I. Indications: Laparoscopic surgery can be considered for patients with the following conditions
1. Infertility of unknown cause. Those who are over 30 years old, have been infertile for more than 3 years and wish to clarify the cause of infertility in the short term can undergo early laparoscopy.
2.Pelvic endometriosis.
3. Dysplasia of the internal genitalia.
4. Fallopian tube incompetence.
5. Unexplained ovulation disorder.
6, Tuberculosis of the internal genitalia.
7. Evaluation of the fallopian tubes before tuboplasty.
If you wish to know the ovulation or luteal function, you can do it during the ovulation or luteal phase.
Common diseases of the internal genitalia related to female infertility
1. Uterine diseases.
(1) Uterine fibroids: Uterine fibroids are solid tumors formed by overgrowth of smooth muscle of the uterus and are benign tumors.
(2) Uterine adenomyosis: It is endometriosis, which is the result of the invasion of the endometrium into the muscle layer and its growth, and is called uterine adenomyosis if it grows diffusely or adenomyoma if it grows in a limited mass. When endometriosis is present in other parts of the pelvis, the uterus may form different degrees of adhesions with the anterior rectal wall, pelvic floor peritoneum, bilateral adnexa, etc. Laparoscopic US blue tubal lavage can observe US blue staining at the lesion site, as this can also help in microscopic judgment.
(3) Uterine dysplasia and malformation: the absence of a uterus is due to the lack of development of the middle and caudal segments of the paramedian tube on both sides. Uterine dysplasia, also known as infantile uterus, is caused by the cessation of development of the paramedian tubules within a short period of time after their rendezvous. Two uteri with normal uterine development and a single fallopian tube and ovary in each of the right and left uteri can be observed microscopically. Bicornuate uterus and saddle-shaped uterus are the result of incomplete fusion of the fundus of the uterus. In unicornuate uterus, only one side of the uterus is developed and the fallopian tubes, ovaries and kidneys on the undeveloped side of the uterus are often absent at the same time. The uterus with one side of the uterus normally developed and the other side of the uterus incompletely developed and connected to the normal side of the uterus by muscular tissue is called a stump uterus, which is usually non-functional and can lead to accumulation of blood in the uterine cavity, dysmenorrhea and even endometriosis if the endometrium is functional. It is worth pointing out that internal genital malformations are often accompanied by kidney and ureteral malformations, and urinary system malformations can also be determined by laparoscopy.
2.Ovarian diseases
(1) Ovarian tumors: ovarian tumors are divided into benign, junctional and malignant. Due to the wide variety of ovarian tumor tissues and complex classification, accurate diagnosis must be based on pathological examination results, although laparoscopy cannot make accurate judgment on the nature and type of ovarian tumors, it has certain clinical significance for the selection of treatment methods for patients with ovarian tumors in infertility. Laparoscopy can observe the size, shape, cystic, solid or cystic solidity of the tumor, the vascular course and growth pattern on the surface of the tumor, the relationship between the tumor and the surrounding organs, the nature and amount of fluid inside the capsule, and the impact of the tumor on the fallopian tubes. The experience of the laparoscopist is closely related to the judgment of the nature and type of ovarian tumor.
(2) Polycystic ovary syndrome: Polycystic ovary syndrome is a syndrome arising from the derangement of menstrual regulation mechanism, with clinical manifestations of sporadic menstruation or amenorrhea, infertility, hirsutism and obesity. The laparoscopic findings show that both ovaries are polycystic in size, one to three times larger than normal ovaries, with a smooth, grayish-white surface and many translucent cystic follicles of varying sizes under the thickened ovarian cortex.
(3) Ovarian endometriosis cysts: see endometriosis.
3. Fallopian tube disease
Closely related to infertility is tubal inflammation, which can be divided into acute tubal inflammation and chronic tubal inflammation. The common causative agents of tubal inflammation are streptococcus, staphylococcus, Escherichia coli and anaerobic bacteria, while tuberculosis infection has been on the rise in recent years.
(1) Acute tubal infection: Acute tubal infection has the following signs under laparoscopy: congestion and edema in the fallopian tubes and surrounding tissues, purulent discharge from the plasma membrane surface, and in severe cases, purulent discharge from the umbilical end. In severe cases, pus discharge from the umbilical end can be seen. If the umbilical end is closed, pus accumulates in the fallopian tubes and the tubes appear to have salami-like changes. When the ovaries are involved, a tubo-ovarian abscess is formed, and the fallopian tubes and ovaries become indistinguishable.
(2) Chronic tubal infection: laparoscopy reveals rigid, twisted and thickened fallopian tubes, which can also form nodular changes (nodular tubal infection), and in cases with closed umbilical ends, fluid accumulation and thickening in the abdomen of the fallopian tubes, which is cystic bag-like. Most of the chronic tubal infections form membranous adhesions with the surrounding tissues and organs. Mild adhesions are seen only in a restricted form, and the adhesions can extend to the ovaries, rectum, sigmoid colon, etc., closing the Douglas concavity and forming a frozen pelvis.
