**2.10. Management of endometrioma**

Endometriomas usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. They typically contain thick brown tar-like fluid (hence the name "chocolate cyst"). Ultrasound is useful for supporting the clinical diagnosis of endometrioma. In case of infertility, the management of endometriomas is controversial. Many women with endometriosis can conceive naturally. For those who have difficulty, surgery often provides a "window of opportunity" during which the chances of conception increase the medical treatment alone usually is inadequate. The ultrasound-guided aspiration of the chocolatecolored fluid aspiration sometimes have serious consequences including post aspiration infection, pelvic adhesions, and ovarian abscess. Laparoscopic cystectomy is the gold standard, and preferred approach for the treatment of endometriosis and endometrioma. Surgical treatment is associated with a high recurrence rate and its employment for women undergoing assisted conception.. Excision of the entire cyst by laparoscopy or laparotomy appears to be the optimum treatment approach. Fenestration and ablation of the lining of an endometrioma is a less preferred option. Aspiration alone is ineffective. Laparoscopic drainage of endometriomas has the same disadvantages as ultrasound-guided aspiration. The recurrence rate is very high (80-90%). Fenestration and ablation is also less effective than excision, both in terms of improving fertility and for reducing pain. Laparoscopic cystectomy remains a first-line choice for the treatment of endometrioma. This consists of: opening the cyst, identifying the cyst wall and removing it from the ovarian cortex by traction and with grasping forceps. Surgery is not only the elimination of the endometrioma effectively but also to reconstruct the pelvic anatomy. The advantage of medical treatment has not been shown to be effective in controlling symptoms or improving fertility potential. After surgical treatment GnRH for a period of 12 weeks or dienogest (Visanne®, 2 mg) should be useful. Birth control pills have been shown to be ineffective in postoperative treatment of endometriomas. Recurrent ovarian surgery is not recommended.

It is generally accepted, that patients with endometriosis have lower success rates with IVF than patients without endometriosis. Several investigations have been occurring to improve the pregnancy rates following treatment with IVF in patients with endometrioma.

### **2.11. Adhesions - laparoscopic adhesiolysis**

Adhesions are bands of scar tissue that connect normally separated pelvic structures. Postoperative adhesions occur in 60% to 90% of patients undergoing major gynecologic surgery. Pelvic adhesions (scars) develop as a normal tissue response to inflammation, which occurs whenever the tissue is damaged. Adhesions are a frequent cause of infertility and pelvic pain in women. Pelvic adhesions impair fertility by disrupting normal tubalovarian relationships. Postoperative adhesions are squeal of impaired fibrinolysis of the fibrin and cellular exudates after peritoneal injury. Both microsurgical and laparoscopic techniques are used to treat pelvic adhesions. Additional studies also indicate the benefit of adhesiolysis in treating infertility. The most important factors which suppress fibrinolytic activity and promote adhesion formation are:


6 Enhancing Success of Assisted Reproduction

(resulting in oocyte phagocytosis)

modulators, TNF-α inhibitors, - Ultrasound-guided aspiration


**2.10. Management of endometrioma** 



up to 6- 9 months after surgery.




**2.9. Endoscopic techniques in endometriosis** 

infertility. Some of the options for treatment to conceive include:



Infertility and pelvic pain in its various forms are the main expressions of endometriosis. The fallopian tubes and ovaries may adhere to the lining of the pelvis or to each other, restricting their movement. Another factor which cause infertility with Endometriosis, may be the over-production of prostaglandins. No laboratory findings are particularly helpful in making or confirming a diagnosis of endometriosis. Treatment of endometriosis, medical or surgical, is directed at ameliorating the symptoms and severity of the pelvic pain and


Surgery may include lysis of adhesions, restoration of normal anatomy and ablation of all endometriotic implants, cystectomy or resection of endometriomas and in extreme cases even the removal of the ovaries and the uterus. During laparoscopy can remove endometrial growths, scar tissue, and adhesions caused by the endometriosis. This is not a really cure, and endometriosis may return later. However, some women will have increased fertility for

Endometriomas usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. They typically contain thick brown tar-like fluid (hence the name "chocolate cyst"). Ultrasound is useful for supporting the clinical diagnosis of endometrioma. In case of infertility, the management of endometriomas is controversial. Many women with endometriosis can conceive naturally. For those who have difficulty, surgery often provides a "window of opportunity" during which the chances of conception increase the medical treatment alone usually is inadequate. The ultrasound-guided aspiration of the chocolatecolored fluid aspiration sometimes have serious consequences including post aspiration infection, pelvic adhesions, and ovarian abscess. Laparoscopic cystectomy is the gold standard, and preferred approach for the treatment of endometriosis and endometrioma.

	- Surgical glove powder
	- Delayed postoperative mobilization of patient

Causes of pelvic adhesions


The incidence and severity of adhesions


Prevention of adhesions in surgery

With an optimal surgical technique intending to minimize mesothelial injury, peritoneal trauma is inevitable. laparoscopy leads to less adhesion formation compared to open surgery.

The Role of Endoscopy in Management of Infertility 9

The most common intraoperative complication is injury to the bowel. With dense adhesions, this risk increases. Other intraoperative complications may include bleeding and injury to adjacent organs such as the gallbladder, spleen, ovaries, especially when working next to

Uterine fibroids are the most common pelvic tumor, occurring in about 70% of women by age 45. However, many fibroids are small and asymptomatic. About 25% of white and 50% of black women have symptomatic fibroids. Fibroids are benign tumors of the muscle of the uterus most myomas do not cause clinical symptoms and do not require intervention. Based on location the various types of myoma are subserous, intramural and submucous fibroid. Most frequently, they develop in the myometrial wall and can lead to uterine distortion. Common problems associated with myomas are pelvic, abdominal, or back discomfort; urinary bladder irritability; abnormal uterine bleeding; bowel dysfunction; infertility; and pregnancy loss and/or complications. Myomas can cause infertility are mechanical interference with implantation, sperm and embryo transport, focal endometrial vascular and endocrine disturbances, endometrial inflammation, and abnormal uterine contractility. During the past few years, there have been a number of studies advancing the knowledge about the efficacy and safety of treatments of myomas, including medical and minimally invasive therapies. Laparoscopic myomectomy was first described by Semm and Metler in 1980 for subserosal fibroid there is an increasing trend for minimal access surgery for treatment of uterine myomas. Laparoscopic myomectomy is a very recent advance in the field of gynaecological surgery. Laparoscopic myomectomy has provided minimal invasive alternative to laparotomy with advantage of faster recovery and less postoperative adhesions. Laparoscopic myomectomy (LM) is an effective technique that is associated with the development of operative laparoscopic equipment and surgical techniques. The size does not matter for performance of a myomectomy laparoscopically. Laparoscopic myomectomy has evolved into a safe, efficient, and cost effective approach for the treatment of intramural, subserosal, and pedunculated fibroids. Criteria for myomectomy for surgical intervention, supported by the American College of Obstetricians and Gynecologists

(ACOG) and American society for reproductive medicine (ASRM) are:



otherwise asymptomatic;

Steps of operation: subserosal myomas


Before myomectomy, Hysteroscopy is performed in most patients at the outset of the



procedure, than all pelvic structures and the abdominal cavity are inspected

**2.14. Complications** 

these organs-

**3. Myomectomy** 

The most commonly used agents for preventing postoperative adhesions:
