per cycle were 4.80 +/- 2.07, 4.02 +/- 2.32, 2.54 +/- 2.06, and 2.57 +/- 1.30, respectively. The pregnancy rate per ET was 29.6%. These data compare with those of other treated women with adhesion-free ovaries over the same period, suggesting that pelvic adhesive disease has no adverse effect on outcome of IVF-ET.

In a study of 204 consecutive infertile couples, 58 women with adnexal abnormalities consistent with prior pelvic infection were identified. The status of those 58 subjects with respect to prior pelvic infection, prior intrauterine device use, and serologic evidence of past chlamydial infection was correlated with the types of adnexal abnormalities identified. Women with serologic evidence of past chlamydial infection were more likely to exhibit severe adhesions and hydrosalpinx formation, and hydrosalpinx formation was related to a history of clinically detected pelvic infection.

It is now possible to identify and study the performance of different subgroups of patients in in vitro fertilization (IVF) programs. Patients with severe pelvic adhesions due to pelvic inflammatory disease (PID) or endometriosis were classed as having a frozen pelvis if less than or equal to 20% of total ovarian surface was visible and if the rest of the ovary was bound down with significant adhesions. IVF offers the only hope of pregnancy for these patients. Fifty-one treatment cycles in 23 such patients were matched against 51 cycles in 48 patients with adhesion-free ovaries. The study group had a significantly higher number of cancelled oocyte retrievals because of poor estradiol (E2) response. They also had a significantly lower rate of E2 rise and a lower peak value of E2 before and after the administration of human chorionic gonadotropin. These patients took longer to respond to a hyperstimulation regime, and when a response occurred they formed fewer follicles, as measured with the use of ultrasound. Lower numbers of oocytes were obtained from this group, but the fertilization rate of oocytes was the same for both groups. One pregnancy occurred in the study group and 11 in the control group. It is possible that disruption of ovarian blood supply or mechanical factors due to the pressure of significant adhesions prevent a good follicular response in patients with a frozen pelvis.

A prospective, randomized study comparing the result of salpingo-ovariolysis using the carbon dioxide (CO2) laser and the microdiathermy needle was conducted. The pregnancy rate after laser surgery was 53.3% (n = 30) and after electrosurgery was 51.5% (n = 33) at 2-year follow-up. Although the surgery-conception interval after laser surgery (9.9 +/- 2.0 months) tended to be shorter than after electrosurgery (13.1 +/- 2.0 months), no statistical difference was reached. This report suggests that there is no difference between the pregnancy rate after salpingo-ovariolysis with the use of the CO2 laser or with the use of the microdiathermy needle. The surgery-conception interval, however, tends to be shorter after laser surgery. A larger series of patients is required to clarify the latter.

Endometrial biopsy is an essential tool in the evaluation of the infertile couple. Among the various causes of infertility which may be elucidated by such a biopsy, endometritis plays a significant role. In this review endometritis has been subdivided into three distinct pathologic entities: acute, chronic, and fibrotic. Detailed histologic features are discussed separately for each of these varieties. Most of the acute inflammations of the endometrium are cauased by bacteria. They are usually of short duration, respond well to treatment, and only rarely are associated with long-standing infertility. Chronic endometritis, on the other hand, can be caused by a variety of agents such as bacteria, viruses, and parasites. However, in the majority of cases with chronic endometritis the etiology cannot be determined and these are then considered nonspecific. Tuberculous endometritis, which is discussed under the heading of chronic endometritis, constitutes a common cause of infertility in certain countries but much less so in the United States. Other less common conditions such as mycoplasma infection and cytomegalic virus infection, have also been associated with reproductive failure. However, chronic endometritis, especially the most common so-called nonspecific type, is a relatively uncommon cause of infertility. The syndrome of intrauterine adhesions or synechiae has been classified here as fibrotic endometritis because of the pathogenesis and histopathology of this lesion. This entity is commonly associated with infertility and may constitute the end result of a long-standing inflammatory process in the endometrium. The diagnosis of endometritis is not a simple one and necessitates close cooperation between the clinician and pathologist. Pertinent clinical and detailed histopathologic data have to be exchanged between the treating physician and pathologist, especially in cases of infertility, in order for the patient to have benefit from the examination of endometrial tissue obtained.

A series of patients is presented in whom lysis of periadnexal adhesions was carried out for correction of infertility. These 35 couples had been infertile for at least 1 year prior to surgery. Seventy-seven per cent had been trying to conceive for more than 18 months. Following diagnostic evaluation, periadnexal adhesions were found to be the sole cause of infertility in 83% of cases. Subsequent to surgery, 63% of the patients conceived, 82% within 18 months, and 57% gave birth to at least one viable child. There can be no doubt that periadnexal adhesions represent true pathology. Although often seemingly insignificant in character, at the macroscopic level, they appear to play a major role at the microscopic level in impairing ovum pickup by the fallopian tube. Gynecologists should recognize the importance of these structures as mediators of a condition of relative sterility. Thus, despite the demonstration of tubal patency, the function of the rather delicate fimbria may be compromised by periadnexal adhesions, conglutinations, and hydatids so that only a fraction of those eggs that leave the ovary at ovulation reach the interior of the fallopian tube.

Forty-two women with peritubal and periovarian adhesions as the only cause of infertility were superstimulated with clomiphene citrate and human menopausal gonadotropin in 103 cycles. Superstimulation resulted in considerable increase in ovarian size, and change in the tubo-ovarian relationship. Twenty-two patients became pregnant, achieving a pregnancy rate of 21% per cycle and an overall rate of 52%. Hyperstimulation syndrome occurred in 85 cycles (82.5%). Four cases of tubal pregnancy were reported (3.8%). This line of treatment could be tried before resorting to microsurgery or in vitro fertilization and embryo transfer in patients with peritubal and periovarian adhesions with at least one patent tube.