**5. Missed mesosalpingeal lesions**

women with history of endometriosis [28,29]. Nevertheless, due to its well known drawbacks and complications (mainly pain), many women are afraid of doing HSG. Trials to improve its performance were described as elimination of traction on the cervix by tenaculum or usage of a pediatric Foley's catheter instead of the standard metal cannula [30] but still low patient acceptability of this invasive procedure is encountered. Saline infusion sonography (SIS) is an attractive alternative to HSG as it is a methodologically simple, cost effective, and time efficient comprehensive evaluation [31]. In 1999, we described a simplified technique of SIS utilizing a simple Nelaton catheter and 0.09% saline [32]. Despite its wide spread usage in many clinics, the main drawbacks of SIS are failure to localize the side of tubal patency and failure to properly visualize the tubes. Trials to improve results of SIS included the use of gel foam instead of saline [33], use of B-flow ultraspnography [34], 3D ultrasonography [35] or even sophisticated automated ultrasonography [36]. In the era of evidence-based medicine, Rubin pertubation tubal patency test is no longer implemented in modern practice [37] because it is very subjective

Definitely, hysteroscopy is the star of gynecologic endoscopy in recent years due to extended indications in modern practice. This position can be attributed to many factors including more technical refinement of instrumentation with better illumination and magnification, increased IVF/ICSI cycles practice and failures, increased interest in studying uterine factor of recurrent pregnancy loss (RPL), office usage with smaller caliber endoscopes omitting hospital admis‐ sion, and increased product promotion. Most important, vaginoscopic approach with elimi‐ nation of speculum insertion and traction on the cervix with a tenaculum had made hysteroscopy as simple as vaginal examination with high patient acceptability as shown in this study. OH saves money, omits stress for the patient, and improves health care services for the community at large. We believe that this attractive tool is not designed just to explore the endometrial cavity. The hysteroscopist should systematically examine the vagina, ectocervix, endocervical canal, endometrial cavity as well as the tubal ostea. Many tubal causes of infertility can be easily detected from the endoometrial cavity like polyps, fine adhesions or occlusion. These advantages are offered to the patient with minimal costs unlike other sophisticated and expensive approaches. For instance, MRI guided HSG was proved to be an effective patency test [38] but the costs and complicity of the technique are against the office

Interest in hysteroscopic testing of tubal patency testing is not new. Hysteroscopic perturbation utilizing a fine catheter inserted into the tubal ostea followed by injection of methylene blue dye had been described [39]. If no reflux was seen, this means that the ostium was patent.

Unfortunately, they changed a simple office procedure into a complicated operation. They used a 5.5 mm operative bridge that would definitely increase pain. They used fine catheters and evaluated patency in a very subjective way without laparoscopic or even sonographic confirmation. Non-reflux of the dye doesn't necessarily mean patency. Intravasation or false passage due to unintentional perforation could be the cause. In short, their approach is similar to hysteroscopic tubal cannulation but in a blind manner without laparoscopic or sonographic

and non-specific.

8 Contemporary Gynecologic Practice

principles.

monitoring.

Mesosalpingeal lesions are perfectly seen by laparoscopy particularly if the lesion is small. They may include:

