Laparoscopy and laparoscopic surgery Laparoscopy -- The Kinder Cut

From the book

How to Have a Baby: Overcoming In ertility

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD. Previous page: Ultrasound - eeing !ith ound "Page #$ %e&t page: 'aparos(opy -- )he *inder +ut "Page #$ )able o, +ontents -hat is laparos(opy . -hen is laparos(opy done. -hat pre(autions need to be taken be,ore laparos(opi( surgery . /o! is the laparos(opy per,ormed . -hat is an operative laparos(opy . -hat is a 0se(ond-look laparos(opy . 0 -hat is laparos(opy . 'aparos(opy " also (alled endos(opy or pelvis(opy$ is a surgi(al pro(edure in !hi(h a teles(ope is inserted inside the abdomen through a small (ut belo! the navel, so that the do(tor (an have a look at the pelvi( organs in the in,ertile !oman. A laparos(opy (an lead to the diagnosis o, many problems !hi(h (ause in,ertility in(luding damaged tubes, endometriosis, adhesions and tuber(ulosis. -hen is laparos(opy done. 1n the past, a diagnosti( laparos(opy !as a routine part o, the !orkup in in,ertile !omen, in order to (omplete their evaluation. 2enerally, the pro(edure !as per,ormed a,ter the basi( in,ertility tests !ere done, sin(e it is a surgi(al " invasive$ pro(edure. )oday, ho!ever, the utility o, laparos(opy in treating in,ertile !omen is very limited, and !e rarely per,orm laparos(opies in our (lini(.

Timing the surgery

ome do(tors !ill time the laparos(opy during the premenstrual phase "the !eek be,ore the ne&t period is due$. )hey (ombine the laparos(opy !ith a dilatation and (urettage "D 3 +$ "s(raping the inside o, the uterine (avity$ so that they (an also get in,ormation on the !oman4s ovulatory status in the same pro(edure. ome do(tors try to per,orm the diagnosti( laparos(opy during the post-menstrual phase , !hen the uterine lining is thin, so that they (an (ombine it !ith a hysteros(opy at the same time. -hat pre(autions need to be taken be,ore laparos(opi( surgery .

)he patient is advised not to eat or drink anything ,or a spe(i,i( time be,ore the operation. ome tests may also be done be,ore the pro(edure, to ensure sa,ety ,or anesthesia, though ,or most young healthy !omen tests are usually not needed. ome do(tors may !ant a / 2 "hysterosalpingogram$ done be,ore per,orming a laparos(opy. )he surgery is usually done on a day-(are basis. 'aparos(opy is done under general anesthesia so that the patient remains asleep during surgery and does not ,eel any dis(om,ort. /o! is the laparos(opy per,ormed .

The laparoscopic procedure

First o, all, the abdomen is (leansed and draped ,or the pro(edure. )hen an instrument may be pla(ed in the uterus through the vagina. A gas, su(h as (arbon dio&ide or nitrous o&ide or air is then allo!ed to ,lo! into the abdomen just belo! the belly button. )his gas (reates a spa(e inside by pushing the abdominal !all and the bo!el a!ay ,rom the organs in the pelvi( area and makes it easier to see the reprodu(tive organs (learly. )he laparos(ope, !hi(h is a slender tube, like a miniature teles(ope, is then inserted through a small in(ision just belo! the navel. During the laparos(opy a small probe is pla(ed through another in(ision in order to move the pelvi( organs into (lear vie!. A diagnosti( laparos(opy is in(omplete !ithout a 0se(ond pun(ture0 be(ause, !ithout this se(ond probe, it is not possible to visuali5e all the stru(tures (ompletely. During the laparos(opy the entire pelvis is (are,ully s(anned and the organs inspe(ted systemati(ally - the uterus6 the ovaries6 and the lining o, the abdomen, (alled the peritoneum. 1n addition to looking ,or diseases a,,e(ting these stru(tures, the do(tor also looks ,or adhesions "bands o, s(ar tissue$, endometriosis and tuber(les. 1n (ase abnormalities are ,ound, the do(tor (an either try to (orre(t them "operative laparos(opy$, or take out bits o, tissue ,or histologi( e&amination "biopsy$ !ith a biopsy ,or(eps. A blue dye "methylene blue$ is then inje(ted through the uterus and ,allopian tubes to (he(k !hether the tubes are open. -hen the surgery is (omplete, the gas is removed and one or t!o stit(hes inserted to (lose the in(isions. in(e the in(isions are so small, o,ten stit(hes are not needed and they (an be (losed !ith 7andAids.

Fig 8. A laparos(opy being per,ormed. %ote that the vie! through the laparos(ope (an be seen on the )9 monitor.

Fig #. %ormal pelvis as seen during a laparos(opy. )he uterus is the reddish stru(ture in the (enter6 on either side o, !hi(h are the pink ,allopian tubes. )hese run to!ards the ovaries, !hi(h are !hite in (olour. As stated earlier, along !ith laparos(opy, some do(tors (arry out a dilatation and (urettage "D 3 +$ and send the endometrial (urettings ,or histologi( e&amination to rule out the possibility o, hidden tuber(ulosis, and also to ,ind out i, ovulation is taking pla(e. :thers !ill do a diagnosti( hysteros(opy at the same time, to ensure that the uterine (avity is normal. Most do(tors today use videolaparos(opy, in !hi(h a video (amera is (onne(ted to the laparos(ope, so that !hat the surgeon sees (an be displayed on a )9 monitor. )his kind o, laparos(opy (an be very use,ul ,or do(umentation and re(ord-keeping. 1t is also very help,ul ,or patient edu(ation, sin(e the do(tors (an use the video or +D later on to e&plain to the patient the e&a(t nature o, her problem. ;e(ent advan(es in miniaturi5ation have allo!ed (ompanies to manu,a(ture very tiny laparos(opes. )hese are as thin as a needle, and are (alled mi(rolaparos(opes or needles(opes. )hese allo! do(tors to per,orm laparos(opy in the (lini( itsel,, !ithout using anesthesia. /o!ever, the <uality o, the images is still not very good !ith these tiny s(opes. Dr 7rosens ,rom 7elgium has also introdu(ed the te(hni<ue o, transvaginal hydrolaparos(opy. )his allo!s the do(tor to e&amine the pelvis by inserting a tiny s(ope through the vagina, so that no abdominal in(ision needs to be made. )he value o, this te(hni<ue as (ompared to (onventional laparos(opy is still being studied.

-hat is an operative laparos(opy . During operative laparos(opy, many problems !hi(h (ause in,ertility (an be sa,ely treated through the laparos(ope at the same time that the diagnosis is made. -hen per,orming operative laparos(opy, additional instruments su(h as probes, s(issors, biopsy ,or(eps, (oagulators and suture materials are pla(ed into the abdomen, either through the laparos(ope or through t!o or three additional in(isions (alled 0suprapubi( pun(tures0, !hi(h are made above the pubis. ome o, the disorders that (an be (orre(ted !ith the help o, the pro(edures above in(lude: releasing s(ar tissue and=or adhesions ,rom around the ,allopian tubes and ovaries6 opening blo(ked tubes6 and removing ovarian (ysts. >ndometriosis (an also be destroyed by burning it ,rom the ba(k o, the uterus, ovaries, or peritoneum during operative laparos(opy. Under (ertain (ir(umstan(es, small ,ibroid tumors (an be removed and e(topi( pregnan(ies (an be treated. -hen per,orming operative laparos(opy, surgeons may use ele(tro(autery instruments, lasers, and sutures. )he (hoi(e o, the te(hni<ue used depends on many ,a(tors in(luding the surgeon4s training, lo(ation o, the problem, and availability o, e<uipment. -hat is a 0se(ond-look laparos(opy . 0 ometimes, a 0se(ond-look0 laparos(opy may be re(ommended. )his pro(edure is per,ormed ,ollo!ing either operative laparos(opy or major tubal surgery. e(ond-look laparos(opy (an take pla(e !ithin a ,e! days ,ollo!ing the initial surgery or many months a,ter!ards. During the pro(edure, the do(tor determines !hether adhesions are re-,orming or i, endometriosis is returning and these (onditions (an be treated in needed. A,ter surgery, the patient needs to rest ,or about # to ? hours in order to re(over ,rom the e,,e(ts o, anesthesia. he (an usually go home the same day and resume normal !ork in # to @ days. e&ual a(tivity (an be resumed in a !eek or so, depending upon the do(tor4s advi(e.

