Role Of Laparoscopy in Infertility

By
Youssef Yasser Ibrahim Abulyazeid
Fourth year student - Faculty of medicine - Port Said University
Round: C
Supervisor
Dr. Ibrahim Arafa
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Index

p.no
3 Introduction
4 What is laparoscopy?
4 Laparoscopy versus IVF
5 Diagnostic Laparoscopy
5 Operative Laparoscopy
6 Infertility Operations
6 Robotic Assisted Laparoscopy
6 Endometriosis and Infertility
7 Uses of Laparoscopy
7 Procedure
8 Laparoscopic ovarian diathermia in PCOS patients
9 Laparoscopy before ovulation induction treatment
10 Laparoscopy during ovulation induction treatment
10 Laparoscopy after failed IUI cycles
10 Diagnostic laparoscopy and IVF
11 Laparoscopy before IVF treatment
11 Serum CAT
12 Laparoscopic treatment of endometriosis after failed IVF treatment
12 When is Laparoscopy Recommended?
12 Benefits of Laparoscopic Surgery for Infertility
13 Side-Effects of Surgery
13 Less-common complications
13 Recovery Time
13 Can Laparoscopic Surgery Affect Pregnancy Chances?
14 References

Introduction
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 Infertility is defined as failure to conceive during one year of unprotected frequent
intercourse1. Leading causes of infertility include tubal disease, ovulatory
disorders, uterine or cervical factors, endometriosis, and male factor infertility
1,2,3. Major causes according to WHO globally are malnutrition, pelvic
tuberculosis and puerperal infections leading to tubal blockage. Laparoscopy is an
essential step and a standard procedure in the investigation and evaluation of
infertile females before initiating infertility treatment 5,6. In the absence of clinical
signs and symptoms suggestive of a diagnosis,
laparoscopy offers an excellent means through direct
visualization to elucidate the hidden pathology.
Diagnostic laparoscopy is generally accepted as the
most accurate procedure to detect tubal pathology and
endometriosis. Less invasive diagnostic tests such as
patient’s history, chlamydia antibody testing (CAT),
ultrasonography and hysterosalpingography (HSG) are available, but it is still a
matter of debate how the value of these tests compares with laparoscopy in the
infertility work-up7 Several studies describe risk factors for tubal pathology such as
previous abdominal surgery and previous pelvic inflammatory disease (PID).
However, up to 68% of patients without any of these risk factors can still possess
abnormalities as shown by laparoscopy.
According to World Health Organization (WHO) guidelines, DLS is still
recommended as a minimal requirement in the investigation of infertility in the
female 19. However, it remains questionable whether DLS in general provides more
information to further diagnosis and treatment decisions. There is a growing
tendency to bypass diagnostic laparoscopy in couples with a normal HSG who will
undergo intrauterine insemination (IUI) treatment for idiopathic infertility, mild
male subfertility, and cervical hostility.
Given the invasive and costly nature of the procedure, we considered it clinically
relevant to investigate the effectiveness of the DLS as part of the IUI work-up. The
purpose of the diagnostic laparoscopy is first to trace abnormalities and secondly to
treat them when necessary. We questioned if the laparoscopy should always be
performed before starting IUI. Considering treatment efficacy and applying
cumulative pregnancy rate findings of the study by 20, we expected that the
difference in the cumulative pregnancy rate with and without laparoscopic

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treatment would be no more than 10% in the IUI setting. To demonstrate such a
difference, a large study sample of at least 1000 patients would have been
necessary.

What is a laparoscope?

