The following chapter is called The Role of Endoscopy, Laparoscopy, and Hysteroscopy in Infertility.

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1 Welcome to Chapter 14. The following chapter is called The Role of Endoscopy, Laparoscopy, and Hysteroscopy in Infertility. The authors are Dr. Jose Remohi and Dr. Jaime Ferro. 1

2 There are several tools available for studying the integrity of the female genital tract prior to a gynecological endoscopy. The importance of these tools has changed in recent years, since the use of transvaginal ultrasound has become a routine practice.

3 Endoscopic evaluation of the female genital tract can be done abdominally or vaginally. Laparoscopy and salpingoscopy are conducted abdominally, while hysteroscopy, salpingoscopy, and culdoscopy are conducted vaginally.

4 Laparoscopy has generally been considered the best tool for evaluating the integrity of the female genital tract. In the 1980s, when hysteroscopy was introduced, it provided an excellent method for completing a study. The complete laparoscopic and hysteroscopic assessment is considered the golden tool.

5 Both methods can guarantee the diagnosis of the morphological and functional integrity of the genital tract However, even with detailed intra- and extrauterine information, at times we find ourselves investigating a permeable anatomical structure, such as the tubes, without the ability to demonstrate total functionality, as detailed in this slide

6 Beginning in the 1990s, it was possible to assess the functionality of permeable tubes thanks to the introduction of the salpingoscopy, a diagnostic method that uses a more integrated concept, from the morphological and functional point of view, in assessing the female genital tract

7 Transvaginal endoscopy is a procedure that combines hysteroscopy, hydric laparoscopy, chromopertubation, and salpingoscopy in one diagnostic method Microsalpingoscopy is an endoscopic method involving direct contact for functional evaluation of endosalpinx cells in the tube

8 We should ask which is the best method to study uterine tubal integrity. There is no golden standard endoscopic method Hysteroscopy may not be the best first step in such a study because other alternatives, such as hysterosalpingography (HSG), transvaginal ultrasound (TVS), and hysterosonography (SHG), are also excellent tools, depending on the pathology under investigation

9 An article was published in Fertility and Sterility in 2000 in which hysteroscopy, HSG, TVS, and SHG were compared in regard to sensitivity, specificity, and predictive value for different pathologies SHG and hysteroscopy had similiar rates in the diagnosis of polyps. The results were nearly equivalent for the 2 methods regarding uterine malformations Regarding adhesions, SHG was as appropiate as HSG These results lead us to be more conscious of the existence of other, less invasive techniques that can help in the assessment of uterine integrity without the need for hysteroscopy

10 Here is an example of Müllerian malformation. When HSG shows a bicornuate uterus, it is possibe that we are not directly in front of the malformation and are instead seeing a uterine septum. This is because HSG, as well as SHG and hysteroscopy, only show us the uterine cavity. 10

11 Transvaginal ultrasound is a diagnostic tool that shows both the uterine cavity and the body This is an easy method because in a complete scan we will notice if there is uterine tissue in between the cavities, in which case we may reinforce the diagnosis with an echo-doppler that allows us to see the presence of uterine vascularization 11

12 When ultrasound (US) fails to provide an accurate diagnosis, we can use 3-D US 12

13 A 3-D US scan provides more detailed cavity and uterine body images that help in the differential diagnosis between a bicornuate uterus and a septum 13

14 If, with all this information, we are not able to diagnose a Müllerian abnormality, we can use magnetic resonance imaging (MRI), which will give us a more complete and detailed view of the uterus 14

15 Laparoscopy is considered the gold standard, but it should be the diagnostic tool of last resort, used only when other methods to demonstrate Müllerian abnormalities fail Although laparoscopy provides a direct view of the abnormality, it is not always necessary to use this diagnostic tool 15

16 The last diagnostic tool is hysteroscopy, but this method will only show us a uterine septum without information of the uterine shape 16

17 For the study of tubal factor, the main test is laparoscopy, but there are many other methods that can demostrate tubal permeability, such as HSG and SHG. Laparoscopy should be used as a last resort because it is the most invasive of these procedures 17

18 Salpingoscopy can give infomation about tubal function if the tube is permeable Does this mean that every time we have a permeable tube we should proceed with salpingoscopy-microsalpingoscopy? The answer is no Tubal and uterine integrity can be demonstrated by less invasive procedures, leaving endoscopy as a last resort for diagnosis and as more of a therapeutic tool 18

19 What happens in a situation where we see endometriosis? This is a special pathology because some types of lesions in endometriosis have no morphologic alterations but can produce funtional alterations in the genital tract 19

20 Here are the Royal British College of Obstetrics guidelines for the diagnosis of endometriosis Laparoscopy is considered B evidence, even though it is the gold standard, while transvaginal ultrasound is recommended for detection of ovarian endometriomas Serum CA-125 has limited value 20

21 The American Society of Reproductive Medicine (ASRM) classification of endometriosis is basically endoscopic Stages I and II are associated with subfertility, in which fecundity rates are reduced to 1/3, while advanced stages III and IV are associated with infertility caused by adhesions, tubal obstruction, and/or anatomical distortion 21

22 This classification shows that there is no need for laparoscopy at stages I and II, since the findings can change up to 10 months after a normal HSG In advanced stages, in which endometriosis is diagnosed, the treatment is surgical 22

23 What is the gold standard probe for diagnosing the integrity of the female tract? Hysterosalpingography Transvaginal ultrasound Hysterosonography Endoscopy MRI 23

24 Laparoscopy is considered the gold standard for evaluating the integrity of the female genital tract, but there are other, less invasive methods with similar positive and negative predictive value For this reason, laparoscopy should not be the procedure initially elected; however, there is no question of the importance of the therapeutic use of laparoscopy in the reproductive field for evaluating results in assisted reproduction procedures

25 25

26 The correct answer is: ( C). 26

27 The correct answer is: ( C ). 27

28 The correct answer is: ( D ). 28

29 The correct answer is: ( C). 29

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