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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.
S Gordts
Lecture
4 years ago
1057 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.
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.
S Gordts
Lecture
5 years ago
799 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 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.
S Gordts
Lecture
5 years ago
1367 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.
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.
S Gordts
Lecture
5 years ago
958 views
30 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.
Hysteroscopic treatment option of hydrosalpinx to improve pregnancy rate
Hydrosalpinges adversely affect fertility and IVF outcomes. The toxic environment affects the endometrium and embryo implantation. Prospective randomized multicentric trials of salpingectomy prior to IVF clearly demonstrate a 2-fold increase in IVF success rates and should be recommended to all women with hydrosalpinges planning IVF. However, salpingectomy impairs regional vascular network, compromising ovarian function and induction of ovulation. In cases with severe pelvic adhesions, this risk and other operative complications increase during salpingectomy or tubal ligation. Micro-insert proximal end occlusion by hysteroscopy is another option to occlude and treat salpingectomy in an office set-up. Seven studies published on the topic have demonstrated generally positive results and success rates of pregnancies comprised between 36% and 64%. Proximal tubal occlusion using micro-inserts seem to be effective, fast, “low risk” in the management of severe forms of hydrosalpinges.
V Tanos
Lecture
5 years ago
987 views
32 likes
0 comments
13:28
Hysteroscopic treatment option of hydrosalpinx to improve pregnancy rate
Hydrosalpinges adversely affect fertility and IVF outcomes. The toxic environment affects the endometrium and embryo implantation. Prospective randomized multicentric trials of salpingectomy prior to IVF clearly demonstrate a 2-fold increase in IVF success rates and should be recommended to all women with hydrosalpinges planning IVF. However, salpingectomy impairs regional vascular network, compromising ovarian function and induction of ovulation. In cases with severe pelvic adhesions, this risk and other operative complications increase during salpingectomy or tubal ligation. Micro-insert proximal end occlusion by hysteroscopy is another option to occlude and treat salpingectomy in an office set-up. Seven studies published on the topic have demonstrated generally positive results and success rates of pregnancies comprised between 36% and 64%. Proximal tubal occlusion using micro-inserts seem to be effective, fast, “low risk” in the management of severe forms of hydrosalpinges.
Hysteroscopic polypectomy
Chronic endometrial inflammation, endometrial erosion and vascular dilatation are usually prominent characteristics in cases with polyp(s). Abnormal bleeding is a frequent symptom due to vascular fragility and surface erosion. Tubocornual polyps interfere with oocyte/embryo transport and implantation. Trials have shown the effectiveness of hysteroscopic polypectomy in enhancing fertility. Using appropriate instruments and techniques, further to a suitable training, hysteroscopic polypectomy can be performed in the office setting without limitations of size, location, histological structure, and number of polyps. The surgical removal of big polyps by shavers and morcellators can reduce learning curve and increase patient safety.
V Tanos
Lecture
5 years ago
1672 views
44 likes
0 comments
12:51
Hysteroscopic polypectomy
Chronic endometrial inflammation, endometrial erosion and vascular dilatation are usually prominent characteristics in cases with polyp(s). Abnormal bleeding is a frequent symptom due to vascular fragility and surface erosion. Tubocornual polyps interfere with oocyte/embryo transport and implantation. Trials have shown the effectiveness of hysteroscopic polypectomy in enhancing fertility. Using appropriate instruments and techniques, further to a suitable training, hysteroscopic polypectomy can be performed in the office setting without limitations of size, location, histological structure, and number of polyps. The surgical removal of big polyps by shavers and morcellators can reduce learning curve and increase patient safety.
