Search

Objectives: Chronic inflammation and pelvic adhesion play a critical role in endometriosis-related infertility. Research studies suggest that TGF-β superfamily members, such as soluble endoglin (sEng), growth differentiation factor 15 (GDF-15) and tumor growth factor-beta (TGF-β1) contribute to the regulation of inflammation, angiogenesis and cell adhesion. The objective of this study is to investigate the association between the concentrations of these TGF-β-related members and the clinical parameters of infertile women with endometriosis., Materials and Methods: Sixty-five infertile women who underwent laparoscopy were divided into two groups in this study: those who had endometriosis (n = 33) and control subjects with benign gynecologic disorders (n = 32). The levels of TGF-β- related members in peritoneal fluid and serum were evaluated by the enzyme-linked immunosorbent assay (ELISA). Clinical and hematological parameters were documented and analyzed., Results: Endometriosis cases had significantly higher levels of sEng, GDF-15 and TGF-β1 in peritoneal fluid (p<0.0005) compared to control subjects, but not in serum. Moreover, serum GDF-15 level was significantly elevated in the late-stage endometriosis compared to the early-stage group. The levels of three TGF-β related molecules in peritoneal fluid showed positive correlations with rASRM score. Blood neutrophil counts have correlation with the peritoneal sEng concentration., Conclusion: Our novel evidence on the elevated concentration of peritoneal sEng and GDF-15 in endometriosis, specifically in the late-stage, may indicate the essential role of TGF-β-dependent signaling in endometriosis. Serum GDF-15 might serve as a candidate biomarker for endometriosis severity. Further studies are warranted to investigate the role and regulation of these molecules in endometriosis., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: This study aimed to assess the feasibility and efficacy of office hysteroscopy to diagnose and treat the specific uterine pathologies frequently diagnosed and thought to be associated with female infertility., Material and Methods: Using office hysteroscopy, we examined the uterine cavity in women with primary or secondary infertility and evaluated the reproductive outcomes of those affected by one or more pathologies, including cervico-isthmic adhesions, intrauterine polyps and intrauterine adhesions. Additional patient characteristics considered were age and parity, uterine pathology, pain during hysteroscopy, and outcomes including spontaneous pregnancies achieved and time between treatment and pregnancy., Results: Reproductive outcomes of 200 patients affected by one or more uterine pathologies were evaluated. Cervico-isthmic adhesions were the most frequent findings in older women, with nearly 80% of them achieving pregnancy sooner than the others in our study. Spontaneous pregnancy rates following office hysteroscopy were 76%, 53% and 22% in women with cervico-isthmic adhesions, polyps (< 5 mm) and intrauterine adhesions, respectively., Conclusions: Office hysteroscopy is a feasible and highly effective diagnostic and therapeutic procedure for cervico-isthmic and intrauterine adhesions, as well as for small polyps, allowing the resolution of female infertility related to these pathologies, without trauma and with only minimal discomfort.

Introduction: intrauterine pathologies were traditionally evaluated by blind dilatation and curettage along with hysterosalpingography. Hysteroscopy is a veritable tool for evaluation of uterine cavity pathologies with an increasing availability in Nigeria. The study aims to report the diagnostic yield and therapeutic outcome of hysteroscopy in women with infertility from a Nigerian metropolis., Methods: a retrospective cross-sectional study of consecutive cases of infertile women referred for hysteroscopy to an ambulatory care endoscopy facility in Port Harcourt, Nigeria. The variables collated included age, parity, past gynaecological history, indication, hysteroscopy findings and interventions. Statistical analysis was performed using SPSS version 25., Results: included in study were 75 patients undergoing a total of 124 hysteroscopic procedures. The age range of patients was 25 to 56 years (mean 40.7 ± 5.9 years). A positive diagnostic yield of 93.3% with non-visualization of intracavitary uterine pathology in 5 patients was recorded. The most common pathologies were submucous myoma-25(31.3%), endometrial polyps- 18(22.5%) and intrauterine adhesions-18(22.5%). There was no statistical difference between the mean age of patients with or without polyp, myoma and intrauterine adhesions (P = 0.185, P = 0.510 and P = 0.619 respectively) but a non-linear relationship between age and polyp detection (Eta2 = 0.024). Operative hysteroscopies were all performed on out- patient basis but staged in 30(40.0%) patients., Conclusion: benign uterine growths and intrauterine adhesions are frequent causes of uterine factor infertility. A high successful completion rate of hysteroscopic interventions was achieved., Competing Interests: The authors declare no competing interests., (Copyright: Emeka Ray-Offor et al.)

Background and Objectives: The aim of the study was to investigate a potential association between previous childhood appendectomy, tube pathology, and female infertility., Methods: We reviewed patients seeking care at the fertility clinic of our university medical center between 2006 and 2016. The history of previous appendectomy was extracted from hospital documentation and by telephone follow-up. Tubal patency was assessed by diagnostic laparoscopy and chromopertubation., Results: In our study cohort (N = 237), 24.9% (n = 59) had a history of previous appendectomy. Previous appendectomy, therefore, was about 3-fold more prevalent in women seeking fertility treatment than in the general population. Patients with previous appendectomy had more intra-abdominal adhesions ( P < .001) and patients with adhesions tended to have compromised tubal patency ( P = .05). However, there was no direct correlation between a previous appendectomy and tube pathology ( P = .727)., Conclusion: Because previous appendectomy was associated with intra-abdominal adhesions, and these were in turn associated with tube pathology, but appendectomy was not directly associated with compromised tubal patency, previous appendectomy may indirectly affect female fertility through mechanisms other than direct tubal obstruction. This is one of the largest study analyzing laparoscopic chromopertubation in association with previous childhood appendectomy., Competing Interests: Conflicts of Interest: All authors declare no conflict of interest regarding the publication of this article.