#### **5.1. Paratubal cyst (Darwish et al., 2005) [42]**

We constructed a study to define the proportion, methods of diagnosis and a simplified laparoscopic technique for treating paratubal and paraovarian cysts in a prospective crosssectional study done at the Gynecologic Endoscopy Unit, Assiut University Hospital, Assiut, Egypt. It comprised a total of 1853 patients submitted to video-assisted laparoscopy. Trans‐ vaginal ultrasonography (TVS) was done in all cases to detect a paratubal or paraovarian cyst. Tubal shape and patency were evaluated using hysterosalpingography (HSG) in the infertile group. Diagnostic laparoscopy was done to confirm the diagnosis of paratubal or paraovarian cyst. Small cysts were punctured and coagulated, while larger cysts required cystectomty and extraction of the cysts using bipolar electrosurgery. Cystectomy was preceeded by endocystic visualization in all cases. Laparoscopically, only 118 patients (15.7%) were proved to have paratubal or paraovarian cysts. Preoperatively, TVS was able to diagnose paratubal or paraovarian cysts in 52 cases (44%) of them. Cysts less than 3 cm in size (34 cases) were treated with simple puncture and bipolar coagulation of the cyst wall whereas larger cysts (84 cases) were treated by cystectomy. Endocystic visualization using the 4-mm rigid hysteroscope was done in 84 cases (71%) with big cysts. There was statistically significant improvement of tubal patency after laparoscopic management. We concluded that sonographic diagnosis of the not uncommon paratubal and paraovarian cysts is not always feasible and requires more aware‐ ness and accuracy. The characteristic laparoscopic differentiation from ovarian cysts is the crossing of vessels over it. Endocystic endoscopic visualization is a valuable simple step prior to cystectomy. Bipolar coagulation or extraction of these cysts diagnosed at laparoscopy is easy and not time consuming and should be routinely done in all cases following the microsurgical laparoscopic principles. The significant effect of paratubal cystectomy on tubal patency and mobility supports the concept of routine removal of any paratubal or paraovarian cyst discovered at laparoscopy. Additional value of removal of these cysts detected at laparoscopy is exclusion of the rare possibility of malignancy (2-3%) and obtaining sufficient tissues for histopathologic evaluation. Lastly, its extraction is relatively easy and less time consuming unlike ovarian cystectomy.

#### **5.2. Lipomesosalpnix**

The classic tubal factors include post-inflammatory peritubal adhesions, prominal or diatal tubal occlusion [43] which can be easily diagnosed by most gynecologists based on HSG. Other rare tubal diseases are seldom investigated. For instance, salpingitis isthmica nodosa which is a nodular swelling of the isthmic segment of the fallopian tube are rarely reported [44]. Anatomically, mesosalpnix is defined as the part of the broad ligament enclosing a fallopian tube forming its mesentry. Histologically, it is formed of a thin layer of squamous epithelium and a small amount of loose areolar connective tissue [45,46]. It contains sympathetic ganglia and plexuses [47]. Laparoscopically, mesosalpnix is a thin vascular layer without evident fat in most cases.

With time interest to discover minute lesions that may affect fertility increased at our institu‐ tion [42]. In practice, we observe some fatty tissue condensation in the mesosalpnix in some cases that deserved studying why it is present in some women. To make this study valuable,

**5.1. Paratubal cyst (Darwish et al., 2005) [42]**

10 Contemporary Gynecologic Practice

unlike ovarian cystectomy.

**5.2. Lipomesosalpnix**

in most cases.

We constructed a study to define the proportion, methods of diagnosis and a simplified laparoscopic technique for treating paratubal and paraovarian cysts in a prospective crosssectional study done at the Gynecologic Endoscopy Unit, Assiut University Hospital, Assiut, Egypt. It comprised a total of 1853 patients submitted to video-assisted laparoscopy. Trans‐ vaginal ultrasonography (TVS) was done in all cases to detect a paratubal or paraovarian cyst. Tubal shape and patency were evaluated using hysterosalpingography (HSG) in the infertile group. Diagnostic laparoscopy was done to confirm the diagnosis of paratubal or paraovarian cyst. Small cysts were punctured and coagulated, while larger cysts required cystectomty and extraction of the cysts using bipolar electrosurgery. Cystectomy was preceeded by endocystic visualization in all cases. Laparoscopically, only 118 patients (15.7%) were proved to have paratubal or paraovarian cysts. Preoperatively, TVS was able to diagnose paratubal or paraovarian cysts in 52 cases (44%) of them. Cysts less than 3 cm in size (34 cases) were treated with simple puncture and bipolar coagulation of the cyst wall whereas larger cysts (84 cases) were treated by cystectomy. Endocystic visualization using the 4-mm rigid hysteroscope was done in 84 cases (71%) with big cysts. There was statistically significant improvement of tubal patency after laparoscopic management. We concluded that sonographic diagnosis of the not uncommon paratubal and paraovarian cysts is not always feasible and requires more aware‐ ness and accuracy. The characteristic laparoscopic differentiation from ovarian cysts is the crossing of vessels over it. Endocystic endoscopic visualization is a valuable simple step prior to cystectomy. Bipolar coagulation or extraction of these cysts diagnosed at laparoscopy is easy and not time consuming and should be routinely done in all cases following the microsurgical laparoscopic principles. The significant effect of paratubal cystectomy on tubal patency and mobility supports the concept of routine removal of any paratubal or paraovarian cyst discovered at laparoscopy. Additional value of removal of these cysts detected at laparoscopy is exclusion of the rare possibility of malignancy (2-3%) and obtaining sufficient tissues for histopathologic evaluation. Lastly, its extraction is relatively easy and less time consuming