Laparoscopy Laparoscopy -- The Kinder Cut !"age #$

From the book

How to Have a Baby: Overcoming In ertility

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD. Previous page: 'aparos(opy -- )he *inder +ut "Page 8$ %e&t page: /ysteros(opy )able o, +ontents -hat (an you e&pe(t to ,eel a,ter the laparos(opy . -hat are the (ompli(ations o, laparos(opy . /o! (an 1 be sure my do(tor !ill per,orm the laparos(opy properly . -hi(h is better - a laparos(opy or a / 2 . -hat happens a,ter the laparos(opy . -hat (an you e&pe(t to ,eel a,ter the laparos(opy . A,ter the operation, there may be some dis(om,ort. )his may in(lude:

Mild nausea as a result o, the medi(ation or the surgi(al pro(edure Pain in the ne(k and shoulder due to the gas inside the abdomen, !hi(h irritates the phreni( nerve and (auses 0re,erred pain0 per(eived in the shoulder Pain in the areas !here the instruments passed through the abdominal !all A s(rat(hy throat and hoarse voi(e i, a breathing tube !as used during general anesthesia +ramps, like menstrual (ramps Dis(harge like a menstrual ,lo! ,or a day or t!o Mus(le a(hes

Most o, these minor symptoms !ill disappear !ithin a day or t!o a,ter surgery. )he abdomen may ,eel s!ollen ,or a ,e! days. Any unusual or pe(uliar symptoms should be reported at on(e to the do(tor. )o really appre(iate the bene,its o, laparos(opy, one should remember that the alternative is major surgery "laparotomy$ !hi(h involves a large abdominal in(ision, a ,our to si& day hospital stay, and ,our to si& !eeks o, postoperative re(overy time. -hat are the (ompli(ations o, laparos(opy . -hile the do(tors may term laparos(opy as being 0minor0 surgery, remember that ,or the patient all surgery is majorA )he risk o, laparos(opy are minimal. 7ut (ertain (onditions in(rease the possibility o, (ompli(ations. 1, there has been previous surgery in the abdomen, espe(ially involving the bo!el, there is an in(reased risk. :ther

(onditions that lead to a higher risk o, (ompli(ations are eviden(e o, an in,e(tion in the abdomen, a large gro!th or tumor !ithin the abdomen, and obesity. +ompli(ations among young, healthy !omen under going laparos(opy are rare and o((ur only in about three out o, 8BBB (ases. )hese (ompli(ations (an in(lude injuries to stru(tures in the abdomen su(h as the bo!el, a blood vessel or the bladder. Most o,ten, these injuries o((ur !hen the laparos(ope is pla(ed through the navel. 1, su(h an injury o((urs during the pro(edure, the physi(ian (an per,orm major surgery and (orre(t the damage through a longer abdominal in(ision. ometimes, (ompli(ations may arise a,ter surgery. 1, bleeding or pain appears e&(essive or i, high ,ever develops, the do(tor should be in,ormed. /o! (an 1 be sure my do(tor !ill per,orm the laparos(opy properly . Un,ortunately, many gyne(ologists are not skilled at per,orming a laparos(opy properly. 1n order to (hoose the best do(tor ,or per,orming your laparos(opy, you need to ask him the ,ollo!ing <uestions. 8. #. @. ?. /o! many laparos(opies have you done. Do you use multiple pun(tures. Do you use a video ,or re(ording the operation. 1, you ,ind a problem, !ill you (orre(t it at the same time. 1deally, i, the do(tor ,inds a problem during the laparos(opy, he should (orre(t it at the same time, rather than (all you again ,or a se(ond surgi(al pro(edure, !hi(h only adds to your e&pense and risk. A good do(tor has a lot o, e&perien(e in per,orming laparos(opies6 uses multiple pun(tures, so he (an assess the pelvis properly6 and al!ays provides do(umentation " in the ,orm o, a video, +D or D9D$ so the ,indings (an be revie!ed by another do(tor. -hi(h is better - a laparos(opy or a / 2 .

Comparing laparoscopy and H%&

1n our pra(tise, !e pre,er using an / 2 to do(ument tubal paten(y, be(ause it is mu(h less e&pensive6 is non-surgi(al6 and provides a hard (opy re(ord , !hi(h all do(tors (an re,er to later on. ome do(tors still believe that both the / 2 and laparos(opy are (omplementary pro(edures, and you may even need both, espe(ially i, your tubes are blo(ked. / 2 provides in,ormation only about the inside o, the tubes and uterine (avity, !hereas in laparos(opy, not only (an the tubal paten(y be determined, but t!o other disorders " endometriosis and tubal adhesions$ inside the abdomen !hi(h a,,e(t tubal ,un(tion and !hi(h do not sho! up on / 2 (an also be diagnosed. /o!ever, !hile it is true that a laparos(opy o,,ers the do(tor a (han(e to diagnose and treat these problems at the same time , it is still unsure !hether (orre(ting these problems a(tually helps to improve the patient4s ,ertility A A (ommon problem !hi(h patients ,a(e in pra(ti(e is that many do(tors !ill insist on repeating the laparos(opy. :ne reason ,or this is that do(tors ,eel that they need to do the laparos(opy ,or themselves, be(ause they (annot 0trust0 another do(tor4s

judgment. )his is, o, (ourse a major problem ,or patients, !ho su,,er repeated "and unne(essary$ laparos(opies. /aving a video re(ord should help to minimi5e this problem. -hat happens i, your laparos(opy !as normal and the se(ond do(tor !ants to repeat it any!ay. ometimes do(tors have little to o,,er in the !ay o, e,,e(tive treatment and sin(e there is nothing else to do, they suggest a repeat laparos(opy to !hi(h the hapless patient is ,or(ed to agree. 1, your ,irst laparos(opy did, in ,a(t indi(ate you had a problem, a se(ond look laparos(opy may be indi(ated "and this should have been dis(ussed !ith you a,ter the ,irst laparos(opy$ to determine i, the problem has been su((ess,ully resolved. Ask the do(tor !hat in,ormation he hopes to get by doing the repeat laparos(opy and ho! this !ill (hange your treatment. 1, you ,eel the do(tor !ants to do a laparos(opy ,or no very good reason, re,use. 1t4s a surgi(al pro(edure a,ter all - and it4s your body.

Thin'ing it over
:ne bene,it o, laparos(opy is that in addition to allo!ing the a((urate diagnosis o, a problem, i, it e&ists, operative laparos(opy (an also be done in the same surgery to (orre(t the problem. /o!ever, !e ,eel that the routine use o, laparos(opy is not (alled ,or in treating in,ertile patients, sin(e a / 2 (an provide similar in,ormation at mu(h less risk and e&pense. -e use the pro(edure very sparingly in our pra(tise. -hat happens a,ter the laparos(opy . At the ,ollo!-up visit, dis(uss !ith the do(tor !hat he ,ound at the time o, the laparos(opy and also ho! to pro(eed on the basis o, the ,indings. )here are three possible (ourses o, a(tion: 8. %ormal ,indings: u(h ,indings are the (ommonest result and (an be very assuring A )hese help to (on,irm the diagnosis o, 0une&plained in,ertility0. #. Abnormal ,indings, su(h as peritubal adhesions or endometriosis, !hi(h (ould be (orre(ted at the time o, laparos(opy itsel,: Perhaps the do(tor may suggest a se(ond look laparos(opy or / 2 a,ter some time to do(ument that the problem has, in ,a(t been (orre(ted or else in addition medi(al treatment may be advised to try to (orre(t a residual problem "e.g. antibioti(s ,or pelvi( in,e(tion$. A <uandary may arise !hen the laparos(opy reveals a ,inding !hi(h may be o, no relevan(e to the problem o, in,ertility. For e&ample during laparos(opy the do(tor may dete(t small ,ibroids, early endometriosis, or an ovarian (yst. )hese are (ommon disorders and are o,ten ,ound in ,ertile !omen as !ell. Cust making a diagnosis o, these disorders does not automati(ally mean that they need to be (orre(ted: they may be red herrings, !hi(h do not a,,e(t ,ertility. 1n ,a(t, unne(essary surgery to remove these disorders (an aggravate your in,ertility. @. Abnormal ,indings: !hi(h (ould not be (orre(ted during the laparos(opy: For treatment o, these problems, the do(tor may advise 19F ",or e&ample, ,or patients !ith irreparably damaged ,allopian tubes$.

