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Stephan GORDTS

Leuven Institute for Fertility and Embryology
Leuven, Belgium
MD
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Laparoscopic myomectomy in infertile women
The incidence of fibroids in women of reproductive age is reported to be between 20 and 40% (Verkauf, 1992; American Society for Reproductive Medicine, 2001). Their presence could cause failure to conceive, but no scientific evidence supports improvement after the surgical removal of the fibroid. This was recently highlighted in a review (Donnez and Jadoul, 2002) reporting a pregnancy rate after myomectomy in infertile women varying between 10 and 80%. Reported results in the literature are confusing due to the heterogeneity of the included patients and the different final outcomes. While subserosal and submucosal leiomyomas are likely to originate respectively from the outer myometrium and junctional zone myometrium, intramural fibroids may originate from the outer myometrium as well as from the junctional zone of the myometrium. It is agreed, although not proven, that patients with submucosal and intramural myomas have an impaired reproductive performance. Removal of submucosal myoma will result in a better reproductive performance, which is not obvious after removal of intramural myoma.
Laparoscopic removal has the benefit to have a lower morbidity and a lower risk for postoperative adhesion formation. Benefits and techniques will be discussed.
Lecture
4 years ago
2791 views
115 likes
0 comments
28:01
Laparoscopic myomectomy in infertile women
The incidence of fibroids in women of reproductive age is reported to be between 20 and 40% (Verkauf, 1992; American Society for Reproductive Medicine, 2001). Their presence could cause failure to conceive, but no scientific evidence supports improvement after the surgical removal of the fibroid. This was recently highlighted in a review (Donnez and Jadoul, 2002) reporting a pregnancy rate after myomectomy in infertile women varying between 10 and 80%. Reported results in the literature are confusing due to the heterogeneity of the included patients and the different final outcomes. While subserosal and submucosal leiomyomas are likely to originate respectively from the outer myometrium and junctional zone myometrium, intramural fibroids may originate from the outer myometrium as well as from the junctional zone of the myometrium. It is agreed, although not proven, that patients with submucosal and intramural myomas have an impaired reproductive performance. Removal of submucosal myoma will result in a better reproductive performance, which is not obvious after removal of intramural myoma.
Laparoscopic removal has the benefit to have a lower morbidity and a lower risk for postoperative adhesion formation. Benefits and techniques will be discussed.
The indications of transvaginal endoscopy for diagnosis and treatment of infertility
Standard laparoscopy is frequently postponed and omitted in the exploration of the infertile patient. It is a rather invasive and not innocuous procedure. However, direct endoscopic visualization of the pelvis and the uterine cavity is still considered the gold standard and it is preferred over indirect imaging techniques.
The transvaginal single access approach offers the opportunity to explore the uterus and tubo-ovarian organs in an ambulatory “one-stop fertility” clinical setting. Only direct visualization of the pelvis allows for an accurate diagnosis of minimal endometriosis, tubo-ovarian adhesions, sequellae of PID. When indicated, the procedure was completed with a patency test, salpingoscopy and hysteroscopy. In patients without obvious pelvic pathology, transvafinal endoscopy (TVE) can be used as a first-line diagnostic procedure without postponing an early diagnosis and accurate therapy.
Because of the easy access to the fossa ovarica, the preferred implantation site of endometriosis, limited surgical procedures such as adhesiolysis become possible, the same goes for the treatment of ovarian endometrioma, and ovarian drilling. It allows for an accurate and meticulous dissection of peri-ovarian adhesions and hydroflotation is very helpful in the identification of the exact cleavage plane between the different organs. Small scissors, forceps, and a bipolar coagulation probe are used. A meticulous hemostasis is mandatory, as bleeding will disturb visualization in a watery medium. In case of endometriosis, after the endometrioma has been opened, the chocolate fluid is removed and the inner site of the cyst is superfluously rinsed. The bipolar probe is used to fulgurate the inner endometrial layering.
To drill the ovarian capsule, we use a 5 French bipolar needle (Karl Storz, Tuttlingen, Germany). On each ovary, 5 to 10 punctures were created preferentially at the antero-lateral side of the ovary. The 5 French bipolar needle is gently pushed against the ovarian surface and current is activated with an energy output of 70 Watts. The procedure was carried out in the ambulatory patient in a one-day clinical setting.
Lecture
4 years ago
1050 views
32 likes
0 comments
30:53
The indications of transvaginal endoscopy for diagnosis and treatment of infertility
Standard laparoscopy is frequently postponed and omitted in the exploration of the infertile patient. It is a rather invasive and not innocuous procedure. However, direct endoscopic visualization of the pelvis and the uterine cavity is still considered the gold standard and it is preferred over indirect imaging techniques.
The transvaginal single access approach offers the opportunity to explore the uterus and tubo-ovarian organs in an ambulatory “one-stop fertility” clinical setting. Only direct visualization of the pelvis allows for an accurate diagnosis of minimal endometriosis, tubo-ovarian adhesions, sequellae of PID. When indicated, the procedure was completed with a patency test, salpingoscopy and hysteroscopy. In patients without obvious pelvic pathology, transvafinal endoscopy (TVE) can be used as a first-line diagnostic procedure without postponing an early diagnosis and accurate therapy.