Objective: To study the prevalence and pattern of tuboperitoneal pathologies among infertile women in Nigeria, using laparoscopy., Methods: A prospective study was undertaken of infertile women who underwent diagnostic laparoscopy in two fertility clinics in Nigeria between November 2015 and April 2017. The rates of identified tuboperitoneal diseases were examined., Results: The age of the 230 women ranged from 21 to 46 years, and most women had a parity group of 0-1 (87.8%; n=202). Secondary infertility accounted for 124 (53.9%) cases, and the mean duration of infertility was 4.6 ± 2.7 years. Tuboperitoneal pathologies were seen in 171 (74.4%) women and mainly comprised tubal occlusion (56.5%; n=130), hydrosalpinx (41.7%; n=96), pelvic adhesions (39.6%, n=91), and endometriosis (8.8%; n=19). Bilateral tubal occlusion was seen in 46 (20.0%) women, whereas proximal tubal occlusion accounted for 73 (56.2%) of all cases of tubal occlusion., Conclusion: There was a high rate of tuboperitoneal abnormalities in the studied population, which mainly comprised tubal occlusion, hydrosalpinx, pelvic adhesions, and endometriosis. The introduction of laparoscopy is recommended in the initial evaluation of all women with infertility in Nigeria., (© 2017 International Federation of Gynecology and Obstetrics.)

There is a need for more accurate Chlamydia trachomatis (CT) IgG antibody tests for tubal factor infertility (TFI) diagnostics. We evaluated the predictive value for TFI of Medac ELISA plus (MOMP) and multitarget Mikrogen ELISA (MOMP-CPAF-TARP). Based on Medac ELISA plus results, 183 subfertile women underwent either hysterosalpingography or laparoscopy to diagnose TFI. TFI was defined as extensive adhesions and/or distal occlusion of at least one tube. Women not fulfilling the definition of TFI served as controls. Serum was subsequently tested with Mikrogen ELISA and results were compared. 48 patients had TFI, 135 were controls. Mikrogen ELISA tested 125 patients positive/borderline of which 32% had TFI. Medac ELISA plus tested 77 patients positive/borderline of which 29.9% had TFI. Mikrogen tested 40 out of 48 TFI patients positive/borderline, Medac 23 out of 48. Kappa value was 0.34. PPV of Mikrogen ELISA and Medac ELISA plus were respectively 32% (95% CI 26%-39%) and 30% (95% CI 24%-37%), and NPV 86% (95% CI 81%-91%) and 76% (95% CI 70%-82%). Both tests were comparable in the prediction of TFI. However, Mikrogen ELISA had a higher NPV and might be more reliable in identifying patients without TFI. Kappa-value showed limited concordance between both tests., (© FEMS 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The objectives were to assess the diagnostic value of hysterosalpingography (HSG) with laparoscopy as gold standard in the evaluation of tubal patency and pelvic adhesions in women suffering from infertility., Methods: We conducted a comparative cross sectional study on 208 medical files of infertile women followed up at the Yaoundé General Hospital during a period of five years (December 2007 to December 2012). Tubal patency, hydrosalpinx and pelvic adhesions detected at HSG were compared with laparoscopic findings as the gold standard. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of HSG were calculated with 95% confidence interval (CI)., Results: Mean age of the patients was 31.4 ± 6.45 years. Secondary infertility was the most frequent type of infertility (66.82%). HSG had a moderate sensitivity (51.0%; 95% IC. 37.5-64.4), high specificity (90.0%; 95% IC.74.4-96.5), high PPV (89.3%; 95% IC. 72.8-96.3) and a moderate NPV (52.9%; 95% IC. 39.5-65.9) in the diagnosis of bilateral proximal tubal occlusion. Concerning, distal tubal patency, HSG had a high sensitivity (86.8%; 95% IC. 76.7-92.9), low specificity (42.2%; 95% CI. 29.0-56.7), moderate PPV (69.4%; 95% IC. 58.9-78.2) and a moderate NPV (67.9%; 95% IC. 49.3-82.0) in the diagnosis of bilateral or unilateral distal tubal occlusion. However, HSG had a low diagnostic value (27.8%; 95%IC.18.8-39.0) in the pelvic adhesions., Conclusion: HSG is of limited diagnostic value in tubal factor infertility and is of low diagnostic value for pelvic adhesions.

Laparoscopy is considered as the preferred modality for the diagnosis of pelvic pathology but its timing and use in the investigation of infertility is an area of debate. A prospective observational study was conducted between 1 November, 2009 and 31 March, 2011, in which 30 women with unexplained infertility with at least three failed cycles of COH and IUI were included and subjected to laparohysteroscopy. On laparoscopy, pelvic abnormalities were found in 11 (36.7%) women. On hysteroscopy, intrauterine lesions were detected in two (6.7%) of the women. The commonest pelvic pathology detected was adhesions followed by minimal to mild endometriosis. Operative procedures were done in nine (30%) cases. Since laparoscopy was not only diagnostic but also therapeutic in a significant number of cases, it was concluded that laparoscopy is beneficial following failure of empirical treatment in women with unexplained infertility while the routine use of hysteroscopy requires further assessment.

