Minimally invasive techniques aim to achieve the best treatment results with minimal trauma. Minimally invasive techniques in gynecology mainly include laparoscopic techniques and hysteroscopic techniques. Laparoscopic techniques can be used to examine the pelvic organs of infertile women to assist in a definitive diagnosis and, if necessary, to perform laparoscopic treatment to restore normal anatomical relationships, remove lesions, and increase the chances of natural pregnancy or improve the success rate of assisted conception techniques. Hysteroscopic techniques can be used to diagnose, treat and follow up lesions in the uterine cavity. Hysteroscopy not only determines the location and extent of the presence of lesions, but also provides a detailed observation of the tissue structure on the surface of the lesion and locates the material or scrapes the uterus under direct vision, greatly improving the accuracy of the diagnosis of intrauterine cavity diseases. In reproductive medicine clinics, hysteroscopy is often used in conjunction with laparoscopy to perform examination and treatment at the same time to find the cause of infertility and to perform the corresponding surgical treatment.
Hysteroscopic examination and surgery
I. Indications for hysteroscopy
Hysteroscopy can directly and clearly observe the situation in the uterine cavity of infertility patients and understand whether there are intrauterine factors causing infertility.
1.Primary or secondary infertility;
2.Ultrasound or hysterosalpingogram suggesting abnormalities in the uterine cavity;
3, Pre-IVF examination and examination of the reasons for embryo implantation failure;
4.Recurrent miscarriage;
5.Diagnosis of foreign body in the uterine cavity;
6.Diagnosis of uterine cavity adhesions and uterine malformations;
7. Diagnosis before hysteroscopic surgery and post-surgical follow-up.
What are the diseases requiring hysteroscopic surgery in infertility patients?
Since the instruments used for hysteroscopic examination and surgery are different, some diseases found during the examination cannot be treated at the same time and require elective surgery.
The common diseases requiring hysteroscopic surgery in infertility patients are
1. endometrial polyps, uterine fibroids (submucosal fibroids or interstitial fibroids that project into the uterine cavity or cervical fibroids)
2, uterine septum (complete or incomplete septum of the uterus)
3.Uterine adhesions (hysteroscopic adhesiolysis)
4.Hysteroscopic COOK loop tubal occlusion (for patients whose tubal effusion affects the success rate of IVF and who have extensive pelvic adhesions with high risk of transabdominal surgery).
Laparoscopic examination and surgery
Among the causes of female infertility, tubal factor is the most important anatomical factor. The two common methods used to check tubal patency are hysterosalpingography (HSG) and laparoscopic lavage.
HSG cannot determine the nature of the lesion; it does not provide information on peritoneal lesions (e.g. endometriosis and adnexal adhesions); in addition, there may be false positives when HSG suggests proximal tubal obstruction (in about 15% of cases of tubal blockage suggested by HSG, it is due to tubal spasm, which is able to recover spontaneously), and further confirmatory tests are needed. Laparoscopy has a higher sensitivity and specificity than HSG and allows simultaneous treatment of the abnormalities found.
Laparoscopic lavage: It is the gold standard for diagnosing tubal patency and also provides quantitative grading of tubal-ovarian adhesions, thus providing a basis for determining the patient’s pregnancy prognosis and treatment, or natural conception or artificially assisted conception, such as artificial insemination and IVF.
Who needs laparoscopic surgery for infertility
Those with normal semen in men and the following problems in women
1.Check for patients with unexplained infertility;
2.Uterine tube imaging abnormalities: such as one or bilateral non-dispersion; distal thickening of the fallopian tube, water retention; fallopian tube imaging but the contrast agent does not disperse or disperse poorly, long-term infertility patients;
3.Infertility combined with uterine abnormalities, ovarian cysts and uterine fibroids;
4. Infertility suspected to have pelvic adhesions;
5.Infertility suspected to have endometriosis;
Laparoscopic surgery for tubal infertility
About 30% of female infertility is tubal infertility. The common causes are: history of pelvic surgery, history of pelvic inflammatory infection, endometriosis, etc. For tubal factor infertility, the treatments currently used are surgical treatment and assisted reproductive technology for pregnancy. Assisted reproductive technology aims to bypass pelvic pathology, while surgery corrects the disease state and also has the potential to modify pelvic pain and menstrual abnormalities. Those who benefit from tubal surgery are patients with mild to moderate tubal damage, and postoperative pregnancy rates of 35-65% can be achieved. Commonly performed procedures.
I. Tubal cystoplasty
This procedure is performed to repair and reconstruct abnormalities of the umbilical end of the fallopian tube caused by adhesions or wrapping of the umbilical end. Since adhesions often involve the fallopian tubes and ovaries, this procedure is preceded by a tubo-ovarian adhesion dissection and then a cystoplasty. During the operation, Melanotomy is performed first, and when the fallopian tube swells, the weakest part of the umbilical end is opened to release the adhesions and restore the shape of the umbilical end of the fallopian tube as much as possible, and the umbilical end is sutured and fixed. (This procedure emphasizes suturing and turning the umbilical end of the fallopian tube rather than electrocautery to avoid damaging the umbilical tube)
Tubal recanalization
Tubo-tubal anastomosis is the anastomosis of any part of the fallopian tube, or the treatment of obstruction caused by disease, or the recanalization by sterilization. The blockage or lesion is removed laparoscopically and the distal and proximal tubal layers are accurately aligned and sutured together.
III. Tubal cannulation and de-tubulation
It is often performed in combination with hysteroscopy by inserting a fine catheter into the opening of the fallopian tube in the uterine cavity. Minor obstruction can be unblocked by intubation with fluid or by using a finer guidewire.
IV. Tubal-ovarian adhesion dissection
In the physiological state, about 2/3 of the fallopian tubes are connected to the ovaries and the distal 1/3 is free from the ovaries, which facilitates egg collection. Adhesions around the fallopian tubes interfere with the egg collection and gamete transport functions of the tubes, and if there are adhesions around the ovaries, they also inhibit egg discharge. Therefore, in some patients, although the HSG indicates a patent fallopian tube, conception is still not possible. The pregnancy rate is significantly higher after this type of surgery.
Precautions to be taken before and after hysterolaparoscopic surgery
1. Patients should consult their fertility doctor before surgery to understand the situation of both spouses and determine the need for surgery by combining the results of semen examination of the male partner;
2. The surgery is usually performed on 3-7 days after menstruation.
3, hysteroscopy generally does not require anesthesia, but can also be performed under intravenous anesthesia, which is often referred to as painless hysteroscopy, preoperative fasting water for 6 hours;
4. Hysteroscopy is often performed under general anesthesia and requires hospitalization for 3-7 days. Pre-operative checkups are done to assess whether the surgery can be tolerated, skin and intestinal preparations are made, and post-operative activities are encouraged to get out of bed as appropriate.
The best time to conceive after surgery is within 1 year. For best results, follow-up treatment should be done at the infertility clinic. The specialist will assess the causes of infertility and the prognosis of treatment based on the intraoperative situation, and will develop a treatment plan based on the specific situation of the patient couple, with early ovulation promotion for those with ovulation disorders. Postoperative pregnancy has the possibility of ectopic pregnancy, and ultrasound examination should be performed in the hospital after pregnancy. Those who are still unable to conceive after 1-2 years of postoperative systemic treatment should undergo IVF as early as possible to improve the pregnancy rate, especially if the cause of infertility is endometriosis.