(3) Tuberculous tubal infection: early tuberculous tubal infection is seen laparoscopically with irregular thickening of the fallopian tubes and nodule-like changes, which in turn can form tubal pus accumulation and adhesions with local tissues and organs, and even corn-like tuberculous nodules.
4. Endometriosis
(1) Ovarian endometriosis: The ovary is the most common site of endometriosis, with about 80% of patients having lesions involving one ovary and 60% having bilateral ovarian involvement. In the early stage of the disease, purple-brown spots or vesicles are seen on the surface of the ovary. As the disease progresses, single or multiple cysts are formed in the ovary due to repeated bleeding, called ovarian endometriosis cysts, and the fluid inside the cysts is dark brown paste-like old blood, like chocolate, so they are also called ovarian chocolate cysts. The surface is smooth. Due to repeated bleeding in the cyst during menstruation, the pressure inside the cyst rises, resulting in the rupture of the cyst wall, the leakage of fluid inside the cyst causes local peritoneal inflammatory reaction and tissue fibrosis forming scar-like adhesions, therefore adhesions with surrounding organs or tissues is one of the characteristic manifestations of ovarian endometriosis cysts, and the formation of denser adhesions with the peritoneum of the ovarian fossa in the lateral wall of the pelvic cavity is the most common, which can also involve the rectum, sigmoid colon, posterior wall of the uterus, and in severe cases In severe cases, the entire Douglas fossa can be closed and disappear. When bilateral ovarian involvement forms endometriotic cysts, the two cysts often adhere together in a “kissing” pattern at the posterior aspect of the uterus, a phenomenon also known as “Kiss Ovarian”, which is also a characteristic of endometriotic cysts of the ovaries. This phenomenon is also called “Kiss Ovarian” and is one of the features of endometriosis cysts.
(2) Endometriosis in other parts of the pelvis: endometriotic lesions often involve the plasma surface of the lower posterior wall of the uterus, the uterosacral ligament, Douglas’ fossa, the round ligament, the reflexed peritoneum of the bladder, the fallopian tubes, and other tissues and organs, and the color and shape of the lesion nodules are varied: the color of the nodules can be red, pink, brown, dark brown, purple-blue, black, off-white, etc. Red and pink nodules are fresh hemorrhagic lesions, and red and pink nodules can be fresh hemorrhagic lesions. fresh hemorrhagic lesions, brown and purple-blue for old hemorrhagic lesions, and white lesions for inactive scar lesions. The shape of the nodules can be flame-like, bruised, polyp-like, blister-like, plaque, or scar-like. Endometriosis Endometriosis can also cause local vascularization of the lesion and can form a radiolucent release centered on the lesion. It is now believed that pelvic floor peritoneal defects are also a feature of endometriosis, with localized peritoneal formation of fish-mouth, sieve-like and tear-like defects.
(3) Staging of endometriosis: The staging method of endometriosis proposed by the American Fertility Society (AFS) in 1985 has been generally accepted by clinicians, and this staging method is mainly based on laparoscopy. This staging method divides endometriosis into four stages: 1 to 5 as stage I (micro), 6 to 15 as stage II (light), 16 to 40 as stage III (medium), and >40 as stage IV (heavy).
5. Laparoscopy for abnormal uterine – tubal iodine oil imaging (HSG): further laparoscopy should be performed for HSG suggestive of tubal abnormalities, which can help to understand the cause of tubal obstruction, further prove the site of tubal obstruction, such as distal tubal obstruction, closed tubal umbilicus, hydrocele, proximal tubal obstruction, etc., and to understand the situation around the tubes, such as the presence of adhesions, etc. such as the presence of adhesions, etc. The knowledge of these conditions can help in the development and selection of the treatment plan. It is worth pointing out that some patients with HSG suggesting complete tubal obstruction were found to have good tubal patency during laparoscopic US blue lavage, which may be due to tubal spasm caused by iodine oil stimulation, resulting in false-positive HSG results.
6. Laparoscopic examination before tubal sterilization and recanalization: For patients who require recanalization after tubal sterilization, preoperative laparoscopic examination should be performed to help understand the mode of tubal sterilization (e.g. wire ligation, ring sleeve, titanium clip, electrocoagulation, drugs, etc.), the site of ligation (proximal length of the fallopian tube, distal length, length of the umbilical end), the morphology of the fallopian tube and the relationship with the surrounding tissues (e.g. the presence of adhesions). Detailed knowledge of the above information is a guide for the selection of tubal reversal surgery plan and the evaluation of post-reversal results.