Laparohysteroscopy in Infertile Women - A Detailed Review

Introduction:

Infertility is a disease of the reproductive system defined by a failure to achieve pregnancy even after 12 or more months of unprotected sexual intercourse. Infertility affects many couples worldwide. It is difficult to detect pelvic diseases by routine pelvic examinations alone. Therefore laparoscopy has been made a part of infertility evaluation. With laparoscopy, the ability to see and operate the uterus, fallopian tubes, and ovaries is much easier. In the same way with hysteroscopy, the uterine cavity can be seen well, and any possible pathologies can be identified. Presently, the gold standard of diagnosis and treatment for infertility is a laparohysteroscopy.

What Is Laparohysteroscopy?

A laparohysteroscopy is a diagnostic procedure done for a complete examination of the internal pelvic structures of a woman. A laparoscopy assesses the exterior portion of the uterus, fallopian tube, ovaries, and other pelvic structures. The hysteroscopy is performed to assess the uterus's internal cavity, identify any abnormalities, and perform certain corrective procedures. These two procedures, laparoscopy and hysteroscopy, have become integral to a complete infertility evaluation. They are used for both diagnostic as well as operative purposes. If any abnormality is detected during this diagnostic procedure, an operative procedure can be performed to correct the abnormality simultaneously, thereby avoiding a second surgery.

Which Infertile Conditions Can Be Diagnosed During a Laparohysteroscopy?

The common infertile conditions found during a laparohysteroscopy were simple ovarian cysts, tubal blockage, polycystic ovarian disease, uterine pathologies, and endometriosis (growth of uterus lining outside uterus).

1) Polycystic Ovarian Disease (PCOD) - Polycystic ovarian disease causes anovulation in women of reproductive age. Anovulation is the absence of ovulation. The egg (ovum) is not released from the ovary during the menstrual cycle. PCOD is associated with obesity, polycystic ovaries, amenorrhea (abnormal absence of menstruation) due to anovulation, and hirsutism. Hirsutism is a condition in women characterized by excessive hair growth in the face and body.

2) Endometriosis - Endometriosis is one of the contributing factors and primary causes of infertility. Endometriosis induces infertility by causing adhesions and altering the normal anatomy of the uterus. In this disorder, a tissue similar to the uterine tissue (endometrium) starts growing outside the uterus region. When these cells start swelling, the uterus tries shedding them, leading to inflammation. When two affected areas try to heal; one affected area tends to get stuck to the other affected areas. This creates scar tissue called adhesions. Endometriosis commonly involves the fallopian tubes, ovaries, and the tissue lining the pelvis. In patients suspected of endometriosis, confirmation is done through laparoscopy. Sometimes, mild endometriosis can only be detected by laparoscopy.

3) Uterine Pathologies - Uterine pathologies are another cause of infertility in couples. Septate uterus is one of the intrauterine abnormalities. A septate uterus is a uterine deformity that happens during the development of the fetus before birth. A membrane runs down to the middle of the uterus, thereby splitting it into two parts. A septate uterus, therefore, contains two cavities rather than one cavity. The septate uterus is the most common cause of infertility among uterine abnormalities.

What Happens During a Laparohysteroscopy?

• During laparohysteroscopy, the pelvic region of a woman is inspected.

• The pelvic region includes fallopian tubes, the uterus, round ligaments (connective tissue bands that support the uterus), and a pouch of Douglas (a small area between the uterus and rectum reason in females).

• Any abnormalities in the length or shape of fallopian tubes are checked.

• The size and shape of the ovaries are inspected.

• Evidence of ovulation, the thickness of the peripheral ovarian follicles (small sacs filled with fluid inside the ovaries), and the relationship with the finger like projections connected to the fallopian tube ends (fimbrial tube ends) are also checked.

