**7.1. Methods of endoscopic proximal occlusion of functionless and harmful hysrosalpnix**

38 Enhancing Success of Assisted Reproduction

10/12 Hegar in even the most resistant cervix.

**6.5. Hysteroscopic site-specific endometrial injury (49)** 

hemostatic drug is administered after the procedure.

**7. Role of endoscopy in cases of hydrosalpnix** 

hydrosalpinx, requires further evaluation.

timing, technique and number of endometrial biopsies needed (50).

outwards the cervical canal projections distorting linearity of the canal are visualized. Linear releasing incisions of approximately a centimeter are made into these projections and a straightening of the canal is achieved. Subsequent to the procedure, dilatation is done to further stretch the incised fibrous tissue, and it is now possible to dilate the cervix up to size

A site-specific hysteroscopic biopsy-induced injury of the endometrium during the controlled ovarian hyperstimulation cycle has been shown to improve subsequent embryo implantation in patients with repeated implantation failure. The procedure starts with performing panoramic hysteroscopy. A flexible claw forceps is introduced through a 2.2 mm working channel which is used to generate a local injury on the posterior endometrium at midline 10-15 mm from the fundus on D4 to D7 of the stimulation cycle. The depth and width of the injured site is 2 × 2 mm (i.e. a bite of the claw forceps). No antibiotic or

Endometrial injury may have a beneficial role in implantation and improve the pregnancy rate. However, there are still many unanswered question including patients selection,

 Tubal pathology, particularly hydrosalpinx, is associated with a low embryo implantation rate in IVF as well as an increased risk for early pregnancy loss. The role of surgery for tubal disease to improve IVF outcomes, in the absence of

In recent years, considerable attention has been given to the possible impact of the presence of hydrosalpinx on implantation and ongoing pregnancy rates following IVF/ICSI (51,52). The mechanism of disruption remains uncertain. However, proposed mechanisms may be attributed to alteration in endometrial receptivity ordirect embryo toxic effect (53). Furthermore, hydrosalpnix is liable be unintentionally punctured at the time of egg retrieval or it may disturb the access to the ovary if it is too big. A systematic review of three RCTs (54) showed that tubal surgery such as laparoscopic salpingectomy significantly increased live birth rate (OR 2.13; 95% CI 1.24 to 3.65) and pregnancy rate (OR 1.75; 95% CI 1.07 to 2.86) in women with hydrosalpinges before IVF when compared with no treatment. There are no significant differences in the odds of ectopicpregnancy (OR 0.42; 95% CI 0.08 to 2.14), miscarriage (OR 0.49; 95% CI 0.16 to 1.52), treatment complication (OR 5.80; 95% CI 0.35 to 96.79) or implantation (OR 1.34; 95% CI 0.87to 2.05). Since hydrosalpinx reduces IVF pregnancy rates (14,55), it is therefore suggested that women with hydrosalpinges should be offered diagnostic/operative laparoscopy and a trial of salpingoneostomy. If failed or inaccessable, salpingectomy could be offered prior to IVF/ICSI to improve the chance of a live birth. Sometimes, laparoscopic access to the isthmic part of the tube is not feasible even in experienced hands particularly in patients with history of repeated laparotomies,


peritoneal cavity is entered, a panoramic evaluation of the pelvis is done. If the pelvis looks frozen or if the access to the fallopian tubes is impossible, the patient is considered failed laparoscopic approach. Those cases are subsequently treated by open laparotomic or hysteroscopic approach but the results of these procedures are not included in this study. If the procedure seems feasible, a third auxillary puncture is done. Utilizing a bipolar forceps, the isthmic part of the fallopian tube is coagulated and incised to ensure complete tubal occlusion as a case of tubal sterilization. The procedure is completed after securing hemostasis. The patient is discharged after 3-4 hours under antibiotic prophylaxis. Group B included 13 patients scheduled for hysteroscopic approach. The cervix is primed in all cases using 200 Mg misoprostol 8 hours prior to the procedure as previously described (57). The procedure is done immediately postmenstrual without specific preparation. Local paracervical anesthesia is selected in 5 cases while spinal anesthesia in 6 cases, and general anesthesia in 2 cases. Selection of the anesthestic technique is chosen according to patient preference after proper explanation by the anesthiologist. The cervix is gently dilated till Hegar's 10 which is followed by insertion of a rotatory continuous flow monopolar resectoscope. Once the peritubal pulge (the proximal part of the intramural segment of the tubeis clearly seen, a roller ball electrode of 3 mm size is bluged inside it and activated at 50 watts for about 8 seconds. A thorough comment on the fundus and the rest of the endometrial cavity is reported. The patients are discharged immediately if the procedure is done under local paracervical anesthesia, while the remaining cases are discharged few hours later. In both groups, the procedure is preceded and done under prophylactic broad spectrum antibiotic coverage to guard against any risk of flaring up of infection of the functionless hydrosalpnix. In both groups, patients are instructed to come back the next cycle postmenstually where hysterosalpingography (HSG) is done for most cases especially those with unilateral functionless hydrosalpnix. If the patient refused and has bilateral hydrosalpnix, sonohysterography (SHG) is done utilizing a simplified technique as previously described (39). Tubal occlusion of the affected side is confirmed if marked resistance is encountered on repeated injection of saline without evidence of intraperitoneal leakage from the occluded side which is the main outcome measure. Second-look office hysteroscopy is done for patients in group B whenever possible. The in-vitro safety phase resulted in bilateral complete coagulation of the proximal part of the tubes with secondary coagulation shown of up to 3 mm as shown in the histopathologic sections. When the power of coagulation is 50-60 W and operating time not prolonged more than 20 seconds , the thermal damage covered corneal end as complete coagulation in addition to2mm -3 mm secondary coagulation of the adjacent cornualendo- myometrium. Serosal temperature is not exceeding 41.9 Cº (range 39 Cº - 41.9 Cº) at any time during the procedure. No full thickness injuries are demonstrated either histologically or suggested by the temperature studies. Hysteroscopic access is achieved in 12 (85.7%)and occlusion is achieved in 9 (64.2%) cases. If the peritubal pulge is not clearly visible, the case is considered as failed access to the proper site of occlusion. In group B, diagnostic hysteroscopy showed fine marginal adhesions in 2 cases (15%) and a small polyp in one case (7.7%). Hysteroscopic tubal occlusion showed Endoscopy versus IVF: The Way to Go 41

