Hysterolaparoscopy has its most important and irreplaceable efficacy in the management of infertility. In the past 20 years, the safety of hysteroscopic surgery and the rapid advancement of various surgical instruments have made it possible to perform laparoscopic surgery on most patients who used to have to go into the abdomen for infertility correction; and many infertility cases caused by uterine factors can be corrected with the help of hysteroscopic surgery. This has brought a boon to the majority of women with infertility.
I. Laparoscopic examination for infertility
(I) Indications and significance of infertility
The patient is one of the indications for laparoscopy, and it is especially suitable for those who are suspected of having endometriosis or tubal lesions.
1. Those with normal HSG. Laparoscopy can detect certain pelvic adhesions or pelvic endometriosis lesions that are not detected by HSG as well as certain ovarian diseases.
2. Those with abnormal HSG. Laparoscopy can reveal the exact nature and severity of tubal lesions in order to decide on further treatment options.
(ii) Choice of surgery time
Generally, the procedure is performed during the follicular phase (i.e. within 3-7 days after menstruation); if ovulation is needed, the examination should be arranged during the early luteal phase; premenstrual examination is good for visual identification of endometriotic lesions in the pelvic and abdominal cavities. However, luteal phase tubal lavage may cause false positive results of high tubal obstruction due to floating endometrium covering the tubal opening in the uterine cavity, and may even block the endometrium in the fallopian tubes, so avoid performing tubal lavage during this period.
(iii) Examination items and key points
1.Whole picture of pelvic and abdominal cavity
The entire abdominal cavity, including the upper abdomen, is examined to rule out the possibility of pelvic involvement by abdominal organ disease. The uterine lever is placed to move the uterus to fully expose all parts of the pelvic cavity, and then the patient is placed in a low head supine position. The second puncture point is made in the right lower abdomen within the anterior superior iliac spine and the lower 2 transverse fingers into the vascular forceps or suction device to push open the intestinal curvature in the pelvis to observe the whole pelvis, which helps to make a preliminary diagnosis of pelvic diseases.
2. Local system examination
(1) Uterus
Observe the size and shape of the uterus, the presence of lesions affecting fertility, such as adenomyosis and myomas, and determine the presence of uterine malformations based on the anatomical relationship between the round ligament, the fallopian tubes and the intrinsic ligament of the ovaries.
(2) Fallopian tubes
The entire length of the fallopian tubes must be carefully examined. With the help of tubal melanotomy, the tubal twist and luminal obstruction caused by adhesions between the plasma surfaces of the fallopian tubes can be more clearly observed. Then, along the isthmus, the diameter, mobility, adhesions with the ovaries, adhesions on the plasma membrane surface and endometriosis lesions on the plasma membrane surface were examined. The last step is to find out whether the fallopian tubes and ovaries are normal and whether there are adhesions or atresia.
(3) Ovaries
Morphologic evidence of ovarian activity, including follicles, corpus luteum, and ovulatory orifice, should be noted. Morphologic examination of the ovaries is helpful in the diagnosis of certain endocrine disorders, such as polycystic ovaries and antagonistic ovaries. Endometriosis of the ovary often occurs with adhesions to the posterior lobe of the broad ligament and often requires careful observation to detect.
(4) Peritoneal fluid
Aspiration of peritoneal fluid exposes the posterior sulcus and sacral ligament. The posterior sulcus is often indicative of an active endometriotic lesion in the pelvis via the blood pool and can be measured for CA125; biochemical and microbiological studies of the peritoneal fluid are valuable in diagnosing pelvic infections and detecting pathogens.
(5) Pelvic peritoneum
Attention should be paid to the examination of endometriotic lesions and adhesion sites on the pelvic peritoneum. The first step is visualization; endoscopy has a magnifying effect and can detect very small foci of endometriosis in the peritoneum.
1) Naked eye diagnosis of endometriosis
Diagnosis is based on the distribution of the implantation lesion, its color, the characteristics of the adhesions caused and the organs involved.
Distribution sites
The common distribution sites are sacral ligament, tau fossa, bladder reflex, and pelvic peritoneum of ovarian fossa. Scattered patches or diffuse distribution may also be seen on the surface of the ovaries and fallopian tubes and appendix. Most are superficially located on the peritoneum and deep lesions are common in the sacral ligaments and ovaries, sometimes involving the rectal musculature.
Color
There are various manifestations depending on the course of the disease. Old lesions are purple-blue, brown-black plaques; hemorrhagic lesions are flame-like, dark red petechiae, petechiae or purple vesicles; early lesions are pink herpes, small blisters or translucent glandular-like redundant protrusions, or even only congestion and vascular hyperplasia, which can be detected only by moving closer to the endoscope.
2) Heat-color test
The principle used to detect endometriosis is the iron-containing hemoglobin effect. The temperature of the endograft is controlled at 100-120°C. After heating the tissue, the protein coagulates and turns white, and the ferric flavin in the lesion turns black and brown; this is a diagnostic method based on the chemical color reaction of the tissue; its advantage is that it can detect early lesions of endometriosis that are not easily recognized by the naked eye, and the lesions detected by the endograft are not missed. The heat-color test can also be used for the etiological diagnosis of pelvic adhesions, which are hemorrhagic adhesions of endometriosis, and the edges of the adhesions and the separated basal surface become black-brown after endografting, while inflammatory adhesions do not have the above-mentioned color changes.
Second, laparoscopic surgery for infertility
Modern laparoscopic techniques are capable of performing minimally invasive corrective surgery for infertility at the same time of diagnosis.
(I) Principles of surgery
To restore the functional integrity of the reproductive organs and avoid the formation of postoperative adhesions, laparoscopic surgery is performed strictly according to the principles of microsurgery.
(II) Types and techniques of surgery
1. Pelvic adhesion dissection
To separate the adhesions wrapped around the fallopian tubes and ovaries and the adhesions behind the uterus, and to restore and reconstruct the normal anatomical relationship of the internal reproductive organs.
2. Fallopian tube surgery
(1) Umbilical endoplasty
It is a procedure to recanalize the obstruction of the end of the fallopian tube and reconstruct the umbilical end where the umbilical end structure exists. This lesion is wrapped within the umbilical end structure; terminal atresia limited to the umbilical end adhesion is often a partial obstruction, and its surface covered by a fibrin layer can lead to complete obstruction.
Umbiloplasty: Step 1 Mechanical disintegration of the umbilical end adhesions by pressure expansion of the tubal lavage and insertion of a separator forceps from the old umbilical orifice. In the second step, the separating forceps are kept open and the mucosa at the end of the umbilicus is ectropioned by pulling back. In the case of adhesions at the end of the umbilicus, it is easy to break through the old orifice by lavage, but in the case of scar formation on the surface covered with fibrin, the orifice must be cut with microscissors after surface electrocoagulation or internal coagulation before proceeding to the second step.
(2) Narrowing ring incision of the anterior tubal opening at the umbilical end
In a few cases, the umbilical end of the fallopian tube is normal in appearance and the narrowing of the opening in the abdomen of the fallopian tube during tubal lavage causes atresia of the umbilical end. In this case, an electric needle should be used to cut the abdomen of the fallopian tube through the narrowing ring from the end of the umbilical end on the opposite side of the tubal tract to loosen the narrowing ring at the opening of the fallopian tube.
(3) Tubal ostomy
An endostomy is required if the distal tube is completely obstructed and a hydrosalpinx is formed. The blind end of the fallopian tube is depressed where the old orifice is located, and a wheel-shaped scar line extending along the orifice can be seen. Stoma method: The tubal lavage dilates the abdomen and the central depression of the blind end of the fallopian tube is endografted and incised to reach the lumen. The blind end is cut along the non-vascular scar line and then the mucosa of the fallopian tube is clamped 2 cm deeper into the lumen with a non-invasive grasping forceps, and the mucosa of the newly opened and turned mucosa is fixed to the plasma membrane of the fallopian tube with 2-3 stitches of 0000 absorbable thread.
(4) Tubal anastomosis
It is used for recanalization of tubal sterilization and occasionally for correction of mid-fallopian tube obstruction.
3. Ovarian surgery
Two types of laparoscopic ovarian surgery to promote fertility are described.
(1) Multi-point ovarian biopsy and follicular puncture
(1) ovarian multipoint biopsy and follicular puncture, which is a modified ovarian wedge resection for patients with polycystic ovaries. The biopsy wound is endocoagulated to stop bleeding and a protective protein film is formed after endocoagulation of the wound without sutures.
(2) Ovarian endometriosis cyst exfoliation
The cyst wall is cut open with a punctate endograft after forming an endograft band on the surface of the ovarian cyst, the cyst fluid is aspirated and the incision is enlarged, the cyst wall is peeled out with a biopsy forceps roll clamp, the trauma is carefully endografted to stop bleeding and the ovarian trauma is closed with sutures.
4. Destruction or excision of pelvic peritoneal endometriosis lesions
Pelvic peritoneal ectopic lesions can be excised, coagulated and destroyed or laser vaporized. Excision can be performed with biopsy forceps, scissors or CO2 laser knife; coagulation destruction with laser coagulation, electrocoagulation and thermal endocoagulation. For larger or more extensive pelvic endometriosis, excision is easy to leave peritoneal trauma; electrocoagulation and laser coagulation destruction or vaporization are suitable for smaller visible lesions, because electrocoagulation and laser vaporization of larger lesions can easily lead to excessive smoke, tissue carbonization particles are not easily removed, and peritoneal trauma is left after surgery; in addition, electrocoagulation is prone to electrical sparks and difficult to control the depth, and accidental damage to adjacent tissues may occur In addition, laser coagulation and vaporization positioning are safer than electrocoagulation. Thermal endocoagulation is an electric current that warms up the instrument and then touches the tissue with the heated instrument; the current does not pass directly through the body; the temperature of endocoagulation is controlled at 100-120°C and the depth of tissue penetration of heat is 2-4 mm, which is sufficient to destroy the endometriotic lesions on the pelvic peritoneum. In addition, the positioning of thermal endocoagulation is accurate and there is no thermal radiation damage to adjacent tissues; the iron-containing heme in endotopic lesions has a specific color reaction to thermal endocoagulation, so that lesions where the endocoagulator probes, especially those not easily identified by the naked eye, will not be missed; moreover, a protein protective film is formed on the surface of the tissue after endocoagulation, so that there is no postoperative trauma and no postoperative adhesions will occur. Therefore, thermal endocoagulation is the most effective and safe method to destroy large endometriotic lesions in the pelvis.
5. Other surgeries: If uterine fibroids are found during surgery, they can be removed and sutured.
(C) Measures to prevent postoperative adhesions
The factors of adhesion formation are: local ischemia, pulling peritoneum and infection. Dryness of the plasma surface, excessive suturing, prolonged surgery and bleeding from the trauma during surgery are all culprits of postoperative adhesions. Ways to reduce these factors are
(i) Strict adherence to microsurgical principles.
(ii) Avoiding intraoperative bleeding.
(iii) Use of absorbable sutures.
④ postoperative pelvic cleansing.
⑤ elimination of fibrous bridges formed by the healing tissue.
(vi) trauma blocking measures.
⑦ Use of hormones or other drugs
1.Microsurgical techniques
Fine and gentle surgery is the key to prevent postoperative adhesions. Microsurgery includes not only the application of magnification, but also all the principles of fine surgery as follows.
①Application of microsurgical instruments
②Clamp the tissue gently
③Continuous irrigation to keep the tissue moist
④Careful hemostasis
⑤ Application of fine sutures
⑥Tissue alignment should be precise.
Current laparoscopes are capable of meeting the above requirements for microsurgery, but require training in technique and proper application of instruments. Laparoscopic surgery is accomplished by introducing operating instruments in a closed abdominal cavity, avoiding frictional damage to the plasma membrane surface of the organ due to gauze pads and touch of the operator’s gloves. According to clinical multicenter studies, postoperative adhesions are reduced in laparoscopic surgery compared to cesarean surgery. The main reason for the higher success rate of laparoscopic correction of infertility compared to its cesarean counterpart is the reduction of postoperative adhesions with laparoscopic surgery.
2. pelvic irrigation
Intraoperative and postoperative lavage of the pelvic cavity with balancing fluid to remove blood, fibrin and any overflowing fluid (from endometriotic cysts or other ovarian cysts) from the abdominal cavity is one of the effective measures to reduce infection and prevent adhesions. Removal of blood before clot formation is easy; large clots are often difficult to remove because they cannot be suctioned into a suction tube and are fragile by clamping. The addition of heparin to the lavage solution reduces blood clotting and facilitates the removal of blood from the pelvic and abdominal cavities.
Once the procedure is over, the lavage solution should be injected to flush the wound with reduced abdominal pressure, and the pelvis should be submerged in the lavage solution to check for bleeding and to track the source of bleeding and carefully stop the bleeding. After the pelvic examination is completed, wash out the pelvic lavage fluid and shift the patient’s position to a lying or foot-low position so that the blood and or lavage fluid collected in the upper abdomen is drained into the pelvic cavity and washed away.
3.Auxiliary measures
The value of microsurgical techniques and laparoscopic surgery in preventing surgical adhesions has been widely recognized. However, even in adhesiolysis with microsurgical techniques postoperative adhesions still often occur, including re-formation of adhesions in the original anatomical location that has been surgically treated and adhesion formation in other areas due to surgical trauma. Therefore, in parallel with the development of microsurgery, medical aids are widely used in the prevention of postoperative adhesions in infertility correction, and the most widely used are the following antibiotics to reduce the risk of infection corticosteroids antihistamines to inhibit fibroblast migration, stabilize lysosomes, and reduce vascular permeability.
Urokinase, streptokinase, etc. Promote fibrinolysis and absorption.
Physical barrier method (liquid or solid phase biofilm) Application of hormones causing low estrogen and or progesterone environment Laparoscopic corrective surgery for infertility has less damage, fast recovery of intestinal function after surgery, plus intraoperative and postoperative measures to prevent adhesions, which greatly reduces the occurrence of postoperative adhesions and can achieve higher efficacy than into the abdominal surgery and has a broad application prospect.
Hysteroscopic diagnosis and surgery of infertility
(I) Indications: clinical symptoms and ultrasound and other auxiliary examinations suggesting occupying lesions in the uterine cavity, uterine adhesions and the need for combined hysteroscopic diagnosis and treatment of tubal obstructive lesions.
(B) Surgery includes
(1) polyps and submucosal myomectomy: electrodesiccation can be performed to avoid recurrence and affect fertility less.
(2) dissection of uterine adhesions (including adhesions at the opening of the fallopian tube): safe and effective.
(3) longitudinal hysterectomy: often performed under ultrasound or laparoscopic surveillance.
4) removal of foreign body residues in the uterine cavity: e.g. expired abortion mechanized material, fetal bones and intrauterine devices.
(5) tubal cannulation and lavage: can be performed under direct vision.
(6) Intubation and evacuation of tubal interstitial and isthmus obstruction, which needs to be performed under laparoscopic supervision to avoid perforation injury of the intubation.
(iii) Energy selection and energy application points of attention
Hysteroscopic surgery in infertility patients should avoid radiation damage to the endometrium and myometrium from energy sources. Bipolar electric cutting (plasma) using hysteroscopy is suitable for various surgeries such as uterine adhesions, longitudinal hysterectomy and endometrial polyp and submucosal myomectomy, which has the advantage of less thermal radiation damage and is a recommended new energy source.
IV. Diagnosis and treatment procedures of infertility
Exclude common causes of infertility by asking medical history; exclude infertility caused by inflammation of internal and external genitalia or other causes by physical examination, and then make a comprehensive judgment through auxiliary examinations as follows.
Normal menstruation → ultrasound examination
Normal → HSG → check immune system or pathogenic microorganisms. If all examinations do not reveal the cause of infertility, hysteroscopy or laparoscopy is recommended. abnormal HSG, occupying lesions in the uterine cavity → hysteroscopy, if polyps, fibroids, adhesions, longitudinal septum and foreign bodies are found, surgical treatment is given; if the tubes are blocked proximally, hysteroscopic tubal intubation and lavage can be done; if the tubes are blocked distally and waterlogged, laparoscopic shaping and stoma should be done.
Menstrual abnormalities: scanty menstruation or amenorrhea → endocrine examination. Also perform ultrasound examination. If PCOS is considered, medication or laparoscopic ovarian perforation can be done. Prolonged menstruation and heavy menstrual bleeding → ultrasound examination → hysteroscopy and pathological examination.
It is very necessary and effective to have a hysteroscopy for patients with unexplained infertility with conditions.