• Tubo ovarian masses, fibroids, presence of fluid in the pouch of Douglas, endometriotic deposits, periovarian (thin strips of noncancerous tissues attached to the outer ovarian surface), peri tubal (scar tissue outside the fallopian tubes), and omental or abdominal adhesions or any pathology present were noted.

• Periovarian, peri tubal, and omental adhesions are potential causes of infertility.

How Is Laparohysteroscopy Performed?

1. Laparoscopy:

• This procedure is usually performed with general anesthesia.

• A laparoscope is a telescope-like tube inserted into the abdominal cavity via a small incision made in the naval area or its surrounding areas.

• Carbon dioxide gas is passed through the abdominal cavity. This gas separates the internal organs from the cavity wall. It also provides a better view through the laparoscope and helps prevent injuries.

• A small probe is then inserted through an incision in the lower abdomen to work on the structures that are being evaluated.

• Fluid is then passed through the uterus, cervix, and fallopian tubes to identify any blockage.

• If any problem is detected, it is corrected with the help of surgical instruments inserted through the additional incisions made in the lower abdomen.

• Once the procedure is complete, the instruments are removed, and the incisions are closed with sutures.

2. Hysteroscopy:

• Hysteroscopy is performed in an outpatient department and does not require any incision.

• In this procedure, the cervical canal (inner part of the cervix region that connects the vagina to the uterus) is widened temporarily with dilators.

• A long tube called the hysteroscope is inserted through the cervix to reach the uterus.

• Carbon dioxide gas or saline fluid is introduced through the history of scope to expand the uterine cavity and provides a better view of its internal structures.

• The hysteroscope also has narrow channels through which surgical instruments can be inserted to reach the inside of the uterus to perform any surgery.

• After completion of the procedure, a catheter is left within the uterus.

• In some procedures, medications are prescribed to prevent infection and stimulate healing.

How Are the Conditions Diagnosed During a Laprohysteroscopy Treated?

Laprohysteroscopy can be accompanied by procedures like polypectomy, septal resection, myomectomy, and adhesiolysis in the same setting:

• Polycystic Ovarian Disease (PCOD): In patients with PCOD, ovarian drilling and cystectomy is done. Women with PCOD tend to produce more testosterone. These high testosterone levels cause irregular periods, excess body hairs, and acne. Ovarian drilling is done in women with PCOD. Here the thick outer surface of the ovaries is broken through, lowering the amount of testosterone produced by the ovaries. This, in turn, helps with the ovulation process and regular monthly menstrual cycles, make it easier to get pregnant. PCOD causes cysts in ovaries which causes irregular periods and affects fertility. Ovarian cystectomy is the procedure to remove cysts in ovaries.

• Endometriosis: Adhesiolysis is performed in patients with endometriosis. Endometriosis causes adhesions that can cause bloating, nausea, constipation, and pain that changes with stretching or position. In adhesiolysis, structures that have been fused with adhesions are cut separately and apart. With adhesiolysis, the normal organ function and anatomy are restored, and symptoms are relieved.

• Uterine Pathologies: Hysteroscopic metroplasty and hysteroscopic polypectomy were done with patients with pathologies in their uterine tract. Hysteroscopic metroplasty is done for a septate uterus. Here, the septum is cut and removed. Once the septum is removed, the uterus returns to a typical uterus type (one uterine cavity) rather than two uterine cavities. Hysteroscopic polypectomy is performed to remove the uterine polyps in the uterus.

How Effective Is Laprohysteroscopy in Infertile Women?

Infertile women do conceive after laparohysteroscopic treatment. Some women conceive spontaneously, whereas others conceive after additional fertility procedures like intrauterine insemination or in vitro fertilization.

Conclusion:

A laparohysteroscopy is a minimally invasive surgical procedure that doctors use to diagnose and manage the treatment of certain infertility conditions like endometriosis, uterine pathologies, and polycystic ovarian disease. A laparohysteroscopy manages infertility and can improve the quality of life by helping with pregnancy.