Hysteroscopy
From the book

How to Have a Baby: Overcoming In ertility

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD. Previous page: 'aparos(opy -- )he *inder +ut "Page #$ %e&t page: /ysteros(opy "Page #$ )able o, +ontents -hat is hysteros(opy . /o! is hysteros(opy per,ormed . -hat is operative hysteros(opy . -hat is hysteros(opi( tubal (annulation . -hat are the (ompli(ations o, hysteros(opy . -hat is hysteros(opy . /ysteros(opy, as the name suggests "hystero D uterus6 s(opy D to see$, is a surgi(al pro(edure in !hi(h a teles(ope is inserted inside the uterus to e&amine the uterine lining. )his pro(edure (an assist in the diagnosis o, various uterine (onditions !hi(h (an (ause in,ertility, su(h as: 8. #. @. ?. submu(ous "internal$ ,ibroids s(arring "adhesions or syne(hiae$ endometrial polyps uterine septa and other (ongenital mal,ormations

7e,ore per,orming hysteros(opy, a hysterosalpingogram "an &-ray o, the uterus and ,allopian tubes$ may be per,ormed to provide additional in,ormation about the (avity !hi(h (an be use,ul during surgery. Many do(tors !ill also do a vaginal ultrasound as a diagnosti( aid. Diagnosti( hysteros(opy is usually (ondu(ted on a day-(are basis !ith either general or lo(al anesthesia and takes about thirty minutes to per,orm. /o! is hysteros(opy per,ormed . )he ,irst step o, hysteros(opy involves (ervi(al dilatation - stret(hing and opening the (anal o, the (ervi& !ith a series o, dilators. :n(e the dilatation o, the (ervi& is (omplete, the hysteros(ope, a narro! lighted teles(ope, is passed through the (ervi& and into the lo!er end o, the uterus. A (lear solution "/yskon or gly(ine$ or (arbon dio&ide gas is then inje(ted into the uterus through the instrument. )his solution or gas e&pands the uterine (avity, (lears blood and mu(us a!ay, and enables the surgeon to dire(tly vie! the internal stru(ture o, the uterus. )he do(tor systemati(ally e&amines the lining o, the (ervi(al (anal6 the lining o, the uterine (avity6 and looks ,or the internal openings o, the ,allopian tubes !here they enter the uterine (avity - the tubal ostia.

ome do(tors may do a (urettage "a surgi(al s(raping o, the inside o, the uterine (avity$ a,ter the hysteros(opy and send the endometrial tissue ,or pathologi( e&amination. -hat is operative hysteros(opy . )he te(hni<ue o, hysteros(opy has also been e&panded to in(lude operative hysteros(opy. :perative hysteros(opy (an treat many o, the abnormalities ,ound during diagnosti( hysteros(opy at the time o, diagnosis. )he pro(edure is very similar to diagnosti( hysteros(opy e&(ept that operating instruments su(h as s(issors, biopsy ,or(eps, ele(to(autery instruments, and graspers (an be pla(ed into the uterine (avity through a (hannel in the operative hysteros(ope. Fibroid tumors, s(ar tissue "syne(hiae or adhesions$, and polyps (an be removed ,rom inside the uterus. +ongenital abnormalities, su(h as a uterine septum, may also be (orre(ted through the hysteros(ope. -hat is hysteros(opi( tubal (annulation . A relatively ne! method ,or treating pro&imal tubal obstru(tion "(ornual blo(ks, !here the tubes are blo(ked at the utero-tubal jun(tion$ is that o, hysteros(opi( tubal (annulation. Many studies have sho!n that this kind o, blo(k is o,ten be(ause o, mu(us plugs or debris !hi(h plug the tubal lining at the uterotubal jun(tion !hi(h is as thin as a hair. 1t is no! possible to pass a ,ine guide!ire through the hysteros(ope into the tubes, and thus remove the plug or debris and open the tubes - thus restoring normal tubal paten(y !ith 0minimally invasive surgery0A Another advan(e has been the development o, the method o, ,allopos(opy - in !hi(h a very ,ine ,le&ible teles(ope is passed into the tube through the hysteros(ope, so as to visuali5e the interior o, the entire tube. A,ter a hysteros(opy, patients o,ten have (ramping similar to that e&perien(ed during a menstrual period6 and some vaginal staining ,or several days. ;egular a(tivities (an be resumed !ithin one or t!o days a,ter surgery. e&ual inter(ourse should be avoided ,or a ,e! days or ,or as long as bleeding o((urs. -hat are the (ompli(ations o, hysteros(opy . +ompli(ations o((ur rarely during hysteros(opy. 1n a ,e! (ases, in,e(tion o, the uterus or ,allopian tubes (an result. :((asionally, a hole may be made through the ba(k o, the uterus - a per,oration. /o!ever, this is usually not a serious problem be(ause the per,oration (loses on its o!n. Fre<uently, !hen e&tensive operative hysteros(opy is planned, diagnosti( laparos(opy is per,ormed at the same time to allo! the surgeon to see the outside as !ell as the inside o, the uterus to try to redu(e the risk o, a((idental uterine per,oration. :ther possible (ompli(ations in(lude allergi( rea(tions and bleeding.

Hysteroscopy : (terine "olyps) *ndometrial "olyps Hysteroscopy !"art #$

From the book

How to Have a Baby: Overcoming In ertility

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD. Previous page: /ysteros(opy "Page 8$ %e&t page: )he )ubal +onne(tion )able o, +ontents -hat are uterine" endometrial$ polyps . /o! do ,ibroids " myomas$ a,,e(t ,ertility . -hat are the ne! te(hni<ues ,or studying the role o, the endometrium in in,ertility . -hat are uterine" endometrial$ polyps .

"olyps
>ndometrial or uterine polyps are so,t, ,ingerlike gro!ths !hi(h develop in the lining o, the uterus "the endometrium$. )hey develop be(ause o, e&(essive multipli(ation o, the endometrial (ells, and are hormonally dependent , so that they in(rease in si5e depending upon the estrogen level. )hey (an usually be dete(ted on an ultrasound s(an i, this is done mid-(y(le, !hen estrogen levels are ma&imal, but are easily missed i, the s(an is not done at the right time o, the menstrual (y(le. Polyps are an un(ommon but important (ause o, in,ertility, be(ause they (an easily be removed during hysteros(opi( surgery.

Fig 8. Uterine polyp as seen during hysteros(opy

Fig #. Uterine polyp seen during ultrasound s(an a,ter in,usion o, saline !hi(h outlines the polyp in the (avity /o! do ,ibroids " myomas$ a,,e(t ,ertility .

