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Fertility Promoting Laparoscopic Surgery: Our Experience Siddhartha Chatterjee, Alokendu Chatterjee, Rajib Gon Chowdhury, Sandip Dey, Debidas Ganguly ORIGINAL ARTICLE ABSTRACT Aim and objective: This study was to find out optimal laparoscopic surgical procedures for fertility promotion and to compare its pregnancy outcome with in vitro fertilization (IVF) procedure. Design and setting: Laparoscopic surgical procedures were performed under one consultant in a tertiary fertility set-up. Materials and methods: Between January 1994 and December 2008, 3,982 cases of fertility promoting laparoscopic surgery (FPLS) were performed in our center. The procedures were related to uterus and appendages and especially endometriosis. Results: The pregnancy rate following the surgical correction of minor tubal defects, ovarian cyst and uterine fibroids was between 25 and 30%, major tubal defects (5.7%) and severe endometriosis 18.5%. But the assisted reproductive technology (ART) outcome for the former was 30% and for the latter too, was between 25 and 30%. Conclusion: Laparoscopic surgical corrections for minor tubal defects yield comparable results to ART, but for other two conditions, the latter is superior to the former. Keywords: Fertility promotion, Laparoscopic surgery, Minor tubal defects, IVF, Pregnancy outcome. How to cite this article: Chatterjee S, Chatterjee A, Chowdhury RG, Dey S, Ganguly D. Fertility Promoting Laparoscopic Surgery: Our Experience. J South Asian Feder Obst Gynae 2012;4(1):12-16. Source of support: Nil Conflict of interest: None declared INTRODUCTION Surgery for correction of anatomical factors of infertility has long been a subject of discussion. With more and more use of laparoscopy, the surgical approach has become less invasive and more acceptable. Major procedures, like extensive adhesiolysis, tubal reconstruction, become rare due to availability of alternatives, like in vitro fertilization (IVF) and embryo transfer (ET). Fertility promoting laparoscopic surgery (FPLS) may be divided in the following groups: Surgeries on fallopian tubes, ovaries, uterus and recovery of the pouch of Douglas (POD). The surgery for endometriosis requires special mention, as often it becomes challenging. FPLS is a separate entity, which can otherwise be called restorative surgery, which requires lot of patience, skill of surgeon, avoidance of widespread oozing and minimal diathermy use. Steps should be taken to prevent future adhesion formation. Liberal washing of tissues with physiological salt solution and other steps to minimize postoperative adhesion formation is necessary. Restoration of anatomical competence of reproductive organs at the cost of functional competence is mostly useless effort, so far promotion of fertility is concerned. So, too much of surgery, like extensive adhesiolysis or complete removal of very large ovarian cyst wall which may lead to vascular compromise and thereby loss of function of pelvic organs, should be avoided. FPLS requires a comprehensive assessment and careful approach to promote future fertility, and hence, it should be considered to be a separate subspecialty of gynecological laparoscopic surgery. MATERIALS AND METHODS Between January 1994 and December 2008, 3,982 cases of operative laparoscopies were performed for correction of pelvic pathology by single surgical team. These patients were aged between 26 and 37 years with infertility between 5 and 7 years duration. Pelvic assessment was performed primarily by manual pelvic examination, followed by transvaginal ultrasonography (TV-USG) performed by same observer. Emphasis was given to detect any pelvic mass and its origin. Possibility of presence of endometriosis was screened very meticulously.1 Many had their tubal status assessed by Hysterosalpingography (HSG) or sonosalpingography (SSG) previously, and some of them had diagnostic laparoscopy too. Routine preoperative investigations, checkup and preparations for laparoscopy were undertaken. All procedures were performed under general anesthesia. Video laparoscopy was must. Usually triple puncture technique was used, but sometimes, four portals were also necessary. Tubal surgery may be for major or minor tubal defects. Major tubal defects were long segment tubal block, severe peritubal adhesion or puckering of tubes or major hydrosalpinx. Minor tubal surgeries may be restoration of tubal length, recovery of tubal motility by correcting peritubal adhesions, restorations of tubo-ovarian relation (TOR) and freeing of the fimbriae. The minor tubal defects noted at laparoscopy have been detailed by Chatterjee et al.2 Following are the different types in our series; (1) tubal kinks due to serosa to serosal adhesion; (2) C-tube or pulled-up tubes toward respective iliac fossa due to shortening of infundibulopelvic (IP) ligaments; (3) fimbrial pathology, like fimbrial eversion, fimbrial agglutination or combination of both; (4) peritubal adhesion causing problem in tubal mobility and adhesions in the POD, causing hindrance to reservoir function and egg pick-up; (5) cornual or
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