1 Leuven Institute for Fertility and Embryology, Leuven, Belgium, 2 Center for Reproductive Medicine, Düsseldorf, Germany, 3 S.I.S.M.E.R., Bologna, Italy and 4 Department of Reproductive Sciences and Medicine, Imperial College School of Medicine, London, UK
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Abstract |
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Key words: infertility investigation/mini-hysteroscopy/outpatient procedure/salpingoscopy/transvaginal hydrolaparoscopy
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Introduction |
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Not surprisingly, some have argued, from a pragmatic point of view, that judicious exploration of the female partner should be abandoned in favour of liberal referral to an IVFembryo transfer programme. However, IVFembryo transfer is expensive, both for the patient or the healthcare provider. Furthermore, in a prospective randomized trial a higher pregnancy rate has been reported (Karande et al., 1999) and lower costs with a traditional treatment algorithm than with IVFembryo transfer as first-line therapy. These observations demonstrate that infertility exploration is beneficial and should be carried out prior to referral to an IVFembryo transfer programme. There is, however, no consensus as to how and to which extent the female partner should be investigated.
Recently, the diagnostic potential of ultrasound in infertile women has been highlighted (Kelly et al., 2001) but, despite the remarkable advances in ultrasound technology, this approach yields insufficient information on the presence of tubal disease, pelvic adhesions or endometriosis. We now discuss the advantages of a one-stop endoscopy-based approach that combines transvaginal hydrolaparoscopy (THL) with mini-hysteroscopy, chromopertubation and fimbrioscopy or salpingoscopy.
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Transvaginal hydrolaparoscopy |
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Clinical validation of THL |
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Feasibility
We have evaluated the use of THL as a diagnostic outpatient procedure under local anaesthesia in 157 consecutive infertile patients (Gordts et al., 2000a). Access to the pouch of Douglas was achieved in 95% of the patients. In six patients the needle failed to enter the pouch of Douglas and in two cases the procedure was aborted for minor complications. If access was successful, both adnexae were fully visualized in 89% of women. Unilateral or bilateral failure to visualize the adnexae occurred in 9 and 2% of the patients respectively, and was invariably due to the presence of adhesions. Several investigators have reported similar experiences with THL, demonstrating that the technique is reproducible (Watrelot et al., 1999
; Bajzak et al., 2000
; Darai et al., 2000
; Dechaud et al., 2001
; Moore and Cohen, 2001
).
Diagnostic accuracy
Several studies have demonstrated that THL is an accurate technique, measured against laparoscopy, for the diagnosis of tubo-ovarian pathology (Watrelot et al., 1999; Bajzak et al., 2000
; Darai et al., 2000
; Dechaud et al., 2001
; Moore and Cohen, 2001
; Shibahara et al., 2001
). A recent prospective comparative study showed a 75% interobserver agreement for the detection of ovarian adhesions with standard laparoscopy versus 90% with THL (Campo et al., 1999a
). Furthermore, the absence of compression of peritoneal capillaries and filmy adhesions during the aquaflotation makes THL superior to standard laparoscopy for the detection of minimal and mild endometriosis (Brosens et al., 2001
). However, the transvaginal approach does not allow inspection of the anterior pelvic cavity and some endometriotic implants, such as bladder endometriosis, are likely to remain undetected (Nawroth et al., 2001
).
THL combined with chromopertubation is also efficient in diagnosing tubal disease and evaluating tubal patency. The culdoscopic approach in combination with hydroflotation favours inspection of the fimbriae and in the early luteal phase of the cycle the ampullary segment can be cannulated in the majority of cases without additional instrumentation (Gordts et al., 1998b). In a comparative study evaluating tubal patency, it has been found found that in 95% of the cases there was agreement between the THL and hysterosalpingography (HSG) findings (Cicinelli et al., 2001
). In one case bilateral obstruction of the intramural portion was diagnosed by HSG, although chromopertubation during THL showed bilateral spill of dye. The prognostic value of the chromopertubation test has been shown to be better than that of HSG (Mol et al., 1999
). Shibahara et al.(2001) compared HSG versus THL in a series of patients with and without a history of Chlamydia trachomatis infection (Shibahara et al., 2001
). Both techniques were equally efficient in determining tubal patency but THL was superior for the diagnosis of peritubal adhesions.
Safety
One of the cardinal reasons for abandoning culdoscopy in favour of laparoscopy was that the transvaginal access increased the risk of bowel injury and sepsis. However, bowel injury remains a recognized major complication of laparoscopy. It occurs as frequently at the time of trocar insertion as during an operative procedure even in experienced hands (Jansen et al., 1997; Brosens and Gordon, 2001
). In a series of 182 visceral injuries caused by trocar insertion, the diagnosis was delayed in 10% of the cases and the mortality in this group was 33% (Bhoyrul et al., 2001
). As THL uses a transvaginal approach, concerns have been raised regarding the risk of bowel injury and sepsis. A recent multinational survey evaluated the incidence and outcome of bowel injury in 3667 THL and fertiloscopy procedures (Gordts et al., 2001
). A total of 24 bowel injuries (0.65%) were reported. The risk increases with retrocervical endometriosis and retroverted uterus. After the initial learning experience with 50 procedures, the incidence of visceral trauma decreased significantly to 0.25%. All injuries were recognized during the procedure and all 22 expectantly managed cases were without apparent consequences. A small, non-leaking injury not larger than 5 mm diameter in healthy bowel tissue can apparently be managed expectantly.
Operative procedures
Several authors have reported on a limited number of operative procedures during THL, such as ovarian capsule drilling in clomiphene resistant patients (Fernandez et al., 2001), superficial endometriosis and adhesions (Moore and Cohen, 2001
) and ovarian endometrioma (Gordts et al., 2000b
). In contrast to the original culdoscopic surgery, the risk of infection during operative THL is greatly reduced as the pelvic organs are not exposed to the vaginal flora.
Patient tolerance
To evaluate the acceptability of this new technique, 60 consecutive patients were asked to score their most intense pain experience during THL on a 10 cm visual analog pain scale immediately after the procedure (Gordts et al., 2000a). The mean pain score was 2.7 (SD ± 1.5) and only five (8%) women marked a score above 5. A total of 96% of the patients agreed to have a repeat procedure if required. Furthermore, a randomized controlled study found that THL combined with mini-hysteroscopy in an outpatient setting is better tolerated than HSG (Cicinelli et al., 2001
). Moore and Cohen (2001) also concluded that outpatient THL does not cause excesssive pain.
Cost-benefit
If outpatient THL replaces laparoscopy then hospital costs, which in places like the USA can amount up to 70% of the total costs of infertility exploration (Bates and Bates, 1996), would be avoided. However, this benefit is likely to be lost if the rate of conversion to laparoscopy is high. In our series, THL findings were normal in 58.5% of the cases and only 28% of the patients required subsequent explorative or operative laparoscopy (Gordts et al., 2000a
). Similarly, Moore and Cohen used office THL in 29 infertility patients and found no need for further surgical intervention in 62% of the cases (Moore and Cohen, 2001
). Clearly, a comprehensive one-stop infertility clinic would further reduce the costs associated with delayed treatment and lost patient productivity.
Patient selection
A one-stop endoscopy-based approach for infertility exploration is appropriate for patients without obvious pelvic pathology. A detailed history, gynaecological examination, and transvaginal sonography are used to exclude patients with vaginal infection, obliteration of the pouch of Douglas, fixed retroverted uterus, lateral displacement of the cervix or suspected pelvic tumour.
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Mini-hysteroscopy |
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Conclusions |
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Notes |
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References |
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