Hysteroscopy is widely performed in infertile women. A review of peer-reviewed, published literature from the PubMed database on uterine intracavitary pathology, proximal tubal occlusion, failed in vitro fertilization procedures, and first trimester miscarriages of infertile women was performed to examine the importance, feasibility, and success rates of diagnostic and operative hysteroscopy when evaluating and treating these conditions., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the application of transvaginal hydrolaparoscopy for exploration of the pelvic cavity exploration in infertile women., Study Design: A total of 510 infertile women were included in this study from May 1st, 2009 to April 30, 2012 in the clinic of the Hebei Research Institute for Family Planning., Results: In 495 of 510 of the patients (97.06%), a successful operation was achieved at the first puncture. Of these 495 patients, 286 (57.78%) showed bilateral patency. Completely normal tubo-ovarian and pelvic structures were observed only in 79 patients (15.96%): 16 patients (3.23%) had bilateral tube obstruction, 18 (3.64%) had hydrosalpinx, and 8 (1.62%) had fimbrial stenosis. Pelvic abnormalities occurred in 240 patients (44.04%), including bilateral and/or unilateral tubo-ovarian adhesions in 80 patients (16.16%) and 160 (32.32%) found with adhesions in other parts of the pelvic cavity. Pelvic endometriosis was found in 82 patients (16.57%) and 19 (3.84%) had two or more lesions in the pelvic cavity. In addition, 9 cases (1.82%) of ovarian cysts, 7 (1.41%) of bilateral vesicular appendices and 43 cases (6.69%) of a unilateral vesicular appendix were observed. In addition, convoluted tubes such as bent or twisted tubes were found in 4 cases of bilateral fallopian tube occlusion patients (0.81%) and 17 cases of unilateral tubal occlusion patients (3.43%)., Conclusions: Transvaginal hydrolaparoscopy is a feasible, safe, and cost-effective microinvasive technique. This technique can be considered as an alternative procedure for evaluating female infertility., (Copyright © 2014. Published by Elsevier Ireland Ltd.)

Objectives: The diagnostic laparoscopy has long been the key consideration in the export of female infertility. This place is being reconsidered, especially in the case of normal hysterosalpingogrophy (HSG), because of the advent of assisted reproductive technologies which are more efficient, and because of the improvement of medical imaging techniques which are more sensitive and specific. We wanted to clarify the place of the diagnostic laparoscopy in the balance of female infertility in normal HSG., Patients and Methods: It is a retrospective study on a series of 100 observations of infertile patients with a normal HSG and having a diagnostic laparoscopy in the department of Gynecology and Obstetrics at Farhat Hached hospital in Sousse (Tunisia) from 1st January 1993 to 1st March 2003., Results: The mean age was 32.3years; the mean duration of infertility was 70.47months. Laparoscopy revealed pelvic abnormalities in 45% of cases, dominated by disease tubo-adhesions (23%), endometriosis was found in 6% of cases. These anomalies are considered major in 23% of cases and minor in 22% of cases. Conducting a surgical procedure in the same operating time (adhesiolysis, tubal plastic surgery, electrocoagulation of endometriosis implants) could improve the prognosis of fertility. Only 20 patients were followed among the 45 with pelvic abnormalities, seven pregnancies have been completed (35% of cases)., Discussion and Conclusion: Laparoscopy has improved the prognosis for the fertility of our patients by treating abnormalities involved in infertility. It is estimated that the prognosis can be improved by selecting patients with risk factors for pelvic abnormalities., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Laparoscopy was performed in women for diagnosis and treatment of infertility and chronic pelvic pain (CHPP). While laparoscopy performance in all the women there was revealed the adhesion process in the region of the uterine accessories, in 42.5% of them--in a small pelvis and abdominal organs, more frequently various forms of genital endometriosis were revealed, and it is interesting, that it was revealed for the first time in 33.75% of women intraoperatively. Coexistence of adenomyosis and external genital endometriosis was noted in 51.25% observations, what is trustworthy more, than in women, suffering infertility without CHPP. The concomitant affection rate is trustworthy enhanced, than in women, suffering infertility without CHPP.

Objective: To evaluate the value of transvaginal hydrolaparoscopy (THL) in infertile women with abnormal hysterosalpingogram results but with no history of previous pelvic surgery and with normal gynecological examination and vaginal sonography., Study Design: This is a retrospective study. From January 2008 to October 2009, 51 infertile women were planned to undergo standard laparoscopy because of abnormal HSG. None of the patients had any history of previous pelvic surgery and all had normal findings on gynecological examination and vaginal sonography. These women underwent THL., Results: Among the 51 cases, successful access to the pouch of Douglas was achieved in 49. There were two failures due to obesity, and the operation was converted to standard laparoscopy. No complication was observed in this study period. In 26 patients (53.1%) the THL procedure showed normal pelvic organs. Four patients were lost to follow-up. Of the remaining 22 cases, four became pregnant (4/22, 18.2%) through intercourse or intrauterine insemination (IUI). There were some morphologic abnormalities seen in the remaining 23 patients such as adhesions, endometriosis and hydrosalpinx. Six cases with mild adhesions and endometriosis were treated with THL alone, and four (4/6, 66.7%) became pregnant with or without IUI. Among the 19 who underwent standard laparoscopy, three were lost to follow-up. In the other 16 cases, natural pregnancy occurred in six (6/16, 37.5%) patients with or without IUI., Conclusions: For women with abnormal HSG results but with no obvious pelvic pathology, THL should be recommended and about 50% could avoid an unnecessary laparoscopy. Adhesiolysis and coagulation of endometriotic lesions under THL in mild adhesion and endometriosis cases could lead to encouraging results., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

This study aimed at evaluating the role of laparoscopy in the management of unexplained infertility in a prospective randomised controlled trial. The study comprised of 255 patients as a study group and 257 patients as a control group. All women had unexplained infertility. Patients in the study group had laparoscopy followed by ovarian stimulation and timed intercourse for six cycles, while patients in the control group were treated directly with ovarian stimulation and timed intercourse for six cycles. Severe adhesions were found in one in each of the two groups, respectively. They were referred directly to the IVF/ICSI programme. Moderate pelvic endometriosis was demonstrated in three cases in the two groups. Again, severe endometriosis was found in two cases in the study groups and they were referred to the IVF/ICSI programme. After 6 months of follow-up, clinical pregnancy occurred in 114/255 (44.7%) in the study group and 107/257 (41.7%) in the control group and the difference was not statistically significant (p > 0.05). The miscarriage rate was similar in the two groups. We concluded that laparoscopy could be postponed when proceeding in the management of unexplained infertility, until ovarian stimulation and timed intercourse had been found to be unsuccessful in achieving pregnancy.