Surgical technique of tubal reanastomosis
Many women who undergo tubal ligation surgery later decide to have children again. One option available to these women is tubal ligation reversal, or tubal reanastomosis. In this microsurgery, the two separated parts of a uterine tube are surgically reunited. It is ideally performed in younger women under 39 years of age with good ovarian reserve. Depending on the previously used tubal ligation method, it may be necessary to first perform a diagnostic laparoscopy to check the condition of the uterus, the uterine tubes, and the ovaries and to make sure that the tubal length is sufficient for reversal. Following the proper principles of microsurgery, this procedure can yield very good results and offer a more economical option to women desirous of childbearing if the tubal pathology related to tubal sterilization is the only cause of infertility.
H Grover, A Padmawar
Surgical intervention
2 months ago
2327 views
15 likes
0 comments
08:48
Surgical technique of tubal reanastomosis
Many women who undergo tubal ligation surgery later decide to have children again. One option available to these women is tubal ligation reversal, or tubal reanastomosis. In this microsurgery, the two separated parts of a uterine tube are surgically reunited. It is ideally performed in younger women under 39 years of age with good ovarian reserve. Depending on the previously used tubal ligation method, it may be necessary to first perform a diagnostic laparoscopy to check the condition of the uterus, the uterine tubes, and the ovaries and to make sure that the tubal length is sufficient for reversal. Following the proper principles of microsurgery, this procedure can yield very good results and offer a more economical option to women desirous of childbearing if the tubal pathology related to tubal sterilization is the only cause of infertility.
Hysteroscopic treatment of a symptomatic isthmocele in a bicorporeal uterus
Clinical case: We report the case of a primigravida 36-year-old woman, with a unicervical bicorporeal uterus type. An isthmocele was diagnosed within a context of postmenstrual abnormal uterine bleeding and secondary infertility arising after C-section. The hydrosonography evidenced a moderate scar defect, the myometrium next to the "niche" measuring 3mm. Because of the symptomatology and the failure of multiple embryo transfer procedures, an operative hysteroscopy was performed. The patient was able to become pregnant spontaneously and give birth to a healthy child via C-section.

Conclusion: A minimally invasive procedure using a hysteroscopic resection of the fibrotic scar tissue is to be considered first, given the existence of an isthmocele in a symptomatic and/or infertile woman, even in the case of a uterine malformation. It is an effective and safe treatment option. However, it has to be considered only if the residual myometrium measures more than 3mm next to the defect.

Key words:
Hysteroscopic resection, isthmocele, cesarean section, bicorporeal uterus.
J Dubuisson, S Wegener, I Streuli
Surgical intervention
1 year ago
4999 views
313 likes
0 comments
05:12
Hysteroscopic treatment of a symptomatic isthmocele in a bicorporeal uterus
Clinical case: We report the case of a primigravida 36-year-old woman, with a unicervical bicorporeal uterus type. An isthmocele was diagnosed within a context of postmenstrual abnormal uterine bleeding and secondary infertility arising after C-section. The hydrosonography evidenced a moderate scar defect, the myometrium next to the "niche" measuring 3mm. Because of the symptomatology and the failure of multiple embryo transfer procedures, an operative hysteroscopy was performed. The patient was able to become pregnant spontaneously and give birth to a healthy child via C-section.

Conclusion: A minimally invasive procedure using a hysteroscopic resection of the fibrotic scar tissue is to be considered first, given the existence of an isthmocele in a symptomatic and/or infertile woman, even in the case of a uterine malformation. It is an effective and safe treatment option. However, it has to be considered only if the residual myometrium measures more than 3mm next to the defect.

Key words:
Hysteroscopic resection, isthmocele, cesarean section, bicorporeal uterus.
Hysteroscopic myomectomy and ART
Fibroids represent an extremely common benign uterine pathology, the incidence of which increases with age, and approximately 10% of women with infertility problems will present a myoma. The association between uterine myoma and infertility is still controversial. Evidence exists that subserosal myomas do not impair the pregnancy rate in IVF whereas submucous myomas significantly decrease the implantation rate. Unfortunately, the effect of intramural myomas upon reproduction outcomes remains unknown, and until now no adequate diagnostic and therapeutic guidelines have been established.