A laparoscope is a thin fiber-optic telescope inserted into the abdomen, usually

through the belly button. Fiber optics allow light to be used to see inside the
abdomen. Carbon dioxide (CO2) gas is placed in the abdomen before inserting the
laparoscope. This lifts the abdominal wall and allows for some
separation of the organs inside the abdomen making it easier
for the fertility doctor to see the reproductive organs during
the surgery. What are the advantages of laparoscopy for
infertility? Which infertile patients should have laparoscopy?
Laparoscopy should be reserved for couples who have already
completed a more basic infertility evaluation including
assessing for ovulation, ovarian reserve, ultrasound and
hysterosalpingogram for the female and semen analysis for
the male. Some couples may elect to skip laparoscopy in favor of proceeding to
other fertility treatments such as superovulation with fertility medications combined
with intrauterine insemination or in vitro fertilization

Laparoscopy versus IVF

Two commonly encountered problems during a laparoscopy, pelvic adhesions, and

endometriosis, can also be effectively treated using IVF. Since IVF is less invasive
than laparoscopy and has a very high success rate, some couples will opt to skip
laparoscopy and proceed directly to IVF. Even if a woman has severe adhesions
that are not treated, this will not impact on her ability to conceive a pregnancy with
IVF.

Diagnostic Laparoscopy

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 Laparoscopy can help physicians diagnose many gynecological problems including
endometriosis, uterine fibroids and other structural abnormalities, ovarian cysts,
adhesions (scar tissue), and ectopic pregnancy.
Whether or not minimal and mild endometriosis should be treated in case of
infertility still remains a seemingly never-ending discussion. The prevalence of
endometriosis in the infertile population (20–68%) is higher than that in the general
female population of reproductive age (2.5–3.3%) Moderate and severe stage
endometriosis leads to disruption of the normal pelvic anatomy, impairing the
reproductive function of the internal genital organs. Minimal and mild stage
endometriosis may impair fertility by a variety of mechanisms, including toxic
factors within the peritoneal fluid, impaired folliculogenesis and luteal function.

Operative Laparoscopy
During operative laparoscopy, many
abdominal disorders can be treated safely
through the laparoscope at the same time
that the diagnosis is made. When
performing operative laparoscopy, the
physician inserts additional incisions.
Lasers, while a significant help in certain
operations, are expensive and are not
necessarily better or more effective than
other surgical techniques used during
operative laparoscopy.

Infertility Operations
Using assisted reproductive technology, and in vitro fertilization (IVF) and embryo
transfer (ET) have, at least for those with financial means, replaced tubal surgery.
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However, for many, when infertility occurs secondary to disruption of the normal
anatomy or anatomic relationships by an inflammatory process, laparoscopically
directed operations used to restore anatomy can be successful and include
fimbrioplasty, adhesiolysis, and salpingostomy for distal obstruction (83).
Fimbrioplasty is distinguished from salpingostomy because it is performed in the
absence of pre-existing complete distal obstruction. Endometriosis associated with
adnexal distortion can be treated by laparoscopic adhesiolysis or resection. Whereas
there is no known additional benefit for medical treatment of coexistent active
endometriosis, the evidence relating to ablation of minimal and mild endometriosis
is mixed (84,85) although when subjected to meta-analytic technique.

Robotic Assisted Laparoscopy

Robotic assisted laparoscopic surgery (RAL) is a more recent development and a
form of operative laparoscopy. 100 Birdem Medical Journal Vol. 2, No. 2, July
2012 in RAL, the instruments and telescope are similar to conventional
laparoscopy, but they are attached to a robot which in turn is controlled by the
surgeon who is seated at a viewing console. This viewing console is usually located
next to the patient, although the feasibility of a surgeon operating on a patient in
another city or continent has been clearly demonstrated.

Endometriosis and Infertility

Women who have been diagnosed with endometriosis are more likely to
experience infertility, and observational studies have shown that the monthly
probability of pregnancy in women with endometriosis is about half of the
probability in normal women. In spite of this well documented association, a true
cause and effect relationship has not been established. When women are having
trouble conceiving, physicians must first determine whether an endometriosis
diagnosis, which can only be determined via surgery, is necessary. When the
woman is under 35, has significant pain with her periods or with intercourse, and
her partner has a normal semen analysis, a laparoscopy may be advised.

