Operative Laparoscopy for Infertility

Historically, only diagnostic procedures were performed with the laparoscope. Using a two-puncture technique for the placement of the laparoscope and a rigid probe to manipulate the reproductive organs, pathologic abnormalities were characterized but rarely treated. In the last decade, use of the laparoscope has expanded. Now various reproductive disorders are diagnosed and treated primarily with the laparoscope including pelvic adhesions, endometriosis, and disorders of the Fallopian tubes.

In many situations, laparoscopy provides important and essential information helpful in the management of infertility. In response to the significant advances in endoscopy, today's gynecologic surgeon faces difficult decisions concerning integration of operative laparoscopy into daily practice. The purpose of this review is to establish guidelines for the use of laparoscopy in the diagnosis and treatment of the infertile couple, and to indicate the expected outcomes of laparoscopically treated pelvic disease.

In most treatment paradigms for infertility, laparoscopy is the final step in the investigation. This strategy is based on the assumption that the risk of intraperitoneal disease is small when few risk factors exist in carefully screened women. Screening generally consists of a review of historical and physical findings for pelvic disease as well as the results obtained from hysterosalpingography. Up to 50% of infertile women will have unsuspected pelvic pathology detected at the time of laparoscopy, underscoring the limited value of historical screening.¹

The diagnostic accuracy of hysterosalpingography is an area of considerable debate. Opsahl and coauthors evaluated the predictive value of the hysterosalpingogram (HSG) in the diagnosis of tubal and peritoneal factors.² As expected, a test indicating bilateral distal occlusion was confirmed at laparoscopy with a high degree of accuracy. In contrast, radiographic studies suggesting alternate types of tubal disease were not as accurate, with only 63% of the findings confirmed at laparoscopy. In women with a completely normal HSG, the test accurately predicted the presence of patent Fallopian tubes with a false negative rate of only 3.6%. However, over 40% of women with a normal HSG had associated pelvic disease (adhesions or endometriosis) detected at the time of laparoscopy.

Based on the results of published studies, it is apparent that no single noninvasive screening test is highly successful in predicting either the presence or absence of pelvic disease. Therefore, many factors must be considered in the decision to perform laparoscopy. Women with significant risk factors, abnormal physical findings, or long-standing infertility are clearly candidates for laparoscopy.³ Moreover, laparoscopy should be considered in women with an abnormal or suspicious HSG. Because success rates of infertility treatment plans are highly dependent on maternal age, early diagnosis and timely intervention are critical in achieving good outcomes. Although it is reasonable to defer laparoscopy in younger women without risk factors after a trial of therapy, a more aggressive strategy is necessary in older women.

Various surgical tools are available to perform laparoscopy. Table 1 comprises a list of the equipment necessary to complete most infertility cases. With extended experience in laparoscopy, many additional surgical adjuncts will be added to the list.

TABLE 1. Level I Basic Equipment

  Primary trocar, 10–12 mm
  Laparoscope, 10–12 mm
  1 to 2 secondary trocars, 5 mm
  Blunt manipulating probe
  Biopsy forceps
  Bipolar coagulator
  Various grasping instruments
  Scissors
  High flow CO₂ insufflator
  Suction/irrigation system
  Uterine manipulator
  Videocassette recorder
  Television monitor
  Video camera
  Lasers, CO₂, KTP, Nd:YAG or argon

Ectopic pregnancy represents a major health problem with over 100,000 estimated cases in 1992.⁴ Hospitalizations for ectopic pregnancy are decreasing, emphasizing the increasing use of outpatient procedures, such as laparoscopy and pharmacologic therapy.⁴ Salpingostomy, segmental resection, or salpingectomy can be performed laparoscopically. The correct operative procedure depends on the location of the pregnancy and the desire for future fertility. Salpingostomy is the most common technique, but it is not advisable when the tubal gestation is >6 cm because of the increased risk of acute or delayed bleeding.⁵ Laparoscopic salpingectomy is appropriate for even very large ectopic pregnancies.⁶ Segmental resection is suggested for isthmic ectopic pregnancies, which occur within 1 cm of the uterotubal junction because of an increased risk of tubal occlusion following salpingostomy.^7,8 Manipulation or “milking” of distal tubal pregnancies is discouraged because of an increased risk of persistent trophoblastic disease and recurrent ectopic pregnancy.⁹

Many studies support the use of laparoscopy in the treatment of ectopic pregnancy (Table 2).^{9,10,11,12,13,14} In a convincing prospective randomized trial comparing laparoscopy and laparotomy, Vermesh and coworkers demonstrated decreased hospitalization stay and cost in the laparoscopy group.¹³ More importantly, crude subsequent pregnancy rates were similar, thus suggesting no obvious adverse effect of laparoscopy on future fertility. The value of laparoscopy was demonstrated in a randomized study by Lundoff and coworkers.¹⁵ In the laparoscopy group, the formation of peritubal adhesions was reduced with tubal patency rates comparable with those found in laparotomy.