Magnetic resonance imaging (MRI) imaging has redefined the functional anatomy of the uterus. Contrarily to ultrasound, MRI demonstrates that the non-pregnant myometrium is not a homogeneous smooth muscle mass but consists of two different structural and functional entities. The myometrium adjacent to the endometrium is a different hormone-dependent uterine compartment called junctional zone (JZ) myometrium. It is a functionally important entity in reproduction and it is ontogenetically related to the endometrium. Submucosal fibroids originate from this JZ myometrium and differ from subserosal fibroids as they have less cytogenetic abnormalities, less expression of Sex Steroid Hormone receptors, and they are more responsive to GnRH analog treatment and provide fewer recurrences after surgery.
Despite the lack of randomized studies, the sharp decline in pregnancy rates in case of submucous myoma is quite convincing and it is based on the existing evidence that myomectomy should be performed prior to ART for junctional zone myomas which protrude into the uterine cavity.
We demonstrate the different modern techniques of hysteroscopic myomectomy, the new instrumentation, the tips and tricks, the possible complications and clinical outcome.
R Campo
Lecture
4 years ago
2109 views
102 likes
0 comments
27:15
Hysteroscopic myomectomy and ART
Fibroids represent an extremely common benign uterine pathology, the incidence of which increases with age, and approximately 10% of women with infertility problems will present a myoma. The association between uterine myoma and infertility is still controversial. Evidence exists that subserosal myomas do not impair the pregnancy rate in IVF whereas submucous myomas significantly decrease the implantation rate. Unfortunately, the effect of intramural myomas upon reproduction outcomes remains unknown, and until now no adequate diagnostic and therapeutic guidelines have been established.
Magnetic resonance imaging (MRI) imaging has redefined the functional anatomy of the uterus. Contrarily to ultrasound, MRI demonstrates that the non-pregnant myometrium is not a homogeneous smooth muscle mass but consists of two different structural and functional entities. The myometrium adjacent to the endometrium is a different hormone-dependent uterine compartment called junctional zone (JZ) myometrium. It is a functionally important entity in reproduction and it is ontogenetically related to the endometrium. Submucosal fibroids originate from this JZ myometrium and differ from subserosal fibroids as they have less cytogenetic abnormalities, less expression of Sex Steroid Hormone receptors, and they are more responsive to GnRH analog treatment and provide fewer recurrences after surgery.
Despite the lack of randomized studies, the sharp decline in pregnancy rates in case of submucous myoma is quite convincing and it is based on the existing evidence that myomectomy should be performed prior to ART for junctional zone myomas which protrude into the uterine cavity.
We demonstrate the different modern techniques of hysteroscopic myomectomy, the new instrumentation, the tips and tricks, the possible complications and clinical outcome.
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
A Wattiez, R Nasir, A Host
Surgical intervention
3 years ago
3951 views
162 likes
0 comments
31:22
Severe complex endometriosis with ascites: laparoscopic management
Frozen pelvis due to endometriosis is one of the most complex and risky situations which surgeons sometimes face. Its laparoscopic management requires a systematic approach, a good anatomical knowledge and a high level of surgical competency. This is a frozen pelvis case secondary to a complicated severe endometriosis in a young nulliparous lady. She had hemorrhagic abdominal ascites secondary to endometriosis, with a sub-occlusive syndrome. Her disease was further complicated with upper abdominal and pelvic fibrosis with a large umbilical endometriotic nodule as well as splenic, omental and sigmoid endometriosis. This video demonstrates the strategy of the laparoscopic management of this condition.
In bag morcellation of a uterine fibroid
For a long time, morcellation of an undiagnosed malignancy, an old and frightening topic, has been a matter of extensive discussions. Clinicians and pathologists still lack instruments to clearly diagnose specific pathologies such as leiomyosarcomas. Minimally invasive surgery brought numerous advantages for the patient. However, morcellation is a key issue for the extraction of a large uterus and myomas. In this video, we present an option for the extraction of myomas. By insufflating a large Endobag®, a virtual abdominal cavity is created, and the mass is morcellated under direct vision. The resistant bag works not only as a protection for the abdominal cavity in case of an undiagnosed malignancy, but also serves to deviate organs from the morcellator.
R Fernandes, A Silva e Silva, JP Carvalho
Surgical intervention
3 years ago
3374 views
131 likes
0 comments
06:37
In bag morcellation of a uterine fibroid
For a long time, morcellation of an undiagnosed malignancy, an old and frightening topic, has been a matter of extensive discussions. Clinicians and pathologists still lack instruments to clearly diagnose specific pathologies such as leiomyosarcomas. Minimally invasive surgery brought numerous advantages for the patient. However, morcellation is a key issue for the extraction of a large uterus and myomas. In this video, we present an option for the extraction of myomas. By insufflating a large Endobag®, a virtual abdominal cavity is created, and the mass is morcellated under direct vision. The resistant bag works not only as a protection for the abdominal cavity in case of an undiagnosed malignancy, but also serves to deviate organs from the morcellator.
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
A Wattiez, R Fernandes, M Puga, J Alves, C Redondo Guisasola
Surgical intervention
5 years ago
2027 views
35 likes
0 comments
03:00
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
Contemporary aspects on etiopathogenesis: strategies on diagnosis
This lecture addresses the etiopathogenesis of endometriosis, as defined by the presence of endometrial glands and stroma out of the uterine cavity. Endometriosis is present in 6-10% of women worldwide, 50-70% of women with pelvic pain and 30-50% of women with infertility. The main risk factors are early menarche, nulliparity and family history. Diagnosis frequently takes a long time from the onset of the first symptoms and constitutes a major healthcare problem in the United States. The most popular theory is retrograde menstruation, but other explanations are coelomic metaplasia, genetic predisposition, immune system dysfunction and environmental factors, which by means of inflammation, prostaglandin production and nerve regeneration could lead to pain and infertility. Endometriosis lesions have a known dependence with ovarian estrogens, but local conversion of androstenedione to estradiol inside the implants has been demonstrated, leading to proliferation of nerve fibers even after oophorectomy. Medical treatment aims to decrease inflammation, estrogen synthesis and local conversion of androgens to estrogens for a limited period of time. Surgical treatment aims to remove lesions and disrupt nerve production in the tissue, but there is a high percentage of symptom recurrence. Regarding infertility, endometriosis can cause adhesions affecting the ovary and the tube, but can also affect spermatozoa motility, migration of the embryo and prevent implantation, accounting for poor pregnancy outcomes in women with endometriosis.
To better visualize the expert's powerpoint presentation, please click here.
Ceana Nezhat
Lecture
7 years ago
2143 views
57 likes
0 comments
21:58
Contemporary aspects on etiopathogenesis: strategies on diagnosis
This lecture addresses the etiopathogenesis of endometriosis, as defined by the presence of endometrial glands and stroma out of the uterine cavity. Endometriosis is present in 6-10% of women worldwide, 50-70% of women with pelvic pain and 30-50% of women with infertility. The main risk factors are early menarche, nulliparity and family history. Diagnosis frequently takes a long time from the onset of the first symptoms and constitutes a major healthcare problem in the United States. The most popular theory is retrograde menstruation, but other explanations are coelomic metaplasia, genetic predisposition, immune system dysfunction and environmental factors, which by means of inflammation, prostaglandin production and nerve regeneration could lead to pain and infertility. Endometriosis lesions have a known dependence with ovarian estrogens, but local conversion of androstenedione to estradiol inside the implants has been demonstrated, leading to proliferation of nerve fibers even after oophorectomy. Medical treatment aims to decrease inflammation, estrogen synthesis and local conversion of androgens to estrogens for a limited period of time. Surgical treatment aims to remove lesions and disrupt nerve production in the tissue, but there is a high percentage of symptom recurrence. Regarding infertility, endometriosis can cause adhesions affecting the ovary and the tube, but can also affect spermatozoa motility, migration of the embryo and prevent implantation, accounting for poor pregnancy outcomes in women with endometriosis.
To better visualize the expert's powerpoint presentation, please click here.
Fertility enhancing surgery
Professor David Adamson focuses on the role of laparoscopy in subfertile patients. Laparoscopy helps to diagnose and manage many gynecologic conditions that may induce spontaneous pregnancy and enhance Assisted Reproductive Technology (ART) results. In endometriosis, laparoscopy is required to establish the diagnosis and provide a better vision: it is first recommended in stage I-II by the American Society for Reproductive Medicine (ASRM). It should be considered in stage III-IV if the patient is young and after several IVF failures. Laparoscopic cystectomy is suitable if endometrioma is larger than 4cm prior to IVF. Myomas have to be removed when they distort the cavity or when they are intramural and voluminous. Laparoscopic myomectomy must be carried out by skilled surgeons. Adnexal masses should be removed if they exceed 5cm and persist for more than 3 months. Concerning polycystic ovarian syndrome (PCOS), ovarian drilling is indicated in case of failure of controlled ovarian hyperstimulation (COH). Laparoscopy is very useful for distal tubal occlusion to assess the quality of the tube and perform fimbrioplasty. It is also useful for ectopic pregnancy and sterilization reversal. As a conclusion, laparoscopy in subfertile patients must be performed in young women, without other infertility factors. Laparoscopy should also be envisaged when the disease is treatable and when the patients agree to have a 9 to 15 months’ interval prior to IVF.
D Adamson
Lecture
7 years ago
2403 views
16 likes
0 comments
26:49
Fertility enhancing surgery
Professor David Adamson focuses on the role of laparoscopy in subfertile patients. Laparoscopy helps to diagnose and manage many gynecologic conditions that may induce spontaneous pregnancy and enhance Assisted Reproductive Technology (ART) results. In endometriosis, laparoscopy is required to establish the diagnosis and provide a better vision: it is first recommended in stage I-II by the American Society for Reproductive Medicine (ASRM). It should be considered in stage III-IV if the patient is young and after several IVF failures. Laparoscopic cystectomy is suitable if endometrioma is larger than 4cm prior to IVF. Myomas have to be removed when they distort the cavity or when they are intramural and voluminous. Laparoscopic myomectomy must be carried out by skilled surgeons. Adnexal masses should be removed if they exceed 5cm and persist for more than 3 months. Concerning polycystic ovarian syndrome (PCOS), ovarian drilling is indicated in case of failure of controlled ovarian hyperstimulation (COH). Laparoscopy is very useful for distal tubal occlusion to assess the quality of the tube and perform fimbrioplasty. It is also useful for ectopic pregnancy and sterilization reversal. As a conclusion, laparoscopy in subfertile patients must be performed in young women, without other infertility factors. Laparoscopy should also be envisaged when the disease is treatable and when the patients agree to have a 9 to 15 months’ interval prior to IVF.
Deep endometriosis excision with ureteral anastomosis followed by segmental rectosigmoid resection, transvaginal specimen extraction, and a transanal colorectal anastomosis
We present the case of a 29-year-old nulligest woman. Four years ago, she had a previous surgery with a rectovaginal nodule removed both by laparoscopy and vaginal approach. She has complained of dyspareunia (8/10), dysmenorrhea (8/10), dyschezia (8/10) and infertility over the last 2 years, but she also suffers from bladder dysfunction requiring urinary self-catheterization during her menstrual periods. The laparoscopic exploration revealed a big fibrotic nodule located in the right pelvic sidewall involving the right ureter and the rectum. Right ureter resection and anastomosis were performed. Segmental rectosigmoid resection was followed by transvaginal specimen extraction and a transanal colorectal anastomosis. The intracorporeal laparoscopic technique allows for a limited bowel devascularization and for an appropriate anastomosis with no need for extra abdominal incisions. No complications were noted and the patient had a good clinical evolution.
A Wattiez, J Leroy, E Faller, J Albornoz, P Messori
Surgical intervention
7 years ago
2561 views
21 likes
0 comments
30:14
Deep endometriosis excision with ureteral anastomosis followed by segmental rectosigmoid resection, transvaginal specimen extraction, and a transanal colorectal anastomosis
We present the case of a 29-year-old nulligest woman. Four years ago, she had a previous surgery with a rectovaginal nodule removed both by laparoscopy and vaginal approach. She has complained of dyspareunia (8/10), dysmenorrhea (8/10), dyschezia (8/10) and infertility over the last 2 years, but she also suffers from bladder dysfunction requiring urinary self-catheterization during her menstrual periods. The laparoscopic exploration revealed a big fibrotic nodule located in the right pelvic sidewall involving the right ureter and the rectum. Right ureter resection and anastomosis were performed. Segmental rectosigmoid resection was followed by transvaginal specimen extraction and a transanal colorectal anastomosis. The intracorporeal laparoscopic technique allows for a limited bowel devascularization and for an appropriate anastomosis with no need for extra abdominal incisions. No complications were noted and the patient had a good clinical evolution.
Laparoscopic management of endometriosis
This lecture reviews the surgical treatment of endometriosis from an evidence-based perspective focusing on outcomes such as pain and infertility in order to provide practical guidelines and recommendations.
The main endometriotic symptoms are pelvic pain (dysmenorrhea and dyspareunia) and infertility. Randomized controlled trials provide evidence that it is better to perform laparoscopy in patients with pain as compared to a wait and see approach. Regarding fertility, laparoscopic ablation or resection of lesions in minimal and mild endometriosis is significantly better than diagnostic laparoscopy alone. Laparoscopic uterosacral nerve ablation (LUNA) is not effective for relief of pain symptoms, but presacral neurectomy might be useful. In contrast, conservative surgery for rectovaginal septum endometriosis is beneficial for pain improvement, quality of life and sexual life, but do not improve fertility. Regarding radical surgery and bowel resection in endometriosis, there is a clear benefit in terms of pain improvement, but not on fertility. Regarding endometrial cyst treatment, excision is better than drainage in terms of risk of relapse, and the use of anti-adhesion barriers (Interceed®) have demonstrated a decreased risk of adhesion formation after endometriosis surgery.
Keys for surgical treatment of endometriosis should be identification of the disease, restoration of normal anatomy, excision of endometriosis, and finally reconstruction.
RP Pasic
Lecture
7 years ago
2031 views
27 likes
0 comments
44:23
Laparoscopic management of endometriosis
This lecture reviews the surgical treatment of endometriosis from an evidence-based perspective focusing on outcomes such as pain and infertility in order to provide practical guidelines and recommendations.
The main endometriotic symptoms are pelvic pain (dysmenorrhea and dyspareunia) and infertility. Randomized controlled trials provide evidence that it is better to perform laparoscopy in patients with pain as compared to a wait and see approach. Regarding fertility, laparoscopic ablation or resection of lesions in minimal and mild endometriosis is significantly better than diagnostic laparoscopy alone. Laparoscopic uterosacral nerve ablation (LUNA) is not effective for relief of pain symptoms, but presacral neurectomy might be useful. In contrast, conservative surgery for rectovaginal septum endometriosis is beneficial for pain improvement, quality of life and sexual life, but do not improve fertility. Regarding radical surgery and bowel resection in endometriosis, there is a clear benefit in terms of pain improvement, but not on fertility. Regarding endometrial cyst treatment, excision is better than drainage in terms of risk of relapse, and the use of anti-adhesion barriers (Interceed®) have demonstrated a decreased risk of adhesion formation after endometriosis surgery.
Keys for surgical treatment of endometriosis should be identification of the disease, restoration of normal anatomy, excision of endometriosis, and finally reconstruction.