+ibroids
-hile the (ommonest problem ,ound in the uterus is a ,ibroid "myoma or leiomyoma$, this is rarely a (ause o, in,ertility, and is usually an in(idental ,inding o, little importan(e. Fibroids are (ommon benign smooth mus(le tumors !hi(h arise in the !all o, the uterus, and may be single or multiple. About #EF o, all !omen over the age o, @E have ,ibroids. Most ,ibroids develop in the !all o, the uterus "intramural $ or protrude outside o, the uterine !all "subserous ,ibroids$, and these (an usually be le,t alone, sin(e they do not hinder ,ertility, and neither do they (ause problems during the pregnan(y. 1n ,a(t, unne(essary surgery to remove the ,ibroid o,ten (auses more harm than good. )his surgery o,ten (reates adhesions, !hi(h (auses the tubes to get blo(ked. /o!ever, i, the ,ibroids are very large, they may need surgi(al removal, and this pro(edure is (alled a myome(tomy. ome do(tors give an inje(tion o, a 2n;/ analog prior to surgery in order to shrink the ,ibroid and make surgery te(hni(ally easier. -hen per,ormed by an e&pert, it is a sa,e and e,,e(tive pro(edure !hi(h (an be a((omplished !ith minimal blood loss. /o!ever, sometimes be(ause o, un(ontrollable bleeding the surgeon may be ,or(ed to remove the entire uterus "a pro(edure (alled a hystere(tomy$, and this is obviously a disaster ,or the in,ertile !omanA )he standard te(hni<ue ,or removing a ,ibroid is through open surgery "laparotomy$. 1t is no! also possible to remove ,ibroids through the laparos(ope, but laparos(opi( myome(tomy does not allo! ,or optimal re(onstru(tion o, the uterus. ubmu(ous ,ibroids are an important (ause o, in,ertility, be(ause they inter,ere !ith implantation o, the embryo, by a(ting as a ,oreign body. )hese are best removed by an operative hysteros(opy. -hile surgery (an remove the ,ibroid, it (an re(ur again, and most do(tors advise the patient to try to (on(eive as soon as possible a,ter surgery.

Fig #. (hemati( sho!ing a submu(ous ,ibroid6 and a subserous ,ibroid (ompressing the right ,allopian tube Fibroids may gro! larger during the pregnan(y, but usually pregnan(y and delivery are unevent,ul. 1n rare (ases, a,ter a myome(tomy, uterine rupture may o((ur during pregnan(y or delivery, and this (ompli(ation may result in severe blood loss, ,etal loss and even maternal death. 7e(ause o, the potential ,or (atastrophi( results, it is re(ommended that !omen have (esarean deliveries in the ,ollo!ing (ir(umstan(es: 8$ !hen the myome(tomy involved ,ull-thi(kness in(ision o, the uterine !all or multiple deep uterine in(isions or #$ !hen myome(tomy !as (ompli(ated by in,e(tion !hi(h may have !eakened the uterine !all or @$ !hen there is doubt regarding the ade<ua(y or e&tent o, the uterine repair. )he uterus !as o,ten a negle(ted organ in the in,ertility !orkup, partly be(ause !e did not have the tools to study it properly. /ysteros(opy, hysterosalpingography and vaginal ultrasound are all (omplementary pro(edures ,or evaluating the uterine (avity in the in,ertile !oman. )he / 2 is good ,or looking ,or polyps, adhesions and septa !hi(h appear as 0,illing de,e(ts0 on the G-ray. /o!ever, (are,ul radiologi( te(hni<ue is a must. 9aginal ultrasound is e&(ellent ,or dete(ting submu(osal ,ibroids or polyps, !hi(h (an be missed on hysteros(opy and / 2. :, (ourse, the major advantage o, hysteros(opy is it o,,ers the (han(e o, treating the problem as !ellA -hat are the ne! te(hni<ues ,or studying the role o, the endometrium in in,ertility . -e are no! also developing ne!er te(hni<ues to study the uterus. :ne o, our major areas o, ignoran(e today is the (omple& pro(ess o, embryo implantation. 1t is obvious that the endometrium has a key role to play in this pro(ess, in !hi(h the embryo has to appose and atta(h itsel, to the maternal endometrium and invade into it. At present, the tools !e have to study endometrial ,un(tion and re(eptivity are very (rude. )hey in(lude primarily transvaginal ultrasound, to assess the endometrial thi(kness and

te&ture, but this provides very limited and indire(t eviden(e o, endometrial ,un(tions. +olour Doppler ultrasound has also been used to assess endometrial blood ,lo! " per,usion$, but its utility is limited. in(e embryo-endometrium intera(tion is a bio(hemi(al pro(ess, a lot o, study has been done on the role o, the mole(ules involved in this pro(ess. ;e(ent resear(h has sho!n that the normal endometrium (ontains various (ell adhesion proteins (alled integrins, !hi(h allo! the embryo to intera(t !ith it. tudies have sho!n that the endometrium o, some in,ertile !omen is de,i(ient in some o, these integrins, and this de,i(ien(y may be responsible ,or ,ailure o, the embryo to implant su((ess,ully. )hus, testing the endometrium ,or beta integrin (an be a use,ul marker ,or uterine re(eptivity. )his test involves doing an endometrial biopsy at a spe(i,i( point in the menstrual (y(le, and evaluating this !ith spe(ial staining te(hni<ues, but is only available on a resear(h basis so ,ar.

+allopian Tubes : H%& Test) "rocedure , In ertilityThe Tubal Connection

From the book

How to Have a Baby: Overcoming In ertility

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD. Previous page: /ysteros(opy "Page #$ %e&t page: )he )ubal +onne(tion "Page #$ )able o, +ontents -hat are the ,allopian tubes . /o! do tubal diseases (ause in,ertility . /o! is tubal disease diagnosed . -hat are the limitations o, diagnosing tubal disease . -hat are the re(ent innovations ,or tubal ,a(tor diagnosis and treatment . -hat are the ,allopian tubes . )he ,allopian tubes proje(t out ,rom ea(h side o, the body o, the uterus and ,orm the passages through !hi(h the egg is (ondu(ted ,rom the ovary into the uterus. )he ,allopian tubes are about 8B (ms long and the outer end o, ea(h tube is ,unnel shaped, ending in long ,ringes (alled ,imbriae. )he ,imbriae (at(h the mature egg and (hannel it do!n into the ,allopian tube !hen released by the ovary . )he tube itsel, is a mus(ular highly movable stru(ture (apable o, highly (oordinated movement. )he egg and sperm meet in the outer hal, o, the ,allopian tube, (alled the ampulla. Fertili5ation o((urs here, a,ter !hi(h the embryo (ontinues do!n the tube to!ard the uterus. )he uterine end o, the tube, (alled the isthmus, a(ts like a

sphin(ter, and prevents the embryo ,rom being released into the uterus until just the right time ,or implantation, !hi(h is about ? to H days a,ter ovulation. )he tube is mu(h more (omple& than a simple pipe, and the lining o, the tube is ,olded and lined !ith mi(ros(opi( hair like proje(tions (alled (ilia !hi(h push the egg and embryo along the tube. )he tubal lining also produ(es a ,luid that nourishes the egg and embryo during their journey in the tube.

Fig 8. %ormal tube and ovary, as seen during laparos(opy /o! do tubal diseases (ause in,ertility .

Tubal disease
)ubal abnormalities a((ount ,or bet!een #EF and EBF o, ,emale in,ertility .)ubal damage usually o((urs through pelvi( in,e(tion , and this is (alled pelvi( in,lammatory disease " P1D$. :,ten, !e (annot ,ind out the (ause ,or the in,lammation. /o!ever, some o, the (auses o, pelvi( in,e(tion that (an be pinpointed are :

e&ually transmitted diseases "e.g. 2onorrhea, +hlamydia$ 1n,e(tion a,ter (hildbirth, mis(arriage, termination o, pregnan(y " M)P$ or 1UD "intrauterine devi(e$ insertion Post-operative pelvi( in,e(tion "e.g. per,orated appendi&, ovarian (ysts$ evere endometriosis )uber(ulosis

7esides (ausing blo(ked tubes, any pelvi( in,lammatory disease (an also produ(e bands o, s(ar tissue (alled adhesions, !hi(h (an alter the ,un(tioning o, the ,allopian tubes. P1D (an be a silent disease, and most !omen !ith tubal damage be(ause o, P1D are (ompletely una!are that they have this disease. Pelvi( tuber(ulosis is a ,airly (ommon (ause o, tubal damage in 1ndia. )he tuber(ulosis ba(teria rea(h the tubes ,rom the lungs through the bloodstream and (an (ause irreparable tubal damage. /o! is tubal disease diagnosed .

