Dr. Mohamed El Sherbiny MD Ob. Gyn. Senior Consultant Damietta, Egypt

2. Sources of Evidences National Guideline Clearinghouse 2000 National Institute of Clinical Excellence(NICE)Guideline. Fertility2004 ESHRE guideline(2005) Royal College of Obstetricians and Gynaecologists (RCOG) infertility , 1999 & Endometriosis ,2006 Society of Obstetricians and Gynaecologists of Canada (SOGC) 244- 2010 Cochrane Library Up To Date 2-19 May 2011 PubMed

3. The availability of assisted reproductive technology (ART) has reduced the need for laparoscopic reconstructive surgery in infertile women. However, there are still many important indications for laparoscopy.

4. When fertility surgery is indicated, operative laparoscopy results in outcome are as good as those performed via open laparotomy. However laparoscopy is associated with Shorter Hospital Stay Lower Incidence Of Ileus Faster Recovery Less Morbidities Lower Postoperative Adhesion Formation

5. Less contamination of the surgical field with glove powder or lint Bleeding is reduced due to tamponade of small vessels by the pneumoperitoneum Drying of tissues is minimal because surgery occurs in a closed environment

6. Laparoscopy in Infertility  Diagnostic Laparoscopy Operative Laparoscopy

8. Indications of Laparoscopy in Female Infertility I. Diagnostic Laparoscopy II. Operative Laparoscopy Adhesiolysis Fimbrioplasty Cornual Obstruction: Laparoscopic guided catheterization Endometriosis: Implant: ablation (electro-surgery or Laser) Endometriomas: Excision, Fenestration & ablation PCOS: Ovarian Drilling Hydrosalpinx before IVF: Salpingectomy Proximal tubal occlusion & salpingostomy

9. Diagnostic Laparoscopy

10. Basic Routine Infertility Investigation Tests which have an established correlation with pregnancy are: Semen analysis Tubal patency by HSG or laparoscopy Mid luteal progesterone for the diagnosis of ovulation

11. What Are The Tubal Patency Testing? Transcervical Media: HSG Laparoscopy HyCoSy (Hysterosalpingo-Contrast Synography)

12. Women who are not known to have co-morbidities (such as PID, previous ectopic pregnancy or endometriosis) should be offered HSG to screen for tubal occlusion. This is a reliable test for ruling out tubal occlusion, it is less invasive and makes more efficient use of resources than laparoscopy. When HSG and When Laparoscopy?

13. Women who are thought to have co-morbidities should be offered laparoscopy and dye so that tubal and other pelvic pathology can be assessed at the same time.

14. Test for Tubal Patency No co-morbidities

15. Case presentation A 27 year old woman, BMI 26 Primary infertility 4 years No history of pelvic pain, infection or ectopic pregnancy or pelvic surgery.

17. Which of The Following is Recommended for Our Patient? Laparoscopy to exclude endometriosis or adhesion IUI 3 cycles IUI + HMG, for 3 cycles IVF/ICSI

18. There is still a considerable debate regarding the place of laparoscopy for cases of unexplained infertility.

19. There has been a growing tendency for bypassing diagnostic laparoscopy in unexplained infertility. In their opinion this approach would probably prove to be the most cost effective and efficient treatment protocol.

20. However, there were several reports indicating that in infertile couples, laparoscopy revealed abnormal findings in 21-78% with normal HSG. After the treatment of these abnormal findings, higher pregnancy rates can often be achieved by timing intercourse or an IUI.

21. Which of The Following is Recommended? Laparoscopy to exclude endometriosis or adhesion IUI 3 cycles IUI + HMG, for 3 cycles. IVF/ICSI

22. Diagnostic laparoscopy can be avoided in: Older women Those with multiple infertility factors These women are better served by IVF, instead of a surgical approach to treatment. The presence of endometriosis and adhesions does not markedly influence the effectiveness of IVF.

