O-024 Endoscopic management of the unexplained infertility, what does it add?

text Endoscopic management of the unexplained infertility, what does it add? Stephan Gordts [email protected] Unexplained infertility “strictu sensu” is not a diagnosis, but a description of a status where no causal factor is identified in a couple trying to conceive for at least one year. The more parameters are assessed, the more likely to identify an etiology, the less likely becomes “unexplained” infertility. Limiting the fertility exploration to indirect visualization techniques like ultrasound, HSG or HycoSy involves the risk of missing existing pathologies. Uterus Uterine volumetric abnormalities can be detected by indirect techniques, but information is lacking on the visualization of the endometrium in case of chronic endometritis and the presence of endometrial defects and hypervascularization areas as seen in patients with adenomyosis. Tubo-ovarian Even with the increased accuracy of indirect visualization techniques, lesions of minimal endometriosis and tubo-ovarian adhesions are not detected (Table). Tubal normality constitutes not only normal tubal patency but also normal tubal function. The importance of subtle tubal lesions is underestimated. Hydatid of Morgagni are detected in 38.1% in patients with infertility versus only in 16,7% in fertile women (Gupta et al. JMIG 2017).Removal of these lesions resulted in a spontaneous pregnancy rate of 58.7% versus 20.6 in the non-treated group (Rasheed et al. EJOG Repr. 2011). Endometriosis In a series of 107 patients with unexplained infertility and 3 failed IVF cycles (Agni Pantou et al. J. Clin. Med. 2019)laparoscopy revealed the presence of endometriosis in 57.97%, peri-adnexal adhesions in 23.3% and was normal in 18.69%. Also, in a group of patients with 3 failed IVF cycles and unexplained infertility (Xiaoming Yu et al.Medicine 2019) laparoscopy showed endometriosis in 57.7%, tubal abnormalities in 31.1% and adhesions in 33.3%. Laparoscopic correction of these pathologies did not only result in a spontaneous pregnancy rate of 35% but resulted also in a higher pregnancy rate after IVF compared to the non-treated control group. Unexplained infertility hides frequently undiagnosed endometriosis. Endometrial BCL6 levels, a proto-oncogene where overexpression is associated with increased cellular proliferation and progesterone resistance, are increased in patients with endometriosis. In case of elevated BCL6 in patients with unexplained infertility, laparoscopy confirmed the presence of endometriosis in 93.8% (Evans-Hoeker et al. 2016). Abnormal BCL6 expression in a population with unexplained infertility reduced the chance of having a successful IVF treatment in 74% of the population (Almquist et al. Fertil Steril 2017). Transvaginal Hydro Laparoscopy Direct endoscopic visualization remains important but due to the invasiveness, diagnostic standard laparoscopy is frequently postponed or omitted in the exploration of the infertile patient. The technique of transvaginal hydro-laparoscopy allows in a minimal invasive way the inspection of the pelvis. In a consecutive series of 2288 patients without obvious pelvic pathology, findings were normal in 49.3%, endometriosis was diagnosed in 15.9% and tubal pathology in 14.5% of the patients (Gordts et al. FVV 2021). The rate of failed access was 1% and the complication rate 0.74%. Causing a minimal ovarian trauma, treatment of these early endometriotic lesions resulted in a spontaneous pregnancy rate of 73.2%. Conclusion The inappropriate use of “unexplained infertility” by omitting the diagnostic endoscopy in the exploration of the infertile patient, can hide undiagnosed and treatable pathology, jeopardizing possibilities for patients for a spontaneous conception and can be responsible for reduced pregnancy rates after IVF.

Systematic use of transvaginal hydrolaparoscopy as a minimally invasive procedure in the exploration of the infertile patient: results and reflections

Background: The aim of this study was to evaluate the added value of transvaginal hydrolaparoscopy (THL) in the investigation of the infertile patient. Methods: A retrospective cohort study, based on records from 01/09/2006 to 30/12/2019 was undertaken in a tertiary care infertility centre. THL was performed in 2288 patients. These were patients who were referred for endoscopic exploration of the female pelvis as part of their infertility investigation. In 374 patients with clomiphene-resistant polycystic ovary syndrome (PCOS), ovarian capsule drilling was also performed. The outcome objectives of this study included the evaluation of the added diagnostic value of THL as well as the feasibility and safety of the visual inspection of the female pelvis using this technique. Results: Of the 2288 procedures failed access to the pouch of Douglas occurred in in 23 patients (1%). The complication rate was 0.74%, due to bowel perforations (n= 13) and bleeding (n= 4) requiring laparoscopy. All bowel perforations were treated conservatively, with 6 days of antibiotics, and no further complications occurred. Findings were normal in 49.8% of patients. Endometriosis was diagnosed in 366 patients (15.9%); adhesions were present in 144 patients. Conclusions: THL is a minimally invasive procedure, with a low complication and failure rate, providing an accurate visual exploration of the female pelvis in a one-day hospital setting. When indicated, minimally invasive surgery is possible in the early stages of endometriosis and for ovarian capsule drilling in patients with clomiphene-resistant PCOS.

Intraluminal Tubal Endometriosis Mimicking Hydrosalpinx: Report of an Unusual Case

Endometriosis is an estrogen-dependent disease causing pelvic pain and infertility and there is still limited knowledge of the pathogenesis. Hydrosalpinx is commonly seen in a heterogeneous spectrum of pathologies of distal tubal occlusion. In general, collection of fluid in uterine tubes occur as the end stage of pyosalpinx or as the advenced stage of endometriosis with pelvic adhesion. In this report we present a very rarely seen case that is called intraluminal tubal endometriosis mimicking hydrosalpinx without pelvic adhesion in an infertile patient. The clinical features and the management of intraluminal tubal endometriosis case which is very rare cause of enlarged tuba uterina in an infertile patient discussed.

Male Infertility: Causes and Optimal Evaluation

Objective: To find out the optimum evaluation tools for male infertility. Methods: Hinari database were searched for articles related to male infertility for review to find out how a male infertile patient can be evaluated optimally.EUA guidelines on Male Infertility and AUA best practice statement on Optimal Evaluation of the Infertile Male updated on 2010 were also considered for review. Results: Initially thirty five articles were obtained and finally twenty eight articles were considered for review. Some cross references were considered to be cited in the reference section. We have mentioned in this review the evaluation tools those are necessary for male factor infertility at the optimum. Conclusion : As male infertility problem are increasing so optimum evaluation should be carried out to diagnose every possible underlying cause. Bangladesh Journal of Urology, Vol. 19, No. 1, Jan 2016 p.43-48