.a'ing a /iagnosis o Tubal disease

A number o, tests are available to judge !hether or not the tubes are open. )he simplest and oldest test ,or tubal paten(y is the ;) or ;ubin4s test named a,ter its inventor. 1n this test, gas is passed under pressure into the tubes through the (ervi& and uterus - either !ith a spe(ial ma(hine ";ubin4s apparatus$ or !ith an ordinary syringe. )he do(tor then listens !ith a stethos(ope pla(ed on the abdomen to determine i, he (an hear the sound o, gas passing through the ,allopian tube. >ven though this test is no! obsolete, be(ause it is so unreliable, a number o, do(tors still do it. 7lood tests ,or (hlamydial antibodies: in(e an in,e(tion !ith (hlamydia is the (ommonest reason ,or tubal disease in the -est, some do(tors test the blood ,or antibodies against (hlamydia . -omen !ho have antibodies against (hlamydia have been e&posed to this in,e(tion in the past, and are (onsidered to be at higher risk ,or tubal damage. /ysterosalpingogram "Uterotubogram$ or / 2 is a spe(iali5ed G-ray o, the uterus and tubes. An / 2 is done a,ter the menstrual ,lo! has just stopped - usually on Day I or H o, the period, at !hi(h time the lining o, the uterus is thin. 1t is done in an Gray +lini(. )he patient is advised to take an antibioti( and a pain-killer be,ore the pro(edure by many do(tors. A,ter being positioned on the G-ray table, the do(tor pla(es a spe(ial instrument into the (ervi&, (alled a (ervi(al (annula, !hi(h is made o, metal. Many do(tors no! pre,er to use a balloon (atheter , as this makes the pro(edure less pain,ul. A radio-opa<ue dye "a li<uid !hi(h is opa<ue to G-rays$ is then inje(ted into the uterine (avity. )his is done slo!ly under pressure, and pi(tures are taken - pre,erably under an image intensi,ier. )he passage o, the dye into the uterine (avity and then into the tubes and ,rom there into the abdomen (an be seen6 and G-ray pi(tures taken. )hese provide a permanent re(ord. At least @ ,ilms need to be taken to provide a reliable re(ord - in(luding an early ,ilm ,or the uterine (avity6 and a delayed ,ilm to make sure the spill in the abdomen is ,ree. A normal / 2 de,ines the inside o, the reprodu(tive tra(t. )his appears as a triangle "usually !hite on a bla(k ba(kground$ !hi(h represents the uterine (avity6 and ,rom here the dye enters the tubes !hi(h appear as t!o long thin lines, one on either side o, the (avity. -hen the dye spills into the abdomen ,rom a patent " open$ tube, this appears as a smudge in the G-rays.

Fig #. %ormal / 2 ,indings " the dye appears bla(k and outlines a normal (avity and ,allopian tubes$ An abnormal / 2 may sho! a problem in the uterine (avity - and this appears as a gap or ,illing de,e(t. /o!ever, the (ommonest problems on / 2 appear in the tubes. 1, the tubes are blo(ked at the (ornual end "at the uterotubal jun(tion$, then no dye enters the tubes and they (annot be seen at all. 1, the blo(k is at the ,imbrial end then the tubes ,ill up6 but the dye does not spill out into the abdominal (avity and the end o, the tubes are o,ten s!ollen up. ometimes, like any other medi(al test, the / 2 may provide erroneous results. For e&ample, the (ornu o, the uterus may go into spasm, as a result o, !hi(h the dye may not enter the tubes at all. )his may be interpreted as a tubal blo(k, !hereas in reality the tubes are open. Also, i, a hydrosalpin& is very thin and i, the dye is inje(ted under pressure, the dye may appear to spill into the abdomen through a tear in the !all o, the hydrosalpin& - suggesting tubal paten(y !hen really the tubes are (losed. -hile the / 2 is usually very reliable ,or determining !hether or not the tubes are open, it provides little in,ormation on stru(tures outside the tube !hi(h (ould nevertheless impair tubal ,un(tion - su(h as peritubal adhesions. 1, the spill is 0lo(ulated0,"i.e. it (olle(ts in small puddles$, the presen(e o, adhesions (an be suspe(ted, but not (on,irmed. An / 2 (an be pain,ul - and !hen the dye is inje(ted into the uterine (avity, most !omen !ill e&perien(e a (onsiderable amount o, pain. Jou should be prepared ,or this - and taking a pain-killer prior to the pro(edure !ill help to redu(e the pain. An / 2 (an be te(hni(ally di,,i(ult ,or some !omen "espe(ially i, the (ervi& is too small or too tight$ - and it is better i, a gyne(ologist is present at the time o, the / 2 to assist the radiologist i, needed. Many gyne(ologists !ill do the / 2 themselves. )he major risk o, an / 2 is that o, spreading an unre(ogni5ed in,e(tion ,rom the (ervi& up into the tubes. )his is un(ommon, but in order to redu(e the risk, many do(tors advise antibioti( (overage during the pro(edure.

1, the / 2 sho!s that the tubes are (losed, then it may be advisable to repeat the / 26 and also to do a laparos(opy to (on,irm this diagnosis. 'aparos(opy. )his has already been des(ribed, and is the gold standard ,or making a diagnosis o, tubal disease. -hat are the limitations o, diagnosing tubal disease .

Limitations o H%& and laparoscopy

)he trouble !ith both / 2 and laparos(opy is that they only provide in,ormation as to !hether or not the tube is open or (losed. -hile a (losed tube !ill never !ork, they do not provide any in,ormation on ho! !ell an apparently open tube !orks. ;emember, that just be(ause a tube is patent does not ne(essarily mean that it !orksA

Fig @. 'aparos(opy sho!s a large hydrosalpin& on the right side Another limitation is that they !ill rarely provide any in,ormation as to !hy the tubes are blo(ked. :((asionally, ho!ever, this (an be suspe(ted by other signs ",or e&ample, by seeing the tuber(les diagnosti( o, )7 in the abdomen during laparos(opy$. -hat are the re(ent innovations ,or tubal ,a(tor diagnosis and treatment .

0ecent innovations in this ield include:

+luoroscopic guided procedures:

Using an image intensi,ier, and te(hni<ues borro!ed ,rom (oronary angioplasty, the radiologists (an no! insert spe(ial (atheters under ,luoros(opi( guidan(e into ea(h o, the tubes. )his is (alled sele(tive salpingography6 and allo!s mu(h better visuali5ation o, ea(h tube. 1t also allo!s the radiologist to treat (ornual blo(ks !hi(h are due to mu(us plugs by tubal (annulation.

%onosalpingography:
Under ultrasound guidan(e, !ith Doppler ,a(ilities i, available, the gyne(ologist (an inje(t ,luid into the tubes through the (ervi& and see the ,lo! o, the ,luid into the tubes and abdomen on the ultrasound s(reen. )his is a simple bedside test !hi(h a gyne(ologist (an do to judge i, the tubes are normal - and (an be reassuring i, positive.

Tuboscopy:
At the time o, laparos(opy, the do(tor (an insert a ,ine teles(ope into the ,allopian tube through its ,imbrial end, to inspe(t the inner lining o, the tube, to judge !hether or not it is healthy. Fallopos(opy is a re(ent advan(e, pioneered by Dr *erin o, U A. 1n this method, a very ,ine ,le&ible ,iberopti( tube is guided through the (ervi& and uterus into ea(h ,allopian tube, thus allo!ing the do(tor to a(tually visuali5e the inner lining o, the entire length o, the ,allopian tube - something !hi(h !as never possible so ,ar. )his (an provide use,ul in,ormation about the e&tent o, tubal damage, and the possibility ,or su((ess,ul repair.