28. Operative Laparoscopy for Female Infertility

29. Adhesiolysis Fimbrioplasty Cornual Obstruction: Laparoscopic guided catheterization

30. When is Tubal Surgery Recommended ? For women with mild tubal disease, tubal surgery may be more effective than no treatment. In centres where appropriate expertise is available it may be considered as a treatment option.

33. What is Recommended for Moderate to Severe Tubal Disease?  IVF should be considered as the first line treatment for moderate to severe distal tubal disease.

35. Cornual Obstruction If the fallopian tubes are not visualized on HSG, a repeat procedure should be done to exclude the possibility of tubal spasm.

37. Tubal Catheterization or Cannulation For women with proximal tubal obstruction selective salpingography plus tubal catheterization, or Hysteroscopic tubal cannulation (laparoscopic guided), may be treatment options because these treatments improve the chance of pregnancy.

40. Tubal Surgery Versus IVF At present, the available research is not adequate to determine the effectiveness. More research is needed, including information about adverse outcomes and costs.

41. Endometrioses Associated Infertility: The Role of Laparoscopy

42. Typical Endometriosis: Black Endometriosis               Blue Endometriosis Atypical (subtle) Endometriosis: Red Endometriosis: Red pink, flam-like & clear White Endometriosis White Yellow Brown Peritoneal Defect

44. Typical Endometriosis In the majority of instances, the laparoscopic appearances of endometriosis lesions are quite characteristic: black-blue, powder-burn appearance. Diagnosis in most cases is simple, without the need for a biopsy.

45. Atypical Endometriosis = Subtle Endometriosis = Non-pigmented Endometriosis Endometriotic lesions that lack the typical black-blue, powder-burn appearance

48. ASRM Classification The most widely used system was introduced by the American Society for Reproductive Medicine (ASRM) in 1979 and revised in 1996 . This system assigns a point score based upon the size, depth, and location of endometriotic implants and associated adhesions. The system was revised for women with infertility to help predict success in achieving pregnancy following treatment of endometriosis.

49. Endometriosis

50. Endometriotic Cyst = Endometrioma

52. Laparoscopic Surgery 1. Laparoscopic treatment of minimal or mild endometriosis improves pregnancy rates regardless of the treatment modality. (I)

54. Laparoscopic Treatment 2. The effect on fertility of surgical treatment of deeply infiltrating endometriosis is controversial. (II) 3. Laparoscopic excision of ovarian endometriomas more than 3 cm in diameter may improve fertility. (II)

55. Ovulation Disorders - 20% The WHO classification is three groups: Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism) Group II: hypothalamic pituitary dysfunction predominately polycystic ovary syndrome (PCOS) Group III: ovarian failure

56. Polycystic Ovary Syndrome (PCOS)

57. When 2 out of 3 features are present: Oligomenorrhoea and/or Anovulation Clinical Hyperandrogenism and/or hyperandrogenemia Polycystic ovaries (U/S) After exclusion of other etiologies.

58. At least one of the following:  12 or more follicles measuring 2–9 mm in diameter Increased ovarian volume (>10 cm3) The distribution of follicles and a description of the stroma are not required for diagnosis. The presence of a single PCO is sufficient to provide the diagnosis.

60. First Step:Lifestyle modification: Weight loss =10%

61. Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS. PCOS: Laparoscopic Drilling

62. PCOS Drilling Optimization A strategy of minimizing the number of diathermy points to: 4/ovary For 4 s At 40 W

68. Laparoscopic Management of Hydrosalpinges Prior to IVF

71. Laparoscopic Management of Hydrosalpinges Prior to IVF Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment as it improves IVF pregnancy rates.

73. Laparoscopic tubal occlusion is an alternative to laparoscopic salpingectomy in improving IVF pregnancy rates in women with hydrosalpinges. Further research is required to assess the value of aspiration of hydrosalpinges prior to or during IVF procedures. Laparoscopic Management of Hydrosalpinges Prior to IVF