shorter operative time (9 ±2.76 min vs. 23.6 ±4.75 min, p= 0.0001) and hospital stay as well (2 ±1.84 hours vs. 5 ±1.13 hours, p= 0.0001). No case of intraoperative complication in either group is reported. There is no case of exaggerated postoperative pelvic pain or fever in either group. HSG or SHG demonstrated complete tubal occlusion of the affected side in all cases in both groups). Second-look office hysteroscopy is done in 8 cases of group B which revealed no significant corneal lesions at the site of hysteroscopic occlusion. Pregnancy is achieved in 4 (28.5%) and 4(30.7%) cases in both groups respectively following IVF/ICSI without any significant difference between both

Hysteroscopic tubal occlusion of functionless hydrosdalpngies is a unioque one. It demonstrates a valuable role of hysteroscopic approach that can be performed in difficult cases with poor access to the isthmic part of the tubes via laparoscopy even with experienced hands. The idea is attractive but further large-sample sized studies are required

One of the interesting additive items of this paper to the literature is the term "functionless" hydrosalpnix. The proposed definition is very crucial to stratify cases suitable for microsurgical salpingoneotomy and those cases suitable for occlusive procedures. By this way, the place of reconstructive surgery is still preserved in modern practice even in the era of IVF/ICSI. Ethically, every effort should be exerted to restore normal anatomy whenever possible. This concept is of utmost importance particularly for the developing countries with limited resources where no national programs to support assisted reproductive techniques. Microsurgery to correct localized damage has the advantage of long-standing restoration of fertility. A simple prognostic classification is lacking. The severity of the tubal damage and the health of the mucosa is key in determining outcome. Proper selection of the tube for either line of management requires expert knowledge with the principles of salpingoscopy. Salpingoscopy during laparoscopy yields the best prognosis in patients with hydrosalpinx. Performing salpingoscopy with laparoscopy could significantly increase accuracy in predicting short-term fertility outcome. Whenever the mucosa is unhealthy, surgery is not

Hysteroscopic tubal occlusion of proximal part of the hydrosalpnix is feasible and promising as a safe, effective, fast, and easy approach. It can be done as an out-patient procedure under local paracervical block. It has the advantage of adding valuable evaluation of the endometrial cavity prior to IVF/ICSI. Further large sample-sized studies are required specially those utilizing bipolar resectoscope. The impact of hysteroscopic tubal occlusion on subsequent implantation and pregnancy rates needs to be addressed in another larger study. Since it is a preliminary study, the current role of hysteroscopic occlusion should be limited to cases of failed laparoscopic approach. Further studies are required before moving hysteroscopic occlusion to replace laparoscopic occlusion prior to

**7.2. Comments on hysteroscopic tubal occlusion in hydrosalpnix** 

groups.

to define the exact role of this approach.

justified; early referral for IVF is indicated.

IVF/ICSI.

shorter operative time (9 ±2.76 min vs. 23.6 ±4.75 min, p= 0.0001) and hospital stay as well (2 ±1.84 hours vs. 5 ±1.13 hours, p= 0.0001). No case of intraoperative complication in either group is reported. There is no case of exaggerated postoperative pelvic pain or fever in either group. HSG or SHG demonstrated complete tubal occlusion of the affected side in all cases in both groups). Second-look office hysteroscopy is done in 8 cases of group B which revealed no significant corneal lesions at the site of hysteroscopic occlusion. Pregnancy is achieved in 4 (28.5%) and 4(30.7%) cases in both groups respectively following IVF/ICSI without any significant difference between both groups.