Tubal %urgery : "rocedure) 0is's) 0eversal o %terili1ation The Tubal Connection !"age #$
From the book

How to Have a Baby: Overcoming In ertility

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD. Previous page: )he )ubal +onne(tion "Page 8$ %e&t page: :vulation -- %ormal and Abnormal )able o, +ontents -hat is the role o, surgery in opening a blo(ked tube . /o! is tubal mi(rosurgery per,ormed . -hat are the options ,or treating pro&imal tubal o((lusion . -hat are the risks o, tubal surgery . /o! (an a tubal ligation be reversed . -hat is the role o, surgery in opening a blo(ked tube .

%urgical Treatment
:n(e the do(tor has assessed the damage and pinpointed the lo(ation o, the blo(kages he !ill de(ide on treatment alternatives and ho! to pro(eed. )he ,irst (hoi(e in the past used to be an attempt at surgery to repair the tubal damage. /o!ever, be(ause results !ith tubal surgery !ere not very en(ouraging, many patients !ith tubal damage are no! advised to undergo 19F "in vitro ,ertili5ation$ as their ,irst treatment option. 1n order to sele(t bet!een 19F and tubal surgery, !e need to di,,erentiate bet!een intrinsi( tubal damage and peritubal damage. 1, the tubes have been damaged be(ause

o, a problem outside the ,allopian tubes, su(h as peritubal adhesions or endometriosis, !hi(h have (aused the tubes to get kinked, then surgery may be use,ul. /o!ever, surgery is not advisable ,or patients i, the tubes have been blo(ked be(ause o, )76 the tubes are very badly damaged6 i, the tubes are blo(ked at multiple pla(es6 or i, the tubes have been blo(ked be(ause o, intrinsi( tubal disease. )he likelihood o, surgi(al su((ess "in terms o, pregnan(y$, depends on the severity o, the tubal damage. 1, a previous in,e(tious pro(ess has (aused s(arring o, the ,allopian tube, the inner deli(ate lining may have be(ome irreversibly damaged. All operations (an result in re-establishing paten(y in some (ases - but the main aim o, the surgery is not to just open the tubes, but to a(hieve pregnan(y - and the tubes have to be(ome (apable o, (apturing the egg and transporting it to the uterus ,or this to happen. Un,ortunately, surgery (annot reverse tubal damage on(e this has o((urred. -hat i, only one tube is blo(ked. :ne normal tube is su,,i(ient to allo! a pregnan(y and most surgeons !ould not advise tubal surgery ,or these patients. :bviously, the (han(es o, pregnan(y ,or su(h patients is hal, that o, normal !omen and there,ore establishing a pregnan(y may take t!i(e as long. )he danger o, trying to surgi(ally repair a single blo(ked tube is that adhesions be(ause o, the surgery may (ause both the tubes to be(ome blo(ked A /o! is tubal mi(rosurgery per,ormed .

Tubal .icrosurgery
Mi(rosurgery entails the use o, the ,ollo!ing surgi(al te(hni<ues:

Using a mi(ros(ope ",or ade<uate magni,i(ation$ Avoiding unne(essary trauma to the tissues >mploying deli(ate surgi(al instruments >mploying ,ine suture "stit(hing$ material and ensuring pre(ise suturing /andling tissues !ith great (are and respe(t, to minimi5e tissue damage >nsuring that no bleeding is le,t unattended and no (lots are le,t behind "be(ause this (an lead to the ,ormation o, adhesions or s(ar tissue a,ter the surgery$

)he mi(rosurgery operation may take ,rom 8 to ? hours. Depending on the e&tent o, pelvi( damage and is usually done under spinal or general anesthesia. )he in(ision used is usually a 0bikini (ut0 "P,annensteil in(ision$ )he length o, stay in hospital is usually @ to H days. )ubal mi(rosurgery (an be e&pensive and may (ost up to ;s.?B,BBB. ometimes a 0(he(k or se(ond-look laparos(opy 0 is per,ormed about one !eek a,ter surgery to ensure that tubal paten(y is maintained and to remove any small adhesions that may have started to re-,orm. -hat are the options ,or treating pro&imal tubal o((lusion .

"ro2imal Tubal /amage

)he tubal obstru(tion (ould be at the uterotubal jun(tion and this is (alled a (ornual blo(k. )he (onventional surgi(al repair o, (ornual blo(ks involved reimplanting the

tube into the uterus - and had dismal su((ess rates. /o!ever, !ith mi(rosurgery, it is possible to see the very ,ine ends o, the tubes under high magni,i(ation and to join them together. )his has a pregnan(y rate o, about EBF, sin(e the ,un(tion o, the rest o, the tube is basi(ally inta(t. ;e(ently, do(tors have reali5ed that a number o, patients have (ornual blo(ks be(ause o, the presen(e o, mu(us plugs and debris in the very ,ine (ornual segment o, the tubes. %e!er nonsurgi(al methods have no! been devised to treat this. )hese involve the passage o, a ,ine guide !ire or a ,ine balloon into the (ornual end o, the tube through the uterus. )his is (alled a 0balloon tuboplasty0 or 0(ornual re(analisation,0 and (an be done under ultrasound guidan(e6 hysteros(opi( guidan(e6 or ,luoros(opi( "G-ray$ guidan(e. )his is a signi,i(ant advan(e, sin(e it saves patients the need ,or major surgery6 and also has e&(ellent pregnan(y rates.

%alpingolysis
)his pro(edure entails division o, adhesions surrounding the tubes. -hen no other damage is apparent, su((ess rates may be as high as IEF.

Tubal 0eanastomosis
)hese in(lude a variety o, pro(edures !hi(h involve removing the damaged portion o, the tubes and rejoining the healthy ends o, the tube together . u((ess rates vary a((ording to the area o, damage but are usually !ithin the range o, #B - EBF.)he (han(es o, su((ess are higher !hen the de,e(t o((urs in the middle se(tion o, the tube.

/istal Tubal /amage

1, the tubes have been severely damaged and have ,ormed a hydrosalpin& "in !hi(h the ,imbriae sti(k to one another and the tube is (losed o,,$ the surgery re<uired is (alled neosalpingostomy, in !hi(h the surgeon opens the hydrosalpin& and (reates a ne! opening ,or the repaired tube. -hile this is te(hni(ally easy, su((ess rates are very poor "about #BF$ be(ause the physiologi( ,un(tioning o, the ,imbriae rarely returns to normal. 1, the damage is less severe ",imbrial agglutination, in !hi(h the ,imbriae are stu(k to one another6 or phimosis, in !hi(h the tube is narro!ed, but open$, then surgi(al repair is more su((ess,ul, !ith pregnan(y rates being about EBF. -hat are the risks o, tubal surgery . )he risk o, having an e(topi( "tubal$ pregnan(y is in(reased ,ollo!ing tubal surgery. Fallopian tubes !hi(h have been operated on may have a damaged inner lining, and this (an impair the movement o, the embryo do!n the tube. )his is !hy, in patients !ho have had tubal surgery, the diagnosis o, a pregnan(y should be made as soon as possible "pre,erably !ithin a ,e! days o, missing a menstrual period$, to rule out the possibility o, an e(topi( pregnan(y. )he best (han(e o, su((ess is !ith the ,irst surgi(al operation6 there,ore, you need to go to a spe(iali5ed (entre. )he (han(es o, su((ess !ill depend upon the e&tent o, tubal

damage and also on the skill o, the surgeon. )he best (han(e o, a(hieving a pregnan(y is in the surgeon. )he best (han(e o, a(hieving a pregnan(y is in the ,irst ,e! months a,ter surgery, and most !omen !ho are going to get pregnant a,ter tubal surgery !ill (on(eive !ithin this time. ome do(tors believe that using ovulation indu(tion and = or intrauterine insemination a,ter tubal surgery helps to ma&imi5e the (han(es o, a pregnan(y. 1, the patient has not (on(eived !ithin one year a,ter the surgery, then ,ollo!-up testing in the ,orm o, an / 2 and = or laparos(opy is advisable, to determine !hether the ,allopian tubes are still open. 1, the ,irst surgery has been unsu((ess,ul, the (han(e o, su((ess as a result o, reoperation is very lo!, and 19F is the only treatment (hoi(e ,or su(h patients. 1n the ,uture, it is possible that tubal transplants may be(ome a reality and that s(ientists may also develop arti,i(ial syntheti( tubes to repla(e damaged ones. -ith operative laparos(opy, it is no! possible to open damaged tubes through the laparos(ope, thus saving the patient major surgery. A hydrosalpin& (an be repaired by opening it !ith a laser or (autery and then keeping it open !ith sutures: and even the (ompli(ated operation o, tubal reanastomosis has been per,ormed by e&perien(ed surgeons through the laparos(ope "using sutures or spe(ial adhesive glue$. /o!ever, the results !ith this surgery are o,ten poor, be(ause these damaged tubes o,ten do not ,un(tion properly even a,ter the surgery.