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Uses of Laparoscopy

Can help a doctor diagnose many conditions that affect fertility,

such as:

 endometriosis
 blocked fallopian tubes
 buildups of scar tissue
 fibroids

Laparoscopy can also help when a woman has

unexplained infertility. This is the diagnosis
when results of other diagnostic tests were
normal, but a woman is still unable to conceive.
By looking at the reproductive organs, the doctor
may be able to identify conditions that are
preventing conception and are otherwise
undetectable.
Procedure

A laparoscopy is a simple outpatient procedure. A person can undergo it in:

 a hospital
 an ambulatory surgical center
 in some cases, a fertility doctor’s office

A person will receive anesthesia before the procedure, so they will not be awake or
able to feel pain. After giving them the anesthesia, a surgeon will:

 insert a needle into the abdomen

 inject gas into the abdomen, to make it easier to see the organs and structures
 remove the needle and insert a small camera on an instrument called a
laparoscope through a tiny incision
 make a second incision and insert a small tool called a probe

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With the camera, the doctor will examine the structures in the abdomen. They will
use the probe to move or lift organs out of the way.
Depending on what the doctor sees, there may be other steps, including:

 injecting dye through the fallopian tubes to see if they are open for sperm and
eggs to travel through
 attempting to open blocked fallopian tubes
 removing scar tissue or adhesions
 correcting abnormalities

 They may make a third incision in the abdomen and insert instruments to
perform these additional procedures.
 Finally, the surgeon will remove the tools and stitch up the incisions.
 A person will have to remain under observation for a few hours to make
sure that there are no complications, and that recovery is going well.

Anyone who has undergone a laparoscopy should have someone else drive them
home. Also, someone should stay with them for up to 24 hours after surgery.

Laparoscopic ovarian diathermia in PCOS patients

About 20% of all patients diagnosed with polycystic ovarian disease (PCOS) and
infertility, will not ovulate after ovulation induction treatment with clomiphene
citrate. Even today, the effective treatment of clomipheneresistant PCOS remains a
challenge for the medical profession. More than 20 years ago,described that
laparoscopic electrocoagulation of the ovarian capsule in 62 clomiphenes resistant
PCOS patients resulted in an ovulation rate of 92% and a pregnancy rate of 69%.

In a recent Cochrane review, the efficacy of laparoscopic drilling of the ovarian

capsule (laparoscopic ovarian diathermy, LOD) by diathermy or laser in
clomipheneresistant PCOS has been compared to gonadotrophin treatment based on
a total of 15 RCTs. Only six trials were included for further analysis. The primary
outcome parameters were the live birth rate, ovulation rate and ongoing pregnancy
rate. Secondary outcome parameters included the rate of miscarriage, multiple
pregnancy rate, ovarian hyperstimulation syndrome and the total cost of the
respective treatments. There was no evidence of a difference in the live birth rate or
ongoing pregnancy rate between LOD and the gonadotrophins.

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Disadvantages of the LOD procedure include the risks related to laparoscopic
surgery, the need for general anaesthesia, the possible risk of thermal damage to
adjacent organs and ovarian adhesion formation, and as clearly mentioned in the
Cochrane review, the lack of knowledge concerning the possible negative long-term
effects of this procedure on the ovarian reproductive function. Moreover, it has
been pointed out that the effects observed are usually temporary and the signs and
symptoms of PCOS may return within months following the LOD,

Advantages of LOD included the opportunity to treat concomitant pelvic pathology

such as peritubal adhesions and endometriosis that can be associated with female
infertility. Furthermore, during the same endoscopic procedure, tubal patency can
be tested, and a hysteroscopy can be performed as part of the infertility work-up. In
summary, the position of diagnostic laparoscopy in the setting of ovulation
induction is at present not clear due to the lack of sound scientific evidence
provided by good-quality studies. The routine use of diagnostic laparoscopy to
evaluate all cases of female anovulatory infertility cannot be advocated, but
laparoscopy can offer the opportunity to assess tuboperitoneal status, to treat pelvic
pathology that may limit conception (endometriosis, adhesions), and to perform
LOD. Laparoscopic ovarian diathermia is a good option when compared with
gonadotrophin treatment in the clomiphene citrate resistant PCOS patient, but
counselling should be offered regarding the unknown long-term effects of this
procedure on the ovarian function.