Patients with unexplained infertility following standard infertility screening tests usually undergo timing therapy that coordinates the time of ovulation and coitus, controlled ovarian hyperstimulation, or intrauterine insemination. If the treatment is unsuccessful, diagnostic laparoscopy is performed. However, with recent improvements in the assisted reproductive technology (ART), there has been a growing tendency that bypasses diagnostic laparoscopy and proceeds directly to ART. Therefore, the value of diagnostic laparoscopy in current fertility practice is under debate. In the present study, we evaluated the usefulness of diagnostic laparoscopy for patients with unexplained infertility and normal hysterosalpingography (HSG) findings. Between January 1997 and December 2006, 57 infertile patients with normal HSG findings underwent diagnostic laparoscopy at Kinki University Hospital. In 46 (80.7%) of these patients, diagnostic laparoscopy revealed pathologic abnormalities. Specifically, endometriosis and peritubal and/or perifimbrial adhesions were found in 36 (63.2%) and 5 (8.8%) of the patients, respectively. In 8 patients (14.0%), the management plan was switched to ART because of severe tubal diseases. Among the 57 patients, 29 pregnancies (50.9%) were achieved, including 6 ART-mediated pregnancies. We conclude that diagnostic laparoscopy is beneficial for patients with unexplained infertility and normal HSG findings. Indeed, by diagnostic laparoscopy, we are able to detect the cause(s) of infertility in the pelvic cavity and to design a suitable management plan, which could lead to postoperative pregnancy. Therefore, because of the potential diagnostic and therapeutic benefits, patients with unexplained infertility and normal HSG findings should undergo diagnostic laparoscopy prior to ART.

Objective: Evaluation of fertiloscopy's place in the management of female infertility., Patients and Methods: Retrospective study including 229 women presenting primary or secondary infertility without pathology raising of an evident surgical sanction and benefitting from a fertiloscopy. Perioperative data analysis (context of the infertility, operating technique, complications)., Results: Two hundred and three fertiloscopic procedures succeeded (88.6%), revealing lesions in 58 cases (28.6%) requiring a laparoscopy. These are represented by adherences (21 cases), endometriosis (17 cases), an abnormality of the tubal permeability (10 cases), complete or partial failure to visualize the adnexae (6 cases) and ovarian cysts visualization (4 cases). Five complications (2.5%) without major consequence will be deplored: two rectal injuries, two hemorrhagic complications and a postoperative salpingitis. Most of procedures (97.5%) have been performed in an ambulatory setting except when a geographic remoteness did not allow it (5 patients)., Discussion and Conclusion: Fertiloscopy is a safe and reliable procedure. It can be substituted to laparoscopy in the routine assessment of infertile women management in case of not obvious surgical indication.

Objectives: To assess the diagnostic benefit of laparoscopy in infertile women thought to be at low risk for altered pelvic anatomy., Design: Retrospective chart review., Patients: 127 infertile patients who underwent laparoscopic evaluation of the pelvis failing to conceive after intrauterine inseminations (IUI) with normal hysterosalpingography (HSG)., Intervention: Diagnostic and/or therapeutic laparoscopy., Main Outcome Measures: Presence of pelvic pathology and predictors of pelvic disease., Results: Although the hysterosalpingograms were read as normal in all women, endometriosis stage I-II was found in 64 (50,4%) patients, stage III and stage IV in 4 (3,1%). Adhaesions were diagnosed laparoscopically in 22 (17%) patients and distal tubal disease in 26 (20%). All of this abnormalities were directly treated by laparoscopic intervention. The time between HSG and laparoscopy was positively correlated with appearance of distal tubal disease and pelvic adhaesions., Conclusion: Laparoscopic findings could lead to a change of treatment decisions in high number of infertile patients with normal hysterosalpingography.

Two women with a ventriculoperitoneal shunt had primary infertility. At laparoscopy they both had extensive peritoneal adhesions that made evaluation of pelvic organs impossible and increased the risk of bowel injury. History of ventriculoperitoneal shunt should be considered a contraindication of laparoscopy.

Background: To establish the value of a new technique called transvaginal hydrolaparoscopy for exploration of the tubo-ovarian structures in the management of patients with unexplained infertility., Methods: A total of 120 women with primary or secondary infertility, and without obvious pelvic pathology, were included in the study. The first 14 patients received general anesthesia and underwent transvaginal laparoscopy immediately before standard laparoscopy. The remaining 106 patients had transvaginal laparoscopy performed under local anesthesia, with standard laparoscopy performed only on those with pathology, which required operative intervention. Information on pathology, complications, and successful access to the pouch of Douglas were recorded., Results: The successful rate of access was 93%. Pathology was found in 29 patients, of whom 15 required operative laparoscopy. Also, out of 19 patients with adhesions, 11 (58%) had normal dye test bilateral, and only two (11%) had bilateral occlusion of the tubes. No complications were observed., Conclusion: Transvaginal hydrolaparoscopy is a safe and well-tolerated method for investigating the tubo-ovarian structures in unexplained infertility. It is superior to hysterosalpingography for diagnosis of adhesions.