Fig ?. (hemati( sho!ing damaged ,allopian tubes be(ause o, pelvi( in,lammatory disease " P1D$. )he le,t tube has ,ormed a hydrosalpin&6 and the right is engul,ed in peritubal adhesions.

Fig E. :perative laparos(opy, during !hi(h an adhesion is being divided "adhesiolysis$ /o! (an a tubal ligation be reversed .

0eversal o %terili1ation
1n !omen, sterili5ation ,or ,amily planning is usually done through an operation (alled tubal ligation, !hi(h is usually (arried out through the laparos(ope. )he aim o, the operation is to blo(k the tubes and prevent the sperm and egg ,rom meeting ea(h other.

3hy /o 3omen 4s' or 0eversal5

)he vast majority o, people are very happy !ith sterili5ation. %evertheless, there are a ,e! !omen !ho are very distressed a,ter!ards and !ould do almost anything to get things undone. )he (ommonest reason !hy su(h !omen regret sterili5ation is be(ause their (hild dies or be(ause they have remarried and !ish to bear their ne! husband4s (hild.

3hat Can Be /one5

1, there is a reasonable amount o, tube remaining, even i, only on one side, then it may be possible to per,orm tubal mi(rosurgery to rejoin the tubes. :n the !hole, the more tube !hi(h has been le,t undamaged, the better the (han(es o, su((ess. )hus, patients !ho have had a tubal ligation done through the laparos(ope, using Falope rings "silasti( bands$ or (lips, have an e&(ellent (han(e o, a(hieving a pregnan(y a,ter mi(rosurgi(al reversal o, the ligation, be(ause these methods (ause minimal tubal damage. A,ter revie!ing the operative notes, a laparos(opy may be advised, so that the e&a(t state o, the ,allopian tubes (an be assessed. 1, the patient has enough normal tube, tubal mi(rosurgery may be attempted and pregnan(y rates (an be as high as HEF in ,avorable (ases. ome skilled surgeons (an even per,orm this type o, tubal reanastomosis through the laparos(ope "using sutures or spe(ial adhesive glue$. 1,, un,ortunately, the patient has had both tubes (ompletely removed or i, the tubes are very badly damaged, then the only (han(e o, su((ess !ill be !ith 19F.

Most patients !ho !ill (on(eive a,ter tubal reanastomosis !ill do so !ithin 8 year. 1, they do not, then the ne&t step ,or them !ould be 19F.

Ovulation -- 6ormal and 4bnormal

From the book

How to Have a Baby: Overcoming In ertility

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD. Previous page: )he )ubal +onne(tion "Page #$ %e&t page: :vulation -- %ormal and Abnormal "Page #$ )able o, +ontents /o! does ovulation o((ur normally . /o! (an 1 ,ind out i, 1 am ovulating . 1s 77) (harting o, any use . -hat about using ,ertility so,t!are programs . :, !hat use is an endometrial biopsy . :, !hat use is a D3+ " (urettage$ . /o! does testing ,or progesterone help . /o! (an 1 ,ind out !hen 1 am ovulating and use this in,ormation to tra(k my ,ertile time . /o! (an 1 use (ervi(al mu(us monitoring to monitor my ovulation . /o! does ovulation o((ur normally .

6ormal ovulation
%ormally, one o, the ovaries releases a single mature egg every month, and this is (alled ovulation. -omen may noti(e pain or abdominal dis(om,ort at the time o, ovulation and o((asionally have some slight vaginal bleeding. )he presen(e o, regular periods, premenstrual tension and dysmenorrhoea "period pains$ usually indi(ate that the menstrual (y(les are ovulatory. >ggs are stored in the ovaries in ,olli(les. Folli(les e&ist in t!o major (ategories gro!ing and non-gro!ing " primordial $. >ggs in the primordial ,olli(le are in a very immature ,orm. 1n this state they are not (apable o, being ,ertili5ed by a sperm until they undergo a maturing pro(ess !hi(h (ulminates in their release ,rom the ovary at the time o, ovulation. >gg maturation and ovulation is stimulated by t!o hormones se(reted by the pituitary - ,olli(le stimulating hormone "F /$ and luteini5ing hormone "'/$ . )hese t!o hormones must be produ(ed in appropriate amounts throughout the monthly (y(le ,or normal ovulation to o((ur. >very month, at the start o, the menstrual (y(le, in response to the F / produ(ed by the pituitary gland, about @B-?B primordial ,olli(les start to gro!. :, these, only one

matures to ,orm a large ,luid-,illed stru(ture, (alled a 2raa,ian ,olli(le !hi(h (ontains a mature egg, !hile the others die " a pro(ess (alled atresia$. )he mature egg is released ,rom the ,olli(le !hen the ,olli(le ruptures in response to a surge o, '/ produ(ed by the pituitary. A,ter ovulation has o((urred, the ,olli(le ,rom !hi(h the egg has been released ,orms a (ysti( stru(ture (alled the (orpus luteum. )his is responsible ,or progesterone produ(tion in the se(ond hal, o, the (y(le. Jou (an see an e&(ellent animation " !hi(h !ill open in a ne! bro!ser !indo!$ o, the hormonal (hanges !hi(h o((ur during a normal menstrual (y(le at erono Fertility 'i,e(y(le. Most !omen !ho have regular periods have ovulatory (y(les. -omen !ho ,ail to ovulate or !ho have abnormal ovulation usually have a disturban(e o, their menstrual pattern. )his may take the ,orm o, (omplete la(k o, periods "amenorrhoea$, irregular or delayed periods "oligomenorrhoea$ or o((asionally a shortened (y(le due to a de,e(t in the se(ond part "luteal phase$ o, the (y(le.

Fig 8. (hemati( o, the ovarian ,olli(le during its development "(lo(k!ise$

Fig #. )he hormonal (hanges !hi(h o((ur during a normal ovulatory (y(le, i, pregnan(y o((urs. )he purple line marks the point !hen the embryo implants.

/o! (an 1 ,ind out i, 1 am ovulating .

/etecting ovulation - when do you ovulate5

.enstrual period timing ! Calendar method$

)o determine the length o, the menstrual (y(le, one only needs to note the date o, the beginning o, the menstrual period ",irst day o, ,lo!$ ,or t!o (onse(utive periods, and then (ount the day ,rom one date to the ne&t. *eeping tra(k o, the length o, menstrual (y(les !ill help determine the appro&imate time o, ovulation, be(ause the ne&t period begins appro&imately t!o !eeks ,rom the date o, ovulation. )he rough rule to (al(ulate the appro&imate date o, ovulation is : %MP minus 8? days, !here %MP is the " e&pe(ted$ date o, the ne&t menstrual period. )his is be(ause the luteal phase ,or most !omen is 8? days long. *eeping tra(k o, the menstrual (y(le by (harting it (an indi(ate other ovulatory disturban(es . For e&ample, i, a menstrual (y(le that is normally #K days starts to o((ur every @E or ?B days, this may mean that ovulation is disturbed, and an evaluation is needed. 1s 77) (harting o, any use .