Because of the easy access to the fossa ovarica, the preferred implantation site of endometriosis, limited surgical procedures such as adhesiolysis become possible, the same goes for the treatment of ovarian endometrioma, and ovarian drilling. It allows for an accurate and meticulous dissection of peri-ovarian adhesions and hydroflotation is very helpful in the identification of the exact cleavage plane between the different organs. Small scissors, forceps, and a bipolar coagulation probe are used. A meticulous hemostasis is mandatory, as bleeding will disturb visualization in a watery medium. In case of endometriosis, after the endometrioma has been opened, the chocolate fluid is removed and the inner site of the cyst is superfluously rinsed. The bipolar probe is used to fulgurate the inner endometrial layering.
To drill the ovarian capsule, we use a 5 French bipolar needle (Karl Storz, Tuttlingen, Germany). On each ovary, 5 to 10 punctures were created preferentially at the antero-lateral side of the ovary. The 5 French bipolar needle is gently pushed against the ovarian surface and current is activated with an energy output of 70 Watts. The procedure was carried out in the ambulatory patient in a one-day clinical setting.
Tubal surgery - neosalpingostomy
The functionality of the uterine (Fallopian) tube depends on the patency of the tubal lumen and on the integrity of the tubal mucosa. The tubal mucosa consists of 3 to 5 major folds and several minor folds with secondary folds on the top. Ciliated cells cover the folds. The tubal transport of gametes and embryos is a result of the ciliary beating activity and of the contractility of the tube through its muscular structure. The tubal mucosa is fragile and is very sensitive to infections such as Chlamydia, gonorrhea. In the most severe cases, the distal tubal end will be blocked with the formation of a hydrosalpinx.
In case of hydrosalpinx, tubal surgery should always be performed. Depending upon the remaining quality of the tubal mucosa, a decision has to be made favoring either salpingostomy or salpingectomy.
Lecture
5 years ago
1355 views
38 likes
0 comments
18:47
Tubal surgery - neosalpingostomy
The functionality of the uterine (Fallopian) tube depends on the patency of the tubal lumen and on the integrity of the tubal mucosa. The tubal mucosa consists of 3 to 5 major folds and several minor folds with secondary folds on the top. Ciliated cells cover the folds. The tubal transport of gametes and embryos is a result of the ciliary beating activity and of the contractility of the tube through its muscular structure. The tubal mucosa is fragile and is very sensitive to infections such as Chlamydia, gonorrhea. In the most severe cases, the distal tubal end will be blocked with the formation of a hydrosalpinx.
In case of hydrosalpinx, tubal surgery should always be performed. Depending upon the remaining quality of the tubal mucosa, a decision has to be made favoring either salpingostomy or salpingectomy.
Transvaginal laparoscopy: subtle lesions and infertility
Transvaginal laparoscopy is performed as a simple needle puncture technique of the pouch of Douglas in patients without an obvious pelvic pathology. An obliterated pouch of Douglas and acute situations such as bleeding and infections are contraindications. As a distension medium, a watery solution such as Ringer lactate is used. This keeps organs afloat. Without extra manipulation, ovaries and tubes can be inspected in their natural position. In absence of a high intra-abdominal pressure as in standard laparoscopy, subtle lesions are not masked but become clearly visible due to the watery distension medium. The transvaginal approach also provides easy access to perform a salpingoscopy and allows the detection of subtle tubal mucosal lesions. The technique allows early detection of peritoneal and ovarian endometriosis with the possibility of early treatment.
Lecture
5 years ago
794 views
27 likes
0 comments
23:35
Transvaginal laparoscopy: subtle lesions and infertility
Transvaginal laparoscopy is performed as a simple needle puncture technique of the pouch of Douglas in patients without an obvious pelvic pathology. An obliterated pouch of Douglas and acute situations such as bleeding and infections are contraindications. As a distension medium, a watery solution such as Ringer lactate is used. This keeps organs afloat. Without extra manipulation, ovaries and tubes can be inspected in their natural position. In absence of a high intra-abdominal pressure as in standard laparoscopy, subtle lesions are not masked but become clearly visible due to the watery distension medium. The transvaginal approach also provides easy access to perform a salpingoscopy and allows the detection of subtle tubal mucosal lesions. The technique allows early detection of peritoneal and ovarian endometriosis with the possibility of early treatment.
Tubal reversal
In several countries, tubal sterilization is frequently used as a definitive form of anti-conception. However, 2 to 13% of women come to express regret and 1 to 3% will have a reversal. Regret is frequently due to change of partner, dead of infant or for psychological reasons. As for laparotomy and also laparoscopy, tubal reversal should always be performed using the principles of microsurgery and gentle tissue handling.
Depending upon the place of tubal ligation, tubal anastomosis can be isthmo-isthmic, isthmo-ampullary, ampullo-ampullary, ampullo-cornual, and isthmo-cornual.
Mean pregnancy rate after tubal reversal is reported to be between 60 and 85%. Additionally, in patients older than 39, an intrauterine pregnancy rate of 40 to 50% can be achieved.
Lecture
5 years ago
948 views
29 likes
0 comments
17:55
Tubal reversal
In several countries, tubal sterilization is frequently used as a definitive form of anti-conception. However, 2 to 13% of women come to express regret and 1 to 3% will have a reversal. Regret is frequently due to change of partner, dead of infant or for psychological reasons. As for laparotomy and also laparoscopy, tubal reversal should always be performed using the principles of microsurgery and gentle tissue handling.
Depending upon the place of tubal ligation, tubal anastomosis can be isthmo-isthmic, isthmo-ampullary, ampullo-ampullary, ampullo-cornual, and isthmo-cornual.
Mean pregnancy rate after tubal reversal is reported to be between 60 and 85%. Additionally, in patients older than 39, an intrauterine pregnancy rate of 40 to 50% can be achieved.