Background: A new technique called transvaginal hydrolaparoscopy (THL) was recently developed for the exploration of the tubo-ovarian structures in infertile patients without obvious pelvic pathology. This study was performed to investigate the usefulness of THL to evaluate Chlamydia trachomatis tubal infertility., Methods: Forty-one women with primary and secondary infertility participated in this study. Fourteen had past C. trachomatis infection. In 38 (92.7%) of the 41, access to the pouch of Douglas was obtained. In total, 71 (93.4%) out of 76 adnexa were clearly visualized. Thirty-seven patients were analysed and compared their tubal passages and peritubal adhesions using both hysterosalpingography (HSG) and THL. Twenty-four tubes from 14 patients with past C. trachomatis infection and 44 tubes from 23 patients without a history of C. trachomatis infection were compared., Results: For the diagnosis of the tubal passage, there were no significant differences in the discrepancy rates between HSG and THL, in patients with and without past C. trachomatis infection. In 14 (58.3%) of the 24 tubes from patients with past C. trachomatis infection and in eight (18.2%) of the 44 tubes from patients without infection, peritubal adhesion was diagnosed only by THL. There was a significant difference in the discrepancy rates of the diagnosis of peritubal adhesion between HSG and THL in the two groups (P = 0.0007 )., Conclusions: These results suggest that C. trachomatis infection is highly associated with peritubal adhesion which is difficult to diagnose by HSG. Therefore, in C. trachomatis antibody-positive patients, exclusion of tubal pathology by THL or standard laparoscopy should be carried out to consider appropriate treatments. Although THL is not a substitute for laparoscopy, it can be proposed as a first line procedure in the early stages of the infertility investigation.

Transvaginal hydrolaparoscopy (THL) was evaluated in comparison with the already established chromolaparoscopy in the detection of tubal factors, adhesions as well as endometriosis. 43 infertile patients without previous pelvic operations and with an inconspicuous clinical examination were included in a prospective comparative study of THL and chromolaparoscopy. THL succeeded in 40 patients (93.0%). Both methods showed 100% agreement with regard to tubal factors and adhesions. However, only 72/80 tubes (90.0%) could be portrayed by THL. In contrast to this, THL failed to identify 8 of 10 laparoscopically verified endometrioses (isolated endometriosis of the bladder peritoneum in 2). No complications occurred with THL. THL could be the method of choice for the clarification of mechanical infertility factors in symptom-free patients with no suspicion of pelvic pathologies. Tubal pathologies and/or adhesions (visible during THL) should be indications for laparoscopy. In the case of inconspicuous genitals during THL and a still unfulfilled desire for offspring postoperatively, laparoscopy should be considered in order to exclude the possibility of unidentified endometriosis. Retroflexio uteri should at least be a relative contraindication for THL. Further studies are necessary to evaluate the role of THL in the diagnostic concept of infertility in the future., (Copyright 2001 S. Karger AG, Basel)

Objective: To evaluate the feasability of transvaginal hydrolaparoscopy in infertile patients undergoing basic infertility investigations, and to determine its usefulness in comparison with standard laparoscopy., Materials and Methods: Twenty-three unexplained infertile women were prospectively included. Selected patients had no history of pelvic disease or previous pelvic surgery and had normal findings on gynecological examination and vaginal sonography. The patients received general anesthesia and underwent the transvaginal hydrolaparoscopy immediately prior to a standard laparoscopy by a different operator. The main outcome measures were the rate of successful access to the pouch of Douglas, the duration of the procedure, and the rate of complications. In order to compare the accuracy of the transvaginal hydrolaparoscopy to the standard laparoscopy, findings in terms of tubal pathology, endometriosis, and adhesions were analyzed., Results: The successful rate of access to the pouch of Douglas was 95.7%. The rate of complications was 4.3%. The mean duration of the transvaginal hydrolaparoscopy procedure was 8 min. The concordance between transvaginal hydrolaparoscopy and laparoscopy for pelvic cavity examination was statistically significant (k=0.57, P=0.02). In 40.9% of cases, the transvaginal hydrolaparoscopy procedure has shown a normal pelvic examination confirmed by laparoscopic diagnosis. According to the findings by laparoscopy, transvaginal hydrolaparoscopic diagnosis was correlated well in 81.8% of cases. When transvaginal hydrolaparoscopy showed pathological findings, there were no normal laparoscopies. Pathological laparoscopies were found in 18.2% of the normal transvaginal hydrolaparoscopies., Conclusion: The transvaginal hydrolaparoscopy is a reproducible and safe method to investigate the pelvis and its structures. The diagnostic accuracy of the transvaginal hydrolaparoscopy suggests that more than 40% of standard laparoscopies for unexplained infertility could be avoided.

Unlabelled: STUDY OBJECTIVE. To evaluate the feasibility of a new endoscopic technique, transvaginal hydrolaparoscopy, for early office screening of subfertile women. DESIGN. Retrospective, descriptive feasibility study (Canadian Task Force classification II-2)., Setting: Office in an infertility center., Patients: One hundred fifty-seven continuous women with primary or secondary subfertility., Intervention: Under local anesthesia, a Veress needle-cannula system was inserted into the posterior fornix with peritoneal distention by saline., Measurements and Main Results: Access was achieved in 95% of patients. In 58.5% the findings were normal and in 28% an explorative or operative laparoscopy was indicated. No major complication occurred. Patients' pain scores were similar to those for office hysteroscopy., Conclusion: Transvaginal hydrolaparoscopy was successfully performed in the office. The technique allows early and complete endoscopic screening of subfertile women.

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.

Study Objective: To evaluate the efficacy of early second-look laparoscopy (ESLL) and the usefulness of the American Fertility Society (AFS) adhesion score at ESLL in terms of reproductive prognosis., Design: Retrospective study (Canadian Task Force classification II-2)., Setting: University hospital., Patients: Ninety-two consecutive women undergoing infertility surgery between January 1983 and December 1996., Intervention: We performed ESLL in all but 32 patients, 27 of whom underwent surgery before institution of the protocol., Measurements and Main Results: The pregnancy rate in 1 year was significantly higher in women having ESLL than in those not having the surgery. The AFS score was not significantly different in pregnant and nonpregnant patients., Conclusion: Early second-look laparoscopy may improve fecundity in women requiring fertility surgery. (J Am Assoc Gynecol Laparosc 6(2):165-168, 1999)