The classic tubal factors include post-inflammatory peritubal adhesions, prominal or diatal tubal occlusion [43] which can be easily diagnosed by most gynecologists based on HSG. Other rare tubal diseases are seldom investigated. For instance, salpingitis isthmica nodosa which is a nodular swelling of the isthmic segment of the fallopian tube are rarely reported [44]. Anatomically, mesosalpnix is defined as the part of the broad ligament enclosing a fallopian tube forming its mesentry. Histologically, it is formed of a thin layer of squamous epithelium and a small amount of loose areolar connective tissue [45,46]. It contains sympathetic ganglia and plexuses [47]. Laparoscopically, mesosalpnix is a thin vascular layer without evident fat

With time interest to discover minute lesions that may affect fertility increased at our institu‐ tion [42]. In practice, we observe some fatty tissue condensation in the mesosalpnix in some cases that deserved studying why it is present in some women. To make this study valuable, we considered mesosalpngeal adipose tissue significant if its caliber was at least similar or exceeds the caliber of the ampulla of the ipsilateral fallopian tube regardless the appearance of its borders.

We constructed a study to estimate the proportion of a significant mesosalpngeal adipose tissue condensation (lipomesosalpnix, at least of a caliber similar to the ampulla of the ipsilateral tube regardless with well-defined or poorly defined margins) among infertile women subjected to diagnostic laparoscopy. It was a cross sectional study done at a specialized endoscopic center. It comprised all infertile women scheduled for diagnoastic/therapeutic laparoscopy during the period between July 1994 and December 2012 were included in this study. Preoperative hysterosalpingography (HSG), transvaginal ultrasonography (TVS) as well as body mass index (BMI) for all cases. Laparoscopic documentation of a significant mesosalpingeal condensation of adipose tissue. Histopathologic assessment of the adipose tissues in some cases. Main outcome measures included number of cases with unilateral or bilateral lipomesosalpnix Significant lipomesosalpnix was diagnosed in 145 cases (5.7%) out of 2563 cases examined by laparoscopy. In all but 7 cases, lipomesosalpnix was seen bilaterally (99.7%). There was insignificant correlation between those cases and high BMI when compared to the rest of cases. Infertility was unexplained by laparoscopy in 621 cases (24.3%) while laparoscopy diagnosed etiologic factors in 1942 (75.7%) cases. Lipomesosalpnix was seen in 46 (7.4 %) and 79 (3.9%) of the unexplained cases and explained cases respectively without a statistically significant difference (P 0.48). We concluded that despite being a rare laparoscopic finding, significant lipomesosalpnix should be reported and documented as a possible missed tubal factor of infertility. Whether to treat lipomesosalpnix or not, bilaterally or unilaterally and by which means require further studies with proper second look laparoscopy.

