**2.8. Endometriosis and infertility**

4 Enhancing Success of Assisted Reproduction










**2.6. Toxic effect** 




**2.5. Stress-related female infertility:** 



**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 following factors increase a woman's risk of infertility:

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.

The sins of endometriosis


Patophysiology of infertility in endometriotic patients:


Some patients with minimal endometriosis and normal pelvic anatomy are also infertile; reasons for impaired fertility include the following:


The Role of Endoscopy in Management of Infertility 7

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.

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

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


the pregnancy rates following treatment with IVF in patients with endometrioma.

Recurrent ovarian surgery is not recommended.

**2.11. Adhesions - laparoscopic adhesiolysis** 

activity and promote adhesion formation are:





accidents, appendicitis)