Laparoscopy before ovulation induction treatment

The available evidence on the role of laparoscopy before ovulation induction

merely focuses on the comparison between HSG and laparoscopy findings for the
diagnosis of tubal pathology, the diagnosis and treatment of adhesions and the
treatment of minimal and mild endometriosis.

With regard to the routine use of HSG prior to laparoscopy in the fertility work-up,
we refer to the multicenter RCT by Perquin et al. (2006). About the CPRs at 18
months (about 1 and a half years), no significant differences were found in 344
women randomized to an intervention group with HSG followed by diagnostic
laparoscopy (CPR at 18 months 49% CI 42–57) or a control group with diagnostic
laparoscopy alone (CPR at 18 months 50% CI 43–58%). Regarding the prospective
value of HSG and laparoscopy we refer to the discussion above. The relevance of
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treating minimal and mild endometriosis will, as also has been shown above,
depend on the prevalence of this disease in the treated population.

Laparoscopy during ovulation induction treatment In a

retrospective study, Ochoa Capelo et al. (2003) performed a diagnostic laparoscopy
in 92 patients after four failed cycles of ovulation induction treatment with
clomiphene citrate. The patients had at least four ovulatory cycles, confirmed by
basal body temperature and midluteal phase serum progesterone, normal HSG
findings and male partners with a normal semen analysis. Laparoscopic findings
were strictly normal in only 36% of cases, whereas endometriosis and/or pelvic
adhesions were observed in 50 and 33%, respectively. The authors concluded that
laparoscopy continues to be a useful tool in the work-up of an infertile couple but
regrettably did not present any pregnancy rates following laparoscopic surgery.

Laparoscopy after failed IUI cycles

To the best of our knowledge, no studies are available on the additive value of
laparoscopy after several failed cycles of COH and IUI. Referring to the above RCT
by Tanahatoe and co-workers (2005), one may be expected to find significant pelvic
pathology (endometriosis all stages, peritubal adhesions) in at least 50% of cases.
Laparoscopic treatment enhances the chance of spontaneous conception. One may,
by extrapolation, expect a higher pregnancy rate after laparoscopic treatment after
several failed IUI cycles. In conclusion, the position of operative laparoscopy for
endometriosis and peritubal adhesions prior to IUI treatment or after several failed
IUI cycles seems a matter of debate. Further, randomized controlled studies are
needed to define the position of laparoscopy in IUI.

Diagnostic laparoscopy and IVF

Without doubt, the progress in assisted reproductive technology (ART) has limited
the field of reproductive surgery and some authors radically advocate immediate
treatment with ART after a limited and non-invasive infertility work-up in all
infertility patients. Two questions of clinical interest can be asked. First, is it always
mandatory to complete the diagnostic infertility phase with a laparoscopy to
diagnose and treat specific pelvic pathology? Second, is it still indicated to do a
laparoscopy after several failed ART treatment cycles?

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Laparoscopy before IVF treatment
Although laparoscopy is still considered to be the gold standard in the diagnosis of
tuboperitoneal infertility, alternative diagnostic methods, for example, HSG and
CAT screening have proven their clinical value and cost-effectiveness for the
diagnosis of tubal infertility in everyday clinical practice. The value of diagnostic
laparoscopy in case of abnormal HSG findings has been highlighted above. Using
these diagnostic procedures and recommendations, it could be argued that
diagnostic laparoscopy can be avoided in all cases where the available evidence
indicates that IVF is the most appropriate and successful treatment. However, there
is a fair degree of consensus that selected adnexal pathology, such as hydrosalpinx
and ovarian endometriotic cysts, still have to be treated by laparoscopic surgery
prior to IVF.