This study directs attention towards more concentration on some factors that would affect tubal motility and commonly missed by gynecologists. Previously, some authors reported on Hydatid of Morgagni as a cause of UI [21]. Likewise, an old study [48] diagnosed fimbrial agglutinations (25%), accessory tubes (13%), accessory ostia (10%), phimoses (13%), and sacculations (7%) more in the infertile women. Tubal abnormalities would affect the prognosis of natural pregnancy as well as assisted reproduction [49, 50]. At our institution, we consider tubal sacculations, diverticulae, convolutions, phimosis or fimbrial agglutination as laparo‐ scopic criteria of subtle tubal endometriosis specially if seen with other typical or atypical endometriotic tubal or peritoneal lesions. Proper endoscopic training would eliminate all these mistakes that would affect diagnosis as well as therapy.

Mesosalpingeal lesions include paratubal cyst [42], leiomyosarcoma of the broad ligament [51], Choristoma of Heterotopic Adrenal Tissue [52], primary Fallopian Tube Carcinoma [53] or lipoma of the Broad Ligament [54]. Preciously, among 1853 cases subjected to laparoscopy, we succeeded to diagnose a paratubal or paraovarian cyst in 118 patients (15.7%) [42]. Fat condensation in the mesosalpnix is not described in text books on histology, pathology or even endoscopic surgery as far as I know. Due to our interest in missed factors of infertility we tried to study the clinical significance of lipomesosalpnix. To be practical, we excluded cases with small amount of adipose tissue that wouldn't expect to affect tubal motility. In this study, preoperative TVS failed to diagnose lipomesosalpnix in all cases. Fallopian tubes are not usually visualized on a routine transvaginal sonographic examination unless outlined by fluid. However, the interstitial segment may be identified on TVS as an echogenic line arising from the endometrial canal and extending through the uterine wall. When surrounded by intra‐ peritoneal fluid, the remaining segments of the fallopian tubes are commonly seen as tubular structures extending between the uterus and the ovaries. Fallopian tubes are best visualized on sonography when thickened or fluid-filled as a result of pelvic inflammatory disease, torsion, ectopic pregnancy, or tumors [55]. Nevertheless, we still recommend performing TVS routinely prior to laparoscopy to detect important findings like paraovarain cysts [42] and more importantly intrauterine lesions that would make concomitant hysteroscopy a manda‐ tory step.

Despite similarity of the histopathologic appearance of lipomesosalpnix to any adipose tissue in the body, failure to prove any correlation between lipomesosalpnix and obesity would support screening for lipomesosalpnix in all infertile women.

To date, there is no uniform definition for unexplained infertility (UI) [56]. With the marvelous advancement in illumination and magnification, endoscopy would add a lot for the diagnostic work-up for cases with UI. The findings of this and our previous [42] studies would support the central role of dual endoscopy (combined laparoscopy and hysteroscopy) in all cases of infertility despite not being clearly stated by most of the infertility-interested societies when defining UI. One of the promising and attractive options for evaluation of subtle tubal and mesosalpingeal lesions is hydrolaparoscopy which offers a comparable accuracy to laparo‐ scopy in 96.1% of cases [55].

Despite being described since a long time [57], the impact of fatty condensation of the meso‐ salpnix on fertility is not yet studied so far and this is the first study in English literature to address this point and to report it in 5.7% of infertile women. Lipomesosalpnix would theoretically affect tubal motility and more importantly leads to failure to reach the pouch of Douglas for ovum pick up despite being a patent tube. Nevertheless, the results of this study failed to prove a positive correlation between lipomesosalpnix and unexplained infertility. Douglas pouch is the site of ovum pick-up by the healthy fimbria. Sometimes, hidden factors

leads to changing environment and may hinder fimbrial pick up. One of the interesting

This calls for a more large sample sized multicentric study. The main value of this study is to direct attention to mesosalpngeal lesions that would affect fertility. contributing to infertility are seen in it. One of the best examples is subtle endometriosis which

**Hidden Douglas Pouch abnormalities** 

#### **6. Hidden Douglas pouch abnormalities** laparoscopic findings is to see and cut fine adhesions that definitely affect ovum pick up. Such

sacculations (7%) more in the infertile women. Tubal abnormalities would affect the prognosis of natural pregnancy as well as assisted reproduction [49, 50]. At our institution, we consider tubal sacculations, diverticulae, convolutions, phimosis or fimbrial agglutination as laparo‐ scopic criteria of subtle tubal endometriosis specially if seen with other typical or atypical endometriotic tubal or peritoneal lesions. Proper endoscopic training would eliminate all these

Mesosalpingeal lesions include paratubal cyst [42], leiomyosarcoma of the broad ligament [51], Choristoma of Heterotopic Adrenal Tissue [52], primary Fallopian Tube Carcinoma [53] or lipoma of the Broad Ligament [54]. Preciously, among 1853 cases subjected to laparoscopy, we succeeded to diagnose a paratubal or paraovarian cyst in 118 patients (15.7%) [42]. Fat condensation in the mesosalpnix is not described in text books on histology, pathology or even endoscopic surgery as far as I know. Due to our interest in missed factors of infertility we tried to study the clinical significance of lipomesosalpnix. To be practical, we excluded cases with small amount of adipose tissue that wouldn't expect to affect tubal motility. In this study, preoperative TVS failed to diagnose lipomesosalpnix in all cases. Fallopian tubes are not usually visualized on a routine transvaginal sonographic examination unless outlined by fluid. However, the interstitial segment may be identified on TVS as an echogenic line arising from the endometrial canal and extending through the uterine wall. When surrounded by intra‐ peritoneal fluid, the remaining segments of the fallopian tubes are commonly seen as tubular structures extending between the uterus and the ovaries. Fallopian tubes are best visualized on sonography when thickened or fluid-filled as a result of pelvic inflammatory disease, torsion, ectopic pregnancy, or tumors [55]. Nevertheless, we still recommend performing TVS routinely prior to laparoscopy to detect important findings like paraovarain cysts [42] and more importantly intrauterine lesions that would make concomitant hysteroscopy a manda‐

Despite similarity of the histopathologic appearance of lipomesosalpnix to any adipose tissue in the body, failure to prove any correlation between lipomesosalpnix and obesity would

To date, there is no uniform definition for unexplained infertility (UI) [56]. With the marvelous advancement in illumination and magnification, endoscopy would add a lot for the diagnostic work-up for cases with UI. The findings of this and our previous [42] studies would support the central role of dual endoscopy (combined laparoscopy and hysteroscopy) in all cases of infertility despite not being clearly stated by most of the infertility-interested societies when defining UI. One of the promising and attractive options for evaluation of subtle tubal and mesosalpingeal lesions is hydrolaparoscopy which offers a comparable accuracy to laparo‐

Despite being described since a long time [57], the impact of fatty condensation of the meso‐ salpnix on fertility is not yet studied so far and this is the first study in English literature to address this point and to report it in 5.7% of infertile women. Lipomesosalpnix would theoretically affect tubal motility and more importantly leads to failure to reach the pouch of Douglas for ovum pick up despite being a patent tube. Nevertheless, the results of this study failed to prove a positive correlation between lipomesosalpnix and unexplained infertility.

mistakes that would affect diagnosis as well as therapy.

12 Contemporary Gynecologic Practice

support screening for lipomesosalpnix in all infertile women.

tory step.

scopy in 96.1% of cases [55].

Douglas pouch is the site of ovum pick-up by the healthy fimbria. Sometimes, hidden factors contributing to infertility are seen in it. One of the best examples is subtle endometriosis which leads to changing environment and may hinder fimbrial pick up. One of the interesting laparoscopic findings is to see and cut fine adhesions that definitely affect ovum pick up. Such fine tiny lesions couldn't be seen by HSG. Practically, proper access to the pouch of Douglas can be aided by using a uterine manipulater with extreme anteversion of the uterus. fine tiny lesions couldn't be seen by HSG. Practically, proper access to the pouch of Douglas can be aided by using a uterine manipulater with extreme anteversion of the uterus.