TABLE 2. Conservative Surgical Management of Ectopic Pregnancy

Laparoscopy is appropriate in most cases of ectopic pregnancy, but it is contraindicated in the unstable and hypovolemic patient. Relative contraindications include active bleeding, obesity, and dense pelvic adhesions. At present, the optimal method of managing the cornual pregnancy is with laparotomy. The generalized recommendation to treat all ectopic pregnancies with laparoscopy is therefore premature. Although laparoscopy demonstrates some cost-saving advantages, the operation requires special surgical skills and equipment. Lacking these, laparotomy may be the prudent choice for many surgeons.

Endometriosis lesions occur in various forms, ranging from classic powder burns to subtle vesicular implants. Using magnification, the multiple forms of endometriosis can be identified with a high degree of certainty,¹⁶ and effectively treated at a single setting. The surgical management of endometriosis is multifaceted. Vaporization, fulguration, and excision are used in the treatment of superficial disease. For adnexal disease, adhesiolysis, ovarian cystectomy, salpingectomy, or oophorectomy are all possible. Retroperitoneal exploration or bowel resection is generally reserved for severe symptomatic disease.

For many years, endometriosis and affiliated pelvic disease were primarily managed by laparotomy. However, studies now indicate that even advanced forms of endometriosis can be treated by laparoscopy. The benefits of laparoscopy include decreased cost and more rapid recovery, which makes it an attractive option. However, a proven advantage of laparoscopy over laparotomy for the treatment of endometriosis remains to be determined.¹⁷

Laparotomy is effective in treating infertility with reported crude pregnancy and fecundity rates of 40% to 73% and 1.5 to 5%, respectively, when all stages are combined (Table 3).^18,19,20,21 More recent experience indicates that laparoscopic treatment of endometriosis is an emerging alternative to laparotomy (Table 4).^{22,23,24,25,26} Based on life table analysis, Crosignani and coauthors reported that pregnancy rates for either laparoscopy (44%) and laparotomy (62%) were equivalent.²⁷ In a large study involving 579 women, Adamson and Pasta evaluated pregnancy outcome as a function of endometriosis stage. For all stages of disease, surgical results with laparoscopy were comparable with those in laparotomy.²⁸

TABLE 3. Treatment of Endometriosis at Laparotomy

* American Society for Reproductive Medicine classification

TABLE 4. Treatment of Endometriosis at Laparoscopy

* Revised American Society for Reproductive Medicine classification

Whether surgical treatment for endometriosis improves fertility for all stages of disease remains controversial. The debate centers on the effect of surgical treatment of early stage disease. For mild and minimal disease, observational studies indicate that expectant management of endometriosis results in pregnancy rates equal to surgery.²⁹ In contrast, several cohort studies suggest that pregnancy rates after surgery are superior when compared with those of hormonal therapy or expectant management.^{30,31,32,33,34} In a prospective randomized study, Marcoux and coauthors concluded that surgery enhanced pregnancy rates for early forms of disease.³⁵ With surgery, a marginal but significant increase in monthly fecundity rates occurred (6.1 versus 3.2). The low fecundity rate indicates that factors not treated by surgery exist in the study population. Based on the reported surgical experience, pregnancy rates are improved following surgical ablation of endometriosis for any stage of disease. Therefore, surgeons must be prepared to both diagnose and treat endometriosis at a single setting in the infertile couple.