Basal Body Temperature !BBT$ chart

During the luteal phase o, the (y(le, the (orpus luteum produ(es the hormone progestrone, !hi(h elevates the basal body temperature. -hen the basal body temperature has gone up ,or several days, one (an assume that ovulation has o((urred. /o!ever, it is important to remember that the 77) (hart (annot predi(t ovulation - it (annot tell you !hen it is going to o((ur A )he basal temperature (hart (an be a use,ul tool. 1t allo!s the patient to determine ,or hersel, i, she is ovulating as !ell as the appro&imate date o, ovulation, but only in retrospe(t. 7asal body temperature (harts are easy to obtain and the only e<uipment re<uired is a spe(ial 77) thermometer. 2eneral instru(tions ,or keeping a basal body temperature (hart in(lude the ,ollo!ing : 8. )he (hart starts on the ,irst day o, menstrual ,lo!. >nter the date here. #. >a(h morning immediately a,ter a!akening, and be,ore getting out o, bed or doing anything else, the thermometer is pla(ed under the tongue ,or at least t!o minutes. )his must be done every morning, e&(ept during the period. @. A((urately re(ord the temperature reading on the graph by pla(ing a dot in the proper lo(ation. 1ndi(ate days o, inter(ourse !ith a (ross. ?. %ote any obvious reason ,or temperature variation su(h as (olds, or ,ever on the graph above the reading ,or that day.

)he major limitation o, the 77) is that it does not tell you in advan(e !hen you are going to ovulate - there,ore its utility in timing se& during the ,ertile period is small. 1nterpreting the 77) (hart (an be tri(ky ,or many patients - rarely do the (harts look like those you see in te&tbooksA Also, keeping a 77) (hart (an be very stress,ul - taking your temperature as the ,irst thing you do !hen you get up in the morning is not mu(h ,un. -hat is !orse is that you start to let the 77) (hart di(tate your se& li,e. )his is !hy though the 77) (hart used to be a use,ul method in the past, it4s utility is limited today - and ne!er methods are available !hi(h are more a((urate are available. -e advise our patients never to (hart their 77)s - !e ,eel they are just a !aste o, time. Manu,a(turers have no! in(orporated a mi(ropro(essor along !ith the digital thermometer, to (reate an ele(troni( ,ertility management devi(e , (alled )he 7iosel, Fertility 1ndi(ator. )his makes (al(ulation o, the 0,ertile days0 mu(h easier, be(ause it (ombines and optimises both the basal body temperature and (alendar method o, ovulation predi(tion. -hat about using ,ertility so,t!are programs .

+ertility %o tware "rograms

%e!er so,t!are programs " easily available on the internet$, su(h as +y(le-at(h, help you learn about your body4s ,ertility signs by giving you the tools to do(ument and analy5e your observations. For !omen !ho are (om,ortable !ith (omputers, this is a use,ul tool to organi5e your (y(le data and analy5e your (y(les to determine ,ertile times. Jou (an also use our ,ree online ,ertility (al(ulator to determine !hen you ovulate A :, !hat use is an endometrial biopsy .

*ndometrial biopsy
A,ter ovulation, the endometrium is prepared ,or implantation o, the ,ertili5ed egg by the progesterone se(reted by the (orpus luteum. 1n order to determine i, ovulation is o((urring normally, an endometrial biopsy used to be done in the past . During this pro(edure, a small amount o, endometrium ,rom inside the uterine (avity is e&tra(ted surgi(ally and sent ,or pathologi( e&amination under a mi(ros(ope. )his is a standard pro(edure usually done just be,ore the period begins. 1t (an be done in the do(tor4s o,,i(e or in an operating theater. %o anesthesia or hospitalisation is needed. /o!ever, it does (ause dis(om,ort during the pro(edure "about as mu(h as a severe menstrual (ramp$ and an analgesi( (an be taken a hal,-hour prior to the pro(edure to de(rease this dis(om,ort. -hen e&amining the endometrial biopsy, the pathologist looks ,or the in,luen(e o, the estrogen and progesterone hormones on the endometrial glands. 1, progesterone has been produ(ed in that (y(le, the endometrial glands sho! se(retory (hanges . 1n ,a(t, the e,,e(t o, progesterone on the endometrium is so predi(table, that the biopsy (an be 0dated0 - that is, the pathologist (an predi(t on !hi(h day the ne&t period !ill startA 1,

there is a 0lag0 bet!een the predi(ted day and the a(tual day, then this suggest a luteal phase de,e(t, !hi(h means that the produ(tion o, progesterone is de,i(ient. 1, no progesterone at all has been produ(ed, then the endometrium !ill be reported as being proli,erative "under the in,luen(e o, only estrogen$ - !hi(h suggests that the (y(les are anovulatory "i.e., ovulation did not o((ur in that (y(le$. 7e(ause an endometrial biopsy is pain,ul and provides limited in,ormation, ,e! do(tors use it anymore. :, !hat use is a D3+ " (urettage$ .

Curettage
A (uretting used to the (ommonest pro(edure done ,or in,ertile patients. 1n ,a(t, a number o, in,ertile patients !ill re<uest that a (uretting be done ,or them, sin(e they ,eel that the (uretting !ill 0(lean out0 the dirt they have in their uterus and allo! them to (on(eive. )his is an old !ive4s tale and is based on 0 1 kno! someone !ho got a baby a,ter a (uretting0. )he (orre(t te(hni(al term ,or (uretting is D and + - dilatation and (urettage - !hi(h means the (ervi& is stret(hed "dilated$ and the uterine (avity s(raped "(uretted$ to (olle(t the endometrium$ . )his is an obsolete pro(edure ,or an in,ertile !oman, and (an a(tually be harm,ul. )he only use o, a D3+ is to provide endometrial tissue !hi(h (an be e&amined under the mi(ros(ope to see i, the !oman is ovulating or not. 1t has absolutely no ,ertility-enhan(ing role !hatsoever. in(e this endometrium (an be obtained mu(h more easily, sa,ely and (heaply !ith an endometrial biopsy "in !hi(h only a strip o, endometrium is removed$ there should rarely be any need to do a D3+ ,or an in,ertile !oman. Patients have o,ten have repeated D3+s - and these (an a(tually damage the (ervi& and even blo(k the tubes, i, in,e(tion o((urs a,ter surgery. )he only possible role ,or a D3+ today is !hen tuber(ulosis o, the uterus is suspe(ted. /o! does testing ,or progesterone help .

Blood test or progesterone

)he progesterone level in the blood may be measured to (on,irm that ovulation has taken pla(e. )his test is done on Day #8 o, the (y(le "about 8 !eek a,ter the e&pe(ted date o, ovulation$ . A normal level is bet!een 8B ng=ml - #B ng=ml and indi(ates that the (orpus luteum is produ(ing enough progesterone, and is good retrospe(tive eviden(e that ovulation o((urred. A very lo! level means that the (y(le !as most probably anovulatory. An intermediate level may suggest a luteal phase de,e(t "in !hi(h the (orpus luteum does not se(rete enough progesterone$. /o! (an 1 ,ind out !hen 1 am ovulating and use this in,ormation to tra(k my ,ertile time . -hile the above tests !ill tell a !omen !hether or not she ovulates, the ,ollo!ing symptoms and tests !hi(h (an be used in order to determine !hen you ovulate are o,

greater importan(e, sin(e they provide in,ormation !hi(h (an be used to identi,y the 0,ertile period0 prospe(tively. /o! (an 1 use (ervi(al mu(us monitoring to monitor my ovulation .

Cervical mucus !Billing7s method$

7y (he(king your (ervi(al mu(us daily, as des(ribed in the (hapter on the (ervi(al ,a(tor, you (an determine !hen you ovulate. Cust be,ore ovulation, your (