Role of transvaginal hydrolaparoscopy in the investigation of female infertility: a review of 1,000 procedures

Diagnosis and treatment of early-stage endometriosis by Transvaginal Hydro laparoscopy

Background: Transvaginal Hydro Laparoscopy (THL) is known as a minimal invasive procedure allowing endoscopic exploration of the female pelvis. Objective: To evaluate the possibilities of the THL as a tool for early diagnosis and treatment of minimal endometriosis. Materials and methods: A retrospective study of a consecutive series of 2288 patients referred for fertility problems to a tertiary centre for reproductive medicine was undertaken. Mean duration of infertility was 23.6 months (SD ±11-48), mean age of patients was 31.25 (SD± 3.8y). With normal findings at clinical and ultrasound examination patients underwent, as part of their fertility exploration, a THL. Main outcome measures: Evaluation of feasibility, identified pathology and pregnancy rate. Results: Endometriosis was diagnosed in 365 patients (16%); the localisation was higher on the left side (n=237) than on the right side (n=169). Small endometriomas, with diameters between 0.5 and 2 cm, were present in 24.3% (right side in 31, left side 48 and bilateral 10). These early lesions were characterised by the presence of active endometrial like cells and a pronounced neo-angiogenesis. Destruction of the endometriotic lesions with bipolar energy resulted in an in vivo pregnancy rate (spontaneous/IUI) of 43.8% (CPR after 8 months: spontaneous 57.7%; IUI/AID 29.7%). Conclusion: THL allowed in a minimally invasive way an accurate diagnosis of the early stages of peritoneal and ovarian endometriosis with the possibility of offering treatment with minimal damage. What is new? This is the largest series reporting the usefulness of THL for the diagnosis and treatment of peritoneal and ovarian endometriosis in patients without obviously visible preoperative pelvic pathology.

Systematic use of transvaginal hydrolaparoscopy as a minimally invasive procedure in the exploration of the infertile patient: results and reflections

Background

The aim of this study was to evaluate the added value of transvaginal hydrolaparoscopy (THL) in the investigation of the infertile patient.

Methods

A retrospective cohort study, based on records from 01/09/2006 to 30/12/2019 was undertaken in a tertiary care infertility centre. THL was performed in 2288 patients. These were patients who were referred for endoscopic exploration of the female pelvis as part of their infertility investigation. In 374 patients with clomiphene- resistant polycystic ovary syndrome (PCOS), ovarian capsule drilling was also performed. The outcome objectives of this study included the evaluation of the added diagnostic value of THL as well as the feasibility and safety of the visual inspection of the female pelvis using this technique.

Results

Of the 2288 procedures failed access to the pouch of Douglas occurred in in 23 patients (1%). The complication rate was 0.74%, due to bowel perforations (n= 13) and bleeding (n= 4) requiring laparoscopy. All bowel perforations were treated conservatively, with 6 days of antibiotics, and no further complications occurred. Findings were normal in 49.8% of patients. Endometriosis was diagnosed in 366 patients (15.9%); adhesions were present in 144 patients.

Conclusions

THL is a minimally invasive procedure, with a low complication and failure rate, providing an accurate visual exploration of the female pelvis in a one-day hospital setting. When indicated, minimally invasive surgery is possible in the early stages of endometriosis and for ovarian capsule drilling in patients with clomiphene- resistant PCOS.

Transvaginal hydrolaparoscopy versus hysterosalpingography in the work-up for subfertility: a randomized controlled trial

RESEARCH QUESTION

Is transvaginal hydrolaparoscopy (THL) non-inferior to hysterosalpingography (HSG) as a first-line tubal patency test in subfertile women in predicting the chance of conception leading to live birth?

DESIGN

A multicentre, randomized controlled trial in four teaching hospitals in the Netherlands, which randomized subfertile women scheduled for tubal patency testing to either THL or HSG as a first-line tubal patency test. The primary outcome was conception leading to live birth within 24 months after randomization.

RESULTS

A total of 149 women were randomized to THL and 151 to HSG. From the intention-to-treat population, 83 women from the THL group (58.5%) conceived and delivered a live born child within 24 months after randomization compared with 82 women (55.4%) in the HSG group (difference 3.0%, 95% CI -8.3 to 14.4). Time to conception leading to live birth was not statistically different between groups. Miscarriage occurred in 16 (11.3%) women in the THL group, versus 20 (13.5%) women in the HSG group (RR = 0.66, 95% CI 0.34 to 1.32, P = 0.237), and multiple pregnancies occurred in 12 (8.4%) women in the THL group compared with 19 (12.8%) women in the HSG group (RR = 0.84, 95% CI 0.46 to 1.55, P = 0.58). Ectopic pregnancy was diagnosed in two women in the HSG group (1.4%) and none in the THL group (P = 0.499).

CONCLUSION

In a preselected group of subfertile women with a low risk of tubal pathology, use of THL was not inferior to HSG as a first-line test for predicting conception leading to live birth.

Transvaginal hydrolaparoscopy and laparoscopy

RESEARCH QUESTION

To evaluate the findings of outpatient transvaginal hydrolaparoscopy (THL) in comparison with diagnostic laparoscopy combined with chromopertubation in subfertile women.

DESIGN

In a retrospective study in four large teaching hospitals, all subfertile women who underwent a THL and a conventional laparoscopy as part of their fertility work-up in the period between 2000 and 2011 were studied. Findings at THL were compared with findings at diagnostic and therapeutic laparoscopies. Tubal occlusion, endometriosis and adhesions were defined as abnormalities.