The goal of endometriosis surgery is to remove visible implants and to restore pelvic anatomy using a technique that limits the induction of pelvic adhesions. Hormonal management may be effective for superficial disease but rarely works for invasive disease.³⁶ Operative strategies for invasive disease generally promote the total excision of affected tissues. Laparoscopic drainage may be successful in selected cases, but recurrence rates are high.³⁷ As a result, ovarian cystectomy is generally performed for endometriomas of all sizes. Both laparoscopy and laparotomy are effective in the treatment of endometriomas. Blood loss, operative time, and postoperative recovery are less for laparoscopic techniques. Importantly, pregnancy rates in retrospective studies are equivalent.³⁸

Special consideration should be given to the surgical management of endometriomas. The pathogenesis of endometrioma formation remains unclear. Endometriomas may form from the invasion of surface disease with the formation of a pseudocyst. Traditional therapy advises complete removal of the cyst wall. A disadvantage of the technique is that both normal and abnormal ovarian tissue is invariably removed. Brosens and coworkers propose incision of endometriomas and then treatment of active implants.³⁹ The cyst wall is not removed. The authors then perform a second laparoscopy to treat residual disease. Despite a relatively conservative approach, only 2 of 15 women had recurrent endometriomas after the first surgery, and none had a recurrence over a 2-year period after the second surgery. Preliminary results of this study are encouraging with the preservation of normal functional ovarian tissue and a low recurrence risk.

Gynecologic surgeons are continually confronted with new operative techniques that can be integrated into clinical practice. Collective data suggest that in skilled hands pregnancy rates following laparoscopy for the treatment of endometriosis are equivalent to those of laparotomy. Less experienced endoscopists may not be as successful. For many, laparotomy may be the most appropriate technique to treat advanced endometriosis when superior results are anticipated.

Preoperative diagnosis of pelvic adhesions is not easily made. The best historical finding is previous surgery (26% of cases), but just as many women with a negative history and negative findings on physical examination will have pelvic adhesions discovered at the time of surgery.⁴⁰ Moreover, use of hysterosalpingography adds little in the diagnosis of pelvic adhesions. In a metaanalysis, Swart and coauthors concluded that the results of HSG tests were unreliable.⁴¹ Therefore, laparoscopy is generally necessary to make a definitive diagnosis of this important infertility factor.

Theoretically, pelvic adhesions impair fertility by disrupting normal tubal-ovarian relationships. As a result, ovum pickup, transport, and fertilization are compromised. To substantiate the role of adhesion surgery in improving pregnancy outcome, Tulandi and colleagues compared pregnancy outcome in women with periadnexal adhesions with and without laparotomy. After 2 years of follow-up, 45% of the treated group conceived compared with 16% in the untreated group.⁴² Additional studies also indicate the benefit of adhesionolysis in treating infertility.^43,44

Both microsurgical and laparoscopic techniques are used to treat pelvic adhesions. However, the superiority of the one method over the other has not been established. Based on results in animal studies⁴⁵ showing less adhesion formation following laparoscopic procedures, it was anticipated that human studies would show similar findings. Although early studies in humans suggested superior results with laparoscopy,^46,47 more recent work has shown equivalent pregnancy rates, ranging from 50% to 75%.^48,49,50,51

Adhesion reformation is a significant problem following adhesionolysis. In a prospective multicenter study performing second-look laparoscopy after adhesionolysis, over 95% of women exhibited adhesion reformation.⁵² The ovary was particularly vulnerable with 80% of the operations showing adhesion reformation in the adnexa. Various techniques are successful in removing adhesions, but it appears that the diverse methods used to remove adhesions are comparable. Despite small series suggesting a benefit, the value of second-look laparoscopy to retreat adhesions appears marginal. In a nonrandomized retrospective study, Trimbos-Kemper and coworkers could not demonstrate an improved pregnancy rate in women undergoing a second procedure.⁵³

Injury to the distal oviduct resulting in a complete or partial occlusion is the most common tubal lesion encountered. Microsurgical repair is the primary method of treatment with pregnancy rates approaching 40% with extended follow-up. Because of the relatively low monthly fecundity rate (<5%), neosalpingostomy is currently reserved for the younger patient, preferably those under age 35, with minimal-to-moderate degree of tubal injury.

Considering the overall pregnancy rate, cost, length of hospitalization, and postoperative recovery period following microsurgery, laparoscopic-directed distal tubal surgery is a reasonable alternative to conventional techniques. In several reported series, overall pregnancy rates using laparoscopy are comparable with those in laparotomy (Table 5).^{54,55,56,57,58} In a retrospective review by Canis and coworkers, pregnancy rates between laparoscopy (41.2%) and microsurgery (51.6%) were similar for early stage disease.⁵⁷ In more severely damaged hydrosalpinges, microsurgery may be marginally more effective. However, clinical trials comparing pregnancy outcome between laparoscopy and microsurgery are nonexistent, therefore, the optimal technique to treat distal injury remains unknown.