Serum CAT

The presence of Chlamydia antibodies (by Chlamydia antibody testing or CAT)

is indicative of an earlier infection with Chlamydia trachomatis, the most important
etiologic factor of PID. The accuracy of serum Chlamydial antibodies in the
diagnosis of tubal pathology has been scrutinized in a meta-analysis by Mol and co-
workers. The discriminative capacity of Chlamydia antibody titers by means of
ELISA, microimmuno-fluorescence, or immunofluorescence in the diagnosis of any
tubal pathology is comparable with that of HSG in the diagnosis of tubal occlusion
or hydrosalpinx as indicated by comparable receiver operating characteristics
(ROC) curves.

Summary ROC curves of studies using ELISA or (micro) immunofluorescence

demonstrated a better discrimination when compared with the summary ROC curve
of studies using immunoperoxidase assay. The same authors published their results
regarding the cost-effectiveness of HSG, laparoscopy and CAT in > 2000 infertile
couples enrolled in the Canadian Infertility Treatment Evaluation Study. The
diagnostic work-up to detect tubal pathology in infertile couples should, according
to their results, start with CAT in couples with good-fertility prospects and
immediate HSG in couples with poor-fertility prospects. Good-fertility prospects
were defined by the authors as having a 3-year chance of conception of > 14%,
whereas poor-fertility prospects were defined by a 3-year chance of conception of <
14%.

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Laparoscopic treatment of endometriosis after failed IVF treatment

Finally, is it worth doing laparoscopic surgery in patients with endometriosis after

several failed IVF cycles? Although no randomized trials are available, a
retrospective cohort study by Littman et al. (2005) deserves a closer look. In a
series of 29 patients with several failed IVF cycles and endometriosis, a radical
treatment of all endometriotic lesions was performed by one very experienced
laparoscopic surgeon. After surgery, 22 pregnancies were obtained, including 15
spontaneous pregnancies and 7 pregnancies after repeated IVF treatment. The non-
controlled retrospective evidence in this study stresses the importance of referring
patients with severe endometriosis to a Centre with the necessary expertise, in
which case even after several failed IVF cycles, radical and appropriate surgery
may still be beneficial to their reproductive outcome. It is clear that further
randomized controlled studies are needed to support this view on laparoscopic
treatment of severe endometriosis after failed IVF cycles.

When is Laparoscopy Recommended?

Following are some infertility issues for which laparoscopic surgery for infertility is
recommended:
 PCOS or polycystic ovarian syndrome
 Fibroids blocking the fallopian tubes
 Ovarian cysts
 Endometrial deposits causing intense pain

Benefits of Laparoscopic Surgery for Infertility

It allows the doctor to have a comprehensive look at the organs inside the abdomen
to identify various infertility issues. Besides diagnoses, laparoscopic surgery may
be performed to treat some causes of infertility, thereby increasing the chances of
conceiving. It also helps in removing endometrial deposits, scar tissues and fibroids.

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Side-Effects of Surgery
Some commonly experienced complications are:
 Irritation of the skin at the incision site
 Bladder infection
 Adhesions
 Infection at the site of infection
 The occurrence of hematomas in the abdominal walls.

Less-common complications
 Severe allergic reaction
 Urine retention
 Severe damage to the blood vessels or abdominal organs
 The occurrence of blood clots
 Damage to the nerves
 Complications associated with general anaesthesia

Recovery Time
Since it is an outpatient procedure, the patient is discharged on the same day. If
there are any complications involved, a hospital stay of 2-3 days may be advised. A
couple of weeks are needed to completely recover from Laparoscopic surgery.
Proper medications will be prescribed to help speedy recovery and less pain.
Patients should seek immediate medical help if they experience:
 A high fever of 101 or more
 Pus or intense pain at the site of the incision
 Severe abdominal pain and discomfort.

Can Laparoscopic Surgery Affect Pregnancy Chances?

Many women wonder if Laparoscopic surgery will affect their chances of
pregnancy. But laparoscopy rarely fiddles with one's ability to conceive and usually
causes no hindrance in getting pregnant. In fact, it may only increase the patient's
chances of conception.

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