To assess the efficiency of transvaginal ultrasonography (TVUS) in the screening of pelvic pathologies in the initial workup of infertile women, we carried out a prospective comparison of sonographic diagnosis with laparoscopic and pathological findings. Between February 1994 and April 1995, 133 premenopausal non-pregnant women underwent TVUS on the day before laparoscopy. The efficiency of TVUS in detecting pelvic pathologies was 90.2% with a sensitivity of 86.2%, a specificity of 97.8% and positive and negative predictive values of 98.6 and 78.8% respectively. If the six false-negative cases with a histological diagnosis of minimal endometriosis were defined as 'normal pelvis', sensitivity and specificity could be corrected to 92.5 and 98.6% respectively. Endometriomas were diagnosed by TVUS with an efficiency of 96.4%, with a sensitivity and a specificity of 90 and 96.7 % and with positive and negative predictive values of 75 and 99.1% respectively. The sensitivity of vaginal sonographic characterization of pelvic adhesions was 61.1% with a specificity and positive predictive value of 98.2 and 84.6%. The negative predictive value of TVUS was 94.1%. These data suggest that it is not possible to characterize pelvic adhesions, especially filmy adhesions, with acceptable accuracy. However, in the initial workup of infertile women, if the patient is young, if both hysterosalpingography and TVUS are negative, laparoscopy could be postponed. In couples with severe male factor infertility and for whom in-vitro fertilization or intracytoplasmic sperm injection is the treatment of choice, laparoscopy might be avoided where the TVUS is negative.

Over a three-year period (1990-1993), a total of 410 diagnostic laparoscopies are performed. The series includes female patients with a minimum one year longstanding of sterility. Diagnostic laparoscopy is taken to be a routine method of making exact diagnosis in female sterility cases, and as a filtering procedure in forthcoming reconstructive operation or in the event of poor outlooks of eventual conception. The commonest finding is endometriosis (in 58.2 per cent), next ranking adhesions free of endometriosis (31.4 per cent) and bilateral obstruction of the uterine tubes (38.5 per cent). Endometriosis is usually located in the uterine body 27.5 per cent, uterine tubes 26.1 per cent and pelvic peritoneum 14.9 per cent.

Study Objectives: To assess the efficacy of salpingoscopy as a routine part of the infertility work-up by comparing laparoscopic findings with salpingoscopic findings, and to match the pregnancies achieved by the patients with findings obtained from the endoscopic evaluation., Design: A retrospective study conducted between January 1990 and June 30, 1994., Patients: One hundred twenty-four women undergoing infertility investigations. Two were suspected of having pelvic inflammatory disease, and one had an extrauterine pregnancy., Setting: The Jan Palfijn General Hospital, Antwerp, Belgium., Interventions: Video hysteroscopy, laparoscopy, and salpingoscopy were performed in every patient. Adhesiolysis was done in 46 and neosalpingostomy in 5. Salpingoscopy was performed on 188 fallopian tubes; 60 tubes (24.15%) could not be cannulated. Drilling of polycystic ovaries was done in eight patients, ovarian cystectomy in five, and myomectomy in one. Endometriosis lesions were treated in 38 women., Measurements and Main Results: In 3 of 13 women who were diagnosed as having endometritis at hysteroscopy, salpingoscopy revealed severe lesions of the mucosal folds. Of the normal-looking tubes at laparoscopy, 25.8% had mucosal lesions. Of the abnormal looking tubes at laparoscopy, only 13.5% had normal mucosal folds. More than one-fourth (28.5%) of patients with endometriosis AFS I and II had mucosal lesions. The number of pregnancies achieved by these women correlated well with salpingoscopy except in those with class III lesions., Conclusion: This study confirms that tubes that look normal externally can have lesions of the endosalpinx. A maximum possibility of spontaneous pregnancy exists when the mucosal folds are normal. Class III lesions are compatible with fertility, although the probability is reduced. With severe mucosal lesions the chances of spontaneous pregnancy are very remote.

This study was designed to evaluate the routine use of rigid salpingoscopy during diagnostic laparoscopy for infertility, and to relate the morphologic image of the endosalpinx with pregnancy outcome. A total of 158 consecutive patients (232 Fallopian tubes) undergoing a diagnostic laparoscopy for infertility were studied. Salpingoscopy was performed at the time of diagnostic laparoscopy for infertility. The intraluminal image was classified using a simplified classification (class I-V). The relationship between this classification and the cumulative pregnancy rates was calculated using life table analysis. Patients with a normal salpingoscopy (class I and II) had a 71% cumulative pregnancy rate. In the intermediate group (class III) the cumulative pregnancy rate was 34%. No intrauterine pregnancies were observed in the group with severe intratubal pathology (class IV and V). Of the 107 slapingoscopies of patients with endometriosis 105 (98%) were class I or II. However, among patients with pelvic adhesions, only 42% were normal. Nine out of 50 abnormal salpingoscopies were found when no tubal factor was suspected during laparoscopy, without any pelvic adhesions. These results suggest that salpingoscopy is an important tool for detecting mucosal abnormalities, and for eventually referring patients for assisted reproductive technology. Salpingoscopy is usually normal in patients with endometriosis, but in patients with non-endometriotic pelvic adhesions it is not.

Study Objectives: To analyze the cost of diagnosis and treatment associated with hydrosalpinges and pelvic adhesions using algorithmic pathways., Design: Analysis of six pathways: (1) Chlamydia IgG antibody titer -> hysterosalpingogram -> diagnostic laparoscopy -> in vitro fertilization (IVF); (2) Chlamydia IgG antibody titer -> diagnostic laparoscopy -> therapeutic laparoscopy -> IVF; (3) hysterosalpingogram -> diagnostic laparoscopy -> therapeutic laparoscopy -> IVF; (4) diagnostic laparoscopy -> therapeutic laparoscopy -> IVF; (5) no treatment; and (6) IVF only., Setting: A tertiary care practice at a university-associated hospital., Patients: Patients were retrospectively chosen on the basis of availability of results of Chlamydia IgG titers, operative notes from laparoscopy, and hysterosalpingograms (HSGs). All patients identified with these three results available were included., Interventions: Determination of results of laparoscopic treatment, IVF, and no therapy (observation only), based on the literature., Measurements and Main Results: The theoretical cost to achieve pregnancy for each pathway was calculated by mathematical modeling. The greatest number of pregnancies for the least cost ($18, 883/pregnancy) was from the diagnosis and treatment of adhesions at laparoscopy with no previous screening. The least costly approach to pregnancy for blocked tubes ($26,614/pregnancy) was to start with an HSG. All pathways for adhesions and any screening pathway using HSG for hydrosalpinges were more cost effective than IVF., Conclusions: These pathways are limited, as they require several assumptions and are based on a tertiary care population. Although HSG and laparoscopy appeared to be the most cost-effective approaches to pregnancy, a primary care group may have a more cost-effective response to the use of Chlamydia trachomatis IgG antibody screening.

Seventy-three women experienced bilateral proximal tubal occlusion caused by adhesions or polyps arising from the uterotubal junction in at least one tube. There were no other identifiable causes of infertility. All patients were treated with cryosurgery, which restored tubal patency in 61 (83.6%). Of 45 women with restored patency, who were followed 6 to 12 months, 20 (27.4% of 73) conceived and 16 (21.9%) delivered viable babies.

Laparoscopy was used to evaluate 130 women whose basic infertility survey revealed no abnormalities. Overall 75 (57.7%) patients were found to have evidence of pelvic disease while the remainder were completely normal. Pelvic endometriosis was the most common pathology accounting for 27.7%, pelvic adhesions 20.8% and mild pelvic inflammatory disease 6.2%. Appropriate treatment of the pelvic conditions resulted in 31 (42.5%) pregnancies compared with 7 (12.3%) pregnancies in the no treatment group. The outcome of this study suggests that additional pregnancies do occur as a direct result of laparoscopic examination and subsequent therapy. We believe that laparoscopy should be performed on all women to search for a tubal or pelvic cause of infertility when all other examinations have been normal.

The range and nature of adhesions found out by means of laparoscopy was analysed in patients diagnosed because of infertility. 38% of patients had laparotomy performed previously. Adhesions concerned 47% of the reproductive organ, although in nearly the same percentage intestine and greater omentum were involved. In 13 (31%) patients occurrence of endometriosis focus was discovered. In the area of Fallopian tube--ovary there were most often non-vascularized, thin adhesions and solid adhesions in the area of Douglas sinus.

From 700 laparoscopies performed, in 600 of them (85.7%) the tuboperitoneal factor was altered. Surgery included: termino-terminal plastia 70 cases (36%), (3 patients had previous plastia); adhensiolysis 62 (31%), salpingostomy 48 (24%), neoimplantation 10 (5%), and mixed surgery 9 (4%). After surgery, desertion was present in 78 patients. Of the 121 remaining, 34 (28.1%) had primary sterility and 87 (71.9%) secondary sterility. 74 patients (61.2%) obtained pregnancy, 62 (83.8%) reached term, seven were abortions of first trimester (9.5%) and were five ectopic pregnancies (6.7%). The interval between surgery and pregnancy achievement was 1 to 48 months, 12.8 months average. We emphasize the 47 patients analysis who didn't has pregnancy, through: remark time after surgery, histerosalpingography, new laparoscopy and reevaluation of sterility factors; the results were: 19 cases (40.5%) have a 5 to 60 months time after surgery, 19.5 months average, 18 (38.3%) had new tubary obstruction, three (6.4%) with endometriosis treatment, three (6.4%) have tuberculosis genital treatment, two (4.2%) with falling again endocrine-ovarian factor, and two (4.2%) with masculine relapse. A decease was present because anesthetic complication. We underline selection surgery criterion and a strictly evaluation, such as an antiadhesion pre, trans and postoperative regime, ligamentopexya of rounds ligaments and a conscious education of the patients in their strictly pursuit.

Over the period of 25 years, 1080 pelvic endoscopy in infertile women were performed, with special attention payed to the pathology of Fallopian tubes. Pelvic endoscopy was performed after previous HSG. During the pelvic endoscopy, the state of the uterus, ovaries and uterine tubes were evaluated, with much attention paid to the condition of the abdominal ostium of the uterine tube, symptoms of active and chronic inflammation, endometriosis, the authors also tried to diagnose the extension and character of pelvic-salpingian adhesions. Confrontation of the results enabled diagnosis in 111 (41.7%) women, out of 266, with patient Fallopian tubes the organic factors which impaired conception or made conception impossible. In the group of 814 women with tubal impotency in 15 (1.8%) cases extratubal factor was found, subserosal myoma in uterine horn, cyst, adhesions, while Fallopian tube itself was patent and unchanged. Organic factors of Fallopian tube disorder were determined. In 360 (44.2%) patients, out of 814, with tubal impotency pathological status was found (active salpingitis, tuberculosis, endometriosis) which required establishing of a necessary treatment and cancelling the surgical treatment.

A total of 324 patients participating in our in-vitro fertilization/embryo transfer (IVF) programme underwent a diagnostic hysteroscopy. Of these, 152 women were referred before their first IVF attempt, because of some hysterosalpingographic suspicion of an intra-uterine abnormality; the other 172 patients had failed to conceive after IVF and transfer of good quality embryos. An intra-uterine pathology (mainly intra-uterine adhesions) was diagnosed in 50% of the patients in each group. Hysterosalpingography, although very sensitive, had low specificity (23%), a false positive rate of 44% and false negative rate of 10%. The main risk factor for intra-uterine pathology was a previous abortion. Conception rates were 22% after surgical treatment and 38% after the diagnostic procedure. We think that hysteroscopy should be performed in every patient failing to conceive after replacement of good quality embryos. It is also recommended whenever a suspicious finding is revealed by hysterosalpingography, before IVF. Routine hysteroscopy before entering an IVF programme should be seriously considered.