TABLE 5. Laparotomy Versus Laparoscopy in Treatment of Hydrosalpinx

Several classification systems exist to help surgeons predict pregnancy outcomes of surgical procedures designed to correct distal tubal disease.^59,60,61 In carefully selected candidates, satisfactory pregnancy rates can be achieved. Because severely damaged tubes promise poor pregnancy rates when treated surgically, alternative therapies such as in vitro fertilization should be considered as primary therapy, particularly in an older woman.

Other more recent work now indicates that hydrosalpinges produces an adverse impact on results of in vitro fertilization (Table 6).^{62,63,64,65,66,67,68,69,70,71,72} In a review by Anderson and coworkers, IVF success rates were lower (19%) when compared with those in nonocclusive forms of tubal disease (33%).⁶⁴ Other retrospective studies have shown similar results. Hydrosalpinges may decrease implantation indirectly by promoting a detrimental inflammatory response. A direct inhibitory action of hydrosalpingeal fluid on endometrial integrin expression, a possible marker of endometrial receptivity, is also a possible mechanism for decreased implantation.⁷³

TABLE 6. Effect of Hydrosalpinx on In Vitro Fertilization Rates

Whether the removal of hydrosalpinges will improve IVF success rates is an important area of investigation. Preliminary work is encouraging in that aggressive surgical treatment improves implantation and pregnancy rates and also restores endometrial integrin expression. Several retrospective studies have examined the impact on the removal or correction of a hydrosalpinx on IVF success rates.^65,68,71,74 Although the studies are limited by methodologic design, a consistent pattern is observed. Nearly all studies report an improvement in pregnancy and implantation rates following surgery. In a recent prospective study of women with repeated IVF failures, Shelton and coauthors observed a 25% pregnancy rate following laparoscopic excision of the damaged tubes.⁷¹ Large clinical trials may be necessary to prove the beneficial effect of salpingectomy on IVF success. However, based on the accumulated published data, salpingectomy or corrective surgery does improve IVF success rates in women with the diagnosis of hydrosalpinx.

Laparoscopic myomectomy has been technically possible since the early 1980s.⁷⁵ The procedure works best for serosal or solitary intramural leiomyomata, but surgical indications and appropriate patient selection are not well defined. Furthermore, incidence of procedure-related morbidity remains uncertain.

The arguments for laparoscopic myomectomy include a decreased cost associated with outpatient surgery and a more rapid recovery. The duration of laparoscopic myomectomy is highly variable. Skilled laparoscopic surgeons may be able to demonstrate an economic advantage; however, prolonged surgical procedures requiring the use of expensive equipment will ultimately raise surgical costs. Although laparoscopy generally is associated with shorter hospitalization, a rapid hospital discharge is now observed with many abdominal procedures.

A major concern is whether laparoscopic uterine surgery predisposes an increased risk of uterine rupture during pregnancy. At present, multilayer closure of myometrial defects is not practical with the use of the laparoscope, so that, a single layer closure is usually performed. Because uterine rupture has been reported with laparoscopic myomectomy, there is basis for concern.^76,77 Significant postoperative adhesion formation is an additional reported risk of abdominal myomectomy, but the frequency of this complication is unknown. Adhesion formation is also observed following laparoscopy, but the degree of adhesions may be less according to observational studies.⁷⁸ For skilled surgeons, laparoscopic myomectomy is a benefit when traditional surgical management and future fertility are declined. At this time, the reported experience does not support its routine use in women who desire future fertility.

Laparoscopy is the most costly and invasive step in the diagnosis of infertility. With the advent of smaller endoscopes, the diagnosis of intraperitoneal pathology can now be made in an outpatient setting. The procedure involves the use of a small endoscope (2 to 3 cm) under local anesthesia using small amounts of carbon dioxide as a distention medium to create a pneumoperitoneum. The pelvic organs are visualized and manipulated with the placement of an accessory suprapubic probe.

Office-based laparoscopy is gaining in popularity. Although originally described for office tubal ligations,^79,80 the technique is currently used in the diagnosis and treatment of infertility. Pelvic adhesions, endometriosis, and tubal disease can be readily identified with current microendoscopes.

Although outpatient laparoscopy is less expensive than conventional laparoscopy, the technique has some limitations. Aggressive treatment of pelvic disease is not possible with the use of local or regional anesthesia. Moreover, management of traumatic injuries may be inadequate in an outpatient setting. Currently, the role of outpatient laparoscopy in the treatment of infertility needs further study. Extended clinical experience may eventually support the use of this surgical technique in the treatment of infertility.