RESULTS

Out of 1119 women, 1103 women underwent THL. A complete evaluation or incomplete but diagnostic procedure could be performed in 989 (89.7%) and 28 (2.5%), respectively. An incomplete non-diagnostic procedure was performed in 11 (1.0%) women. Failure of THL occurred in 75 women (6.8%) and 40 of these women (3.6%) subsequently underwent laparoscopy. Laparoscopy was performed in a total of 126 patients with a median time interval of 7 weeks (interquartile range [IQR] 3-13 weeks). Of 64 patients who successfully underwent both THL and laparoscopy, concordant findings were found in 53 women and discordant results in 11 women, 6 of which were caused by tubal spasm. Sensitivity of THL in detecting abnormalities was 100% and specificity was 22.2%, with a likelihood ratio of 1.29.

CONCLUSION

THL in an outpatient setting can detect anatomical abnormalities comparable to the more invasive reference standard diagnostic laparoscopy. If THL succeeds, there is no need to add a diagnostic laparoscopy in the work-up.

The usefulness of transvaginal hydrolaparoscopy in infertile women with abnormal hysterosalpingogram results but with no obvious pelvic pathology

OBJECTIVE

To evaluate the value of transvaginal hydrolaparoscopy (THL) in infertile women with abnormal hysterosalpingogram results but with no history of previous pelvic surgery and with normal gynecological examination and vaginal sonography.

STUDY DESIGN

This is a retrospective study. From January 2008 to October 2009, 51 infertile women were planned to undergo standard laparoscopy because of abnormal HSG. None of the patients had any history of previous pelvic surgery and all had normal findings on gynecological examination and vaginal sonography. These women underwent THL.

RESULTS

Among the 51 cases, successful access to the pouch of Douglas was achieved in 49. There were two failures due to obesity, and the operation was converted to standard laparoscopy. No complication was observed in this study period. In 26 patients (53.1%) the THL procedure showed normal pelvic organs. Four patients were lost to follow-up. Of the remaining 22 cases, four became pregnant (4/22, 18.2%) through intercourse or intrauterine insemination (IUI). There were some morphologic abnormalities seen in the remaining 23 patients such as adhesions, endometriosis and hydrosalpinx. Six cases with mild adhesions and endometriosis were treated with THL alone, and four (4/6, 66.7%) became pregnant with or without IUI. Among the 19 who underwent standard laparoscopy, three were lost to follow-up. In the other 16 cases, natural pregnancy occurred in six (6/16, 37.5%) patients with or without IUI.

CONCLUSIONS

For women with abnormal HSG results but with no obvious pelvic pathology, THL should be recommended and about 50% could avoid an unnecessary laparoscopy. Adhesiolysis and coagulation of endometriotic lesions under THL in mild adhesion and endometriosis cases could lead to encouraging results.

Transvaginal hydrolaparoscopy, its history and present indication

The investigation of the infertile couple by hysterosalpingography and laparoscopy is currently a highly debated issue. The purpose of this paper is to review whether transvaginal hydrolaparoscopy (THL), a new culdoscopic approach, in combination with minihysteroscopy and chromopertubation test can be offered as a complete one-stop endoscopic exploration. The technique allows complete endoscopic exploration of the reproductive tract in an office or outpatient setting and has been validated during the past years for its accuracy, safety and patient tolerance. Although further prospective randomized studies are required to prove the superiority and cost-benefit of transvaginal hydrolaparoscopy as diagnostic tool in comparison with hysterosalpingography (HSG) and laparoscopy, the technique can be proposed as a safe first-line investigation predicting the fertility outcome in women.

Prognostic capacity of transvaginal hydrolaparoscopy to predict spontaneous pregnancy

BACKGROUND

In 1998, transvaginal hydrolaparoscopy (THL) was introduced as a new outpatient procedure for exploration of tubo-ovarian structures and tubal patency in subfertile patients. At present, there are no large studies that relate the findings at THL to fertility outcome.

METHODS

Consecutive patients undergoing THL for subfertility between 2000 and 2004 were included in this prospective cohort study. Follow-up ended when ongoing pregnancy or tubal surgery occurred or at the day of last contact. Kaplan-Meier curves for the occurrence of intrauterine pregnancy (IUP) (spontaneous or after intrauterine insemination) were constructed for a normal THL, a THL with a one-sided tubal pathology and a THL with a two-sided tubal pathology. Fecundity rate ratios (FRRs) were calculated to express the association between THL findings and the occurrence of IUP. Patients rated their pain experiences and acceptability on a visual analogue scale (VAS).

RESULTS

We included 272 women. In 96% (261) of the patients, access to the pouch of Douglas was achieved. Complications occurred in 2% of the procedures. In 203 (78%) patients, both tubo-ovarian structures could be visualized and tubal patency was shown. One-sided tubal occlusion was found in 10%, whereas two-sided tubal occlusion was seen in 4% of the patients. Adhesions and/or endometriosis were observed in 8% of the patients. The FRRs for one-sided tubal pathology, two-sided tubal pathology and adhesions/endometriosis were 0.59, 0 and 0.80, respectively. The VAS scores showed pain to be limited and the procedure to be acceptable.

CONCLUSION

THL is a feasible technique. Its capacity to predict spontaneous ongoing pregnancy is comparable to that of laparoscopy.