Ninety cases of infertility and habitual abortion were analyzed by hysteroscopy from April 1983 to July 1990 in our hospital. Abnormal changes of the uterine cavity were seen in 75.6%. The result of hysterosalpingography was found to correspond to that of hysteroscopy in 62.5%, and the result of B-ultrasound corresponded to that of hysteroscopy in 52.5%. The diagnosis of adhesion and polyps of the uterine cavity was made accurately by hysteroscopy, and both could be operated under hysteroscopy. After operative removal of the adhesion, an IUD should be put into the uterine cavity for 3 months.

Infertility is secondary to pelvic adhesions in 15-20% of cases. Pelvic adhesions result from pelvic inflammatory disease, previous pelvic surgery, foreign bodies and previous appendicitis with pelvic abscess. As a result of the insult to the peritoneal surfaces of the pelvic organs, the concentrations of peritoneal fluid leukotriene, B4 and prostaglandin E2 are increased. Also, there is a decrease in plasminogen activity. The end result will be the formation of fibrin deposits, which will end in the formation of pelvic adhesions. The diagnosis of adhesions can be achieved by a high index of suspicion in patients with a history of pelvic infections or surgery. A pelvic examination with fixation of the uterus and/or adnexa is also highly suggestive. A hysterosalpingogram might lead to a suspicion of the presence of pelvic adhesions; however, there is some degree of false-positive and -negative results. The definitive diagnosis depends on laparoscopy. The use of an internationally accepted classification, such as that of the American Fertility Society, allows investigators to compare the results of treatment. Various adjuvants have been used following lysis of adhesions to prevent their recurrence; they yield various results. The most significant recommendation is to prevent the occurrence of adhesions by following the principles of microsurgical technique during every surgical procedure.

Investigation of the tubal factor in infertility is limited to an assessment of anatomical structure and tubal patency. No test of ascendant tubal function is currently available. The migration of radionuclide (99mTc-labelled human albumin microspheres) through the genital tract in 96 infertile women was compared with pelvic findings at laparoscopy and chromopertubation. The radionuclide test correlated with laparoscopy in the diagnosis of patency or blockage in 83 cases (86%). In nine patients, where 'blockage' was diagnosed on the radionuclide test but patency found at laparoscopy, a higher prevalence of pelvic abnormality was found, compared to the 78 patients where both tests demonstrated patency (P less than 0.02). The radionuclide test may facilitate detection of diseased but patent tubes and, as an adjunct to laparoscopy and chromopertubation, may provide useful information about tubal function.

In 97 female patients the respectively less damaged tube has been laparoscopically assessed with the help of on adhesions-score and a chromopertubation-score. The correlation to postoperative fertility has been examined. The rate of conception of patients who underwent a laparoscopic examination was 28.8%. The live birth rate was 17.5%, the rate of spontaneous abortions was 2.1% and the rate of ectopic pregnancies 9.2%. The preoperative adhesions-score doesn't allow prognostical statements, whereas the postoperative adhesions-score closely correlated with the postoperative rate of conceptions. Female patients with a preoperative partial tubal occlusion (CPS = 1) postoperatively chances of conceptions twice as high as female patients with a preoperatively total tubal occlusion (CPS = 2). A postoperative total tubal occlusion (CPS = 2) is a primary indication for in-vitro fertilization.

The benefit of routine hysterosalpingography (HSG) and pre- and postoperative laparoscopy in diagnosing and treating anatomical infertility was investigated in 115 women. The findings at HSG and laparoscopy were compared with the diagnoses obtained by laparotomy. Laparoscopy was significantly better than HSG in detecting adhesions. Both procedures were of equal value in assessing tubal pathology. Although HSG revealed additional findings in 5 per cent of cases, none of these needed operative correction. Postoperative laparoscopy, which was performed in 70 patients, did not affect the incidence of either intra- or extra-uterine pregnancy. It is concluded that all patients should be offered diagnostic laparoscopy. HSG and second-look laparoscopy should not be used routinely.

Our previous publications have demonstrated a high prevalence of hysteroscopic findings, particularly adhesions and polyps. It was the purpose of this study to compare the findings in 992 women in whom hysteroscopy was successfully performed by Dextran 70 with a similar group of 335 women in whom hysteroscopy was performed by CO2 as the distention medium. The incidence of uterine abnormalities in women with primary infertility, secondary infertility, and requesting reversal of sterilization when Dextran was used as the distention medium was 29%, 41%, and 33%, respectively, but only 7.2%, 11%, and 6%, respectively, when CO2 was used. It was concluded from these data that many of the findings of our preliminary studies were probably artifactual and a function of the technique of hysteroscopy and that our early reports must be read with caution.

Asymptomatic or undiagnosed tuboovarian autoamputation in teenagers may have its impact on fertility later in life. Two cases are presented with infertility following unilateral adnexal autoamputation. The importance of awareness for possible subtorsion or torsion of adnexa in childhood and adolescence and its impact on fertility are discussed.

In a series of 42 patients, the findings during fertility microsurgery were compared to the findings at both laparoscopy performed by referring gynaecologists and re-laparoscopy performed in our regimen. Since significantly fewer discrepancies were found in the latter group, this re-laparoscopy may be considered useful and justified. The importance of meticulous laparoscopy is emphasized.

During laparoscopy for investigation of infertility 68 women with no findings had their fallopian tubes catheterized. In 20 of these women small interfimbrial adhesions were found and divided. The subsequent pregnancy rate in this group was 14 (70%), which was significantly higher than that in the control group, 26 of 59 women (44%) who did not have their tubes catheterized during laparoscopy. These results indicate that interfimbrial adhesions, which are easily overlooked during routine laparoscopy but easily found when catheterization of the tubal ostia is performed, can be a contributing factor in infertility.