The role of endoscopy in managing infertility:
The diagnosis and treatment of infertility stands out as one of the most rapidly evolving areas in medicine. It is seen that most of the tests like Ultrasonography (trans-abdominal and vaginal) and HSG are likely to miss many intra-abdominal lesions like adhesion, endometriosis, exact ovarian pathology and tubal conditions which can be easily demonstrated by laparoscopy. The ability to see and manipulate the uterus, fallopian tubes, and ovaries during laparoscopy has made it an essential part of infertility evaluation.
What should I know about Laparoscopy?
Laparoscopy is an operation involving small cuts on the woman’s tummy. A fine telescope measuring 5 or 10 mm in diameter is introduced inside the tummy to check if the tubes are open and if there are any other undetected issues. This helps us to visualise the reproductive organs (uterus, tubes, ovaries and the rest of the pelvis and abdomen) on the screen. Additionally, three small cuts of 5mm length may be required on the tummy to insert other instruments that are required during the laparoscopy. This procedure helps to visualise the pelvic organs.
If any problem, such as a tubal block, fibroid or endometriosis is found, it should be treated at the same sitting. In some centre’s, such facilities and skills may not exist for the operative part and that part is performed at a later date again. This leads to doubling of the effort and should be avoided preferably. In some women, this operation gets performed repeatedly and leads to increased pain sufferings and costs.
Role of Laparoscopy in improving IVF success rates
A proper transvaginal sonography is crucial to diagnose tubal disease, ovarian abnormalities, uterine factors and other pelvic abnormalities that can adversely affect an IVF cycle. Tubal disease includes infections that lead to fluid collection within the tubes (hydrosalpinx), ovaries may have cysts and the uterus may have fibroids and polyps. If the ultrasonography has detected any of the above abnormalities, laparoscopy becomes necessary to improve the outcome of the IVF cycle. If the tubes are infected and filled with fluid, they have to be disconnected from the uterus. If not, the unhealthy fluid can prevent the implantation of embryos in the cavity of the womb. It is important to ensure that both ovaries are free and located normally so that they are well accessible for the egg collection procedure. Ovaries can be adherent due to adhesions resulting from conditions such as endometrioisis, pelivic infections and previous surgeries. In these situations, laparoscopy can help in the breakdown of these adhesions and free the ovaries. Before starting an IVF cycle, cysts in the ovaries need to be removed. These could be simple cysts, endometriotic cysts or even complex cysts such as dermoids. This improves the success of the IVF treatment. If the uterus has fibroids which are large (>4cm) and if they are located within the cavity or near the lining of the womb, then it may be advisable to remove them. These advanced procedures need special skills and are only performed in the highly specialised units.
Most women recover quickly from this procedure and are well mobile within 48 hours. Majority of the women are able to go home by the next day. Major surgical procedures may need extra few days for the full recovery. Slight discomfort is felt in the tummy for first few days after the operation.
Laparoscopy is a very commonly performed operation. The possible complications include: Bowel injury, Bladder injury, Vessel injury, Possibility of Laparotomy. These are very rare complications with an incidence of less than 1 in 1000 patients. They are more seen in patients with risk factors such as previous surgery with a midline vertical incision, previous complicated abdominal surgery and so on.
What should I know about Hysteroscopy?
Hysteroscopy is an operation in which a fine telescope is introduced into the cavity of the womb through its neck. Visualizing the uterine cavity and identifying the possible pathology has made hysteroscopy an equally important tool in infertility evaluation. The question of tubal morphology and patency, ovarian morphology, any unsuspected pelvic pathology, and uterine cavity abnormalities can all be resolved with accuracy at one session. Additionally, hysteroscopic guided biopsy and therapeutic procedures like polypectomy, myomectomy, septal resection, and adhesiolysis can be done in the same sitting.
Laparoscopy and Hysteroscopy have an important role to improve the success of IVF treatment. Hysteroscopy is beneficial in almost every patient undergoing IVF treatment, whereas laparoscopy is done selectively as indicated. Modern technology and improved instrumentation has increased the efficiency of these procedures. Improvement in imaging systems, better and safer energy sources for the operative procedures have increased the role of hysteroscopy and laparoscopy in maximising the success of IVF treatment.