Endoscopy in Infertility work up
In cases of doubt or detection of pathology after performing a hysterosalpingogram or ultrasonogram, there may need to proceed to the performance of hysteroscopy and/or laparoscopy as parts of the diagnostic investigation.
Hysteroscopy:
It is a diagnostic as well as an operative tool for the management of pathologies of the uterine cavity. It is performed after the end of menstruation or prior to menses, gives us a precise visualization of the cervical canal and the uterine cavity together with the tubal ostia. It is a simple procedure done under mild sedation. After sedation Hysteroscope (a long, thin optical instrument) is inserted through the cervix with no use of any other instruments and with or without performing any cervical dilatation until it advances to the uterine cavity which is simultaneously filled with normal saline to enable visualization.
Operative Hysteroscopy:
Pathological findings can be treated in the same sitting by operative hysteroscopy using hysteroscopic instruments.
Uterine Polyp:
It is an overgrowth of a uterine inner line called Endometrium. They vary in size, attaching to projecting in the endometrial cavity by a large base or thin stalk. Polyps are usually benign in nature.
Uterine Fibroids:
These are noncancerous outgrowths of uterine musculature. They can be located on the outer side of the uterus (subserosal), in uterine musculature (intramural) or projecting in the uterine cavity (submucosal). Submucous fibroids can cause decreased fertility by affecting the blood supply of endometrium or can increase the chances of miscarriages.
Submucus fibroid can be removed by Electro resection via hysteroscopy. Larger intramural or subserosal component requires laparoscopic management.
Uterine Synechiae ( Intrauterine Adhesions):
It is the formation of scar tissue inside the uterus and/or cervix. Adhesions can occur in small portions of the uterus or in severe cases walls of the uterus can be stuck to each other. Adhesions can be thick or thin, spotty in location or confluent. They are generally nonvascular.
Operative hysteroscope along with scissors (resectoscope in severe cases) can be used for excision of adhesions. Fertility outcome post surgery depends upon the amount of endometrium present.
Septate Uterus:
Septate uterus is congenital malformation in which the uterine cavity is divided by longitudinal septum. Outside of uterus has a normal shape. The septum can be in the superior part of the cavity – Incomplete or subseptate uterus or cavity can be divided in total length – complete septum. It can result in the inability to conceive or repeated abortions.
The septum can be excised by Hysteroscopic scissors, Bipolar Diathermy or resectoscope.
Proximal Tubal Cannulation:
Can be due to tubal spasm, Fibrotic obliteration, endometriosis or corneal polyp, Mucous agglutination.
In the case of proximal tubal obstruction without any other tubal abnormality, Hysteroscopic cannulation of tubal ostia can help.
Laparoscopy:
This involves the visualization of pelvic and abdominal cavity under general anesthesia. The abdomen is filled with CO2 gas and laparoscope is introduced through a small cut below the umbilicus.
Visualization is done on monitor. 2 or 3 more cuts are given to introduce other instruments for the operative procedure.
By laparoscopy Uterus and adnexa is visualized, Tubes are checked for patency by the installation of dye.
Adhesiolysis can be done in the presence of turbo ovarian adhesions or abdominal organ adhesions to restore anatomy.
In cases of polycystic ovaries resistant to stimulation, ovarian drilling can be done for a better response.
Management of distal tubal diseases Injury to the distal part of the tube resulting in partial or complete occlusion. The commonest tubal lesion is seen.
Microsurgical tubal repair in younger patients with mild to moderate damage gives good results.
In cases of severe damage of tubes, Hydrosalpinx, success rate of tubal surgery is limited as the tubal function is lost in severe damage.
Endometriosis:
In this disorder tissue that normally lines uterus grows outside the uterus. Lesions bleed during each menstrual period giving rise to severe pain during the cycle. Commonest sites for endometriosis are Ovaries, fallopian tubes, surfaces of uterus, bladder.
Ovarian lesion- the chocolate cyst is the commonest lesion of endometriosis.
Surgical excision, medical management in cases of small and recurrent endometrioma coupled with ART procedures give good results.
