Académique Documents
Professionnel Documents
Culture Documents
Sources of Evidences
National Guideline Clearinghouse 2000 National Institute of Clinical Excellence(NICE)Guideline. Fertility2004 ESHRE guideline(2005) Royal College of Obstetricians and Gynaecologists (RCOG) infertility , 1999 & Endometriosis ,2006 Society of Obstetricians and Gynaecologists of Canada (SOGC) 244- 2010 Cochrane Library Up To Date 2-19 May 2011 PubMed
Laparoscopy in Infertility
Diagnostic Laparoscopy
Operative Laparoscopy
P4 /HSG
Laparoscopy
Obstruction or Adhesion: traumatic or inflammatory
Laparoscopic Drilling
Endometriosis
Laparoscopy
Moderate / Mild Moderate Severe Minimal or Severe or Mild Adhesiolysis Resection ? / Adhesiolysis
Laparoscopic ablation Fenestration ? Laparoscopic
Laparoscopic
COH + IUI
El Sherbiny
IVF/ ICSI
Diagnostic
Laparoscopy
Direct cannulation of the fallopian tubes: Radiological: Selective Salpingography Hysteroscopic Guided by Laparoscopy
Co-morbidities
HSG
Or
Grade B
HyCoSy
Grade A
Unexplained Infertility
Case presentation A 27 year old woman, BMI 26 Primary infertility 4 years No history of pelvic pain, infection or ectopic pregnancy or pelvic surgery.
Semen
Fertile semen Volume :4 ml
Count: 48 million/mL
HSG: OK
2. IUI 3 cycles
3. IUI + HMG, for 3 cycles
4. IVF/ICSI
2. IUI 3 cycles
3. IUI + HMG, for 3 cycles.
4. IVF/ICSI As this patient is young and the period of infertility is not to long, laparoscopy may be a good choice.
The following images are examples of possible findings during laparoscopy that include:
Normal laparoscopic findings Mild fimbrial adhesions Moderate adhesions Severe adhesions Hydrosalpinx
Fine adhesion
Fimbria
Fimbria
Douglas Pouch
Fimbria
Moderate adhesion
Severe Adhesions
Dr.Sherbiny
Hydrosalpinx
Uterus
L. Ovary
L. Tube
R .Ovary
IVF should be considered as the first line treatment for moderate to severe distal tubal disease.
RCOG Guidelines : Grade B Recommendation
Dr.Sherbiny
Cornual Obstruction
If the fallopian tubes are not visualized on HSG, a repeat procedure should be done to exclude the possibility of tubal spasm.
Hysteroscopic catheterization
Dr.Sherbiny
Dr.Sherbiny
Hysteroscopic catheterization
Dr.Sherbiny
At present, the available research is not adequate to determine the effectiveness. More research is needed, including information about adverse outcomes and costs.
Pandian et al The Cochrane review 2007 revised 2009 Issue 1, 2009
Typical Endometriosis
Black Endometriosis Blue Endometriosis
Black
Blue
Atypical Endometriosis
= Subtle Endometriosis
= Non-pigmented Endometriosis Endometriotic lesions that lack the typical black-blue, powder-burn appearance
Jansen & Russel,1986 American Society For Reproductive Medicine (ASRM) 1996
Atypical Endometriosis
Red Endometriosis(Flam-like) Yellow Brown Endometriosis
Peritoneal Defect
White Endometriosis
ASRM Classification
The most widely used system was introduced by the American Society for Reproductive Medicine (ASRM) in 1979 and revised in 1996 . This system assigns a point score based upon the size, depth, and location of endometriotic implants and associated adhesions. The system was revised for women with infertility to help predict success in achieving pregnancy following treatment of endometriosis.
American Society For Reproductive Medicine (ASRM) Robert S Schenken, UpToDate 2-19 May 2011
Endometriosis
Stage I: Minimal (score 1-5)
(score 6-15)
51
American Society For Reproductive Medicine (ASRM)
Excision
Fenestration & ablation
Laparoscopic Surgery
1. Laparoscopic treatment of minimal or mild endometriosis improves pregnancy rates regardless of the treatment modality. (I)
Jacobson et al , Cochrane Library Review, 20 JAN 2010 SOGC Clinical Practice Guidelines 244, 2010
Laparoscopic treatment: Ablation or excision of implants and adhesions via Mechanical, electro-surgery or LASER surgery
Laparoscopic Treatment
2. The effect on fertility of surgical treatment of deeply infiltrating endometriosis is controversial. (II)
3. Laparoscopic excision of ovarian endometriomas more than 3 cm in diameter may improve fertility. (II)
SOGC Clinical Practice Guidelines 244, 2010
(PCOS)
What are?
When 2 out of 3 features are present: Oligomenorrhoea and/or Anovulation Clinical Hyperandrogenism and/or hyperandrogenemia Polycystic ovaries (U/S) After exclusion of other etiologies.
PCO
Management of PCOS
First Step: Lifestyle modification: Weight loss 10%
Second Step: Clomiphene citrate (CC) or Tamoxifen
Third Step: Improving the CC Resistant: Metformin Fourth Step: Gonadotropin Versus Drilling Intrauterine insemination Fifth Step: IVF /ICSI
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Hydrosalpnex
Incomplete septation
Dr.Sherbiny
Salpingostomy
Salpingostomy
Laparoscopic tubal occlusion & salpingostomy of Hydrosalpinges prior to IVF to improve pregnancy rate
Thank You
Egypt