**2.7. HSG versus Chromopertubation**

The diagnosis of uterine and/or tubal pathology as causes of female infertility represents a fundamental step in the evaluation of the infertile couple. As a tubal factor is a common cause of infertility, evaluation of the infertile couple should include assessment of the fallopian tubes for patency. Several others diagnostic techniques useful to the clinical evaluation of the uterine cavity and tubal anatomy are: transvaginal sonography (TVS), hysterosalpingography (HSG), hysteroscopy and hydrosonography (HDS) and laparoscopy. In the evaluation of uterine and tubo-peritoneal factors causing infertility, almost all the protocols retain hysterosalpingography (HSG), hysteroscopy and laparoscopy, first choice diagnostic tools. HSG was widespread as a test method before the development of the Echovist®, which made it possible to visualize the fallopian tubes with ultrasound. Laparoscopy provides the most comprehensive information on the status of the internal genitalia. It permits the use of a contrast medium or dye to examine the fallopian tubes (chromopertubation). Secondly, the procedure provides important information regarding the presence of adhesions, inflammatory changes and endometriosis.

The Role of Endoscopy in Management of Infertility 5

Endometriosis is a condition in which endometrium tissue, normally found lining the uterus, spreads to other areas within a woman's pelvic cavity and abdomen, usually the fallopian tubes, ovaries and intestines. It is a leading cause of disability among reproductive age women secondary to infertility and pelvic pain. The epidemiology of endometriosis is poorly defined. The most widely accepted hypothesis is that endometrial cells are transported from the uterine cavity and subsequently become implanted at ectopic sites. Retrograde flow of menstrual tissue through the fallopian tubes could transport endometrial cells intra-abdominally; the lymphatic or circulatory system could transport endometrial cells to distant sites (eg, the pleural cavity). Another hypothesis is coelomic metaplasia: Coelomic epithelium is transformed into endometrium-like glands. According to medical statistics the infertility can affect around 40% of women with Endometriosis. Pelvic examination may be normal, or findings may include a retroverted and fixed uterus, enlarged ovaries, fixed ovarian masses, thickened rectovaginal septum, indurations of the cul-de-sac, and nodules on the uterosacral ligament. Rarely, lesions can be seen on the vulva or cervix or in the vagina, umbilicus, or surgical scars. Association between endometriosis and autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, hypothyroidism, hyperthyroidism, and multiple sclerosis have recently been described. In order to properly diagnose endometriosis, it is necessary to have a laparoscopy performed. During a Laparoscopic procedure, endometrial implants can be easily seen once these implants have reached a reasonable size. Endometriosis may be found in up to 50% of

infertile women, according to the American Society for Reproductive Medicine.

Some patients with minimal endometriosis and normal pelvic anatomy are also infertile;

**2.8. Endometriosis and infertility** 

The sins of endometriosis - General Pelvic Pain - Painful Sexual Intercourse - Heavy Menstrual Periods





Patophysiology of infertility in endometriotic patients:


reasons for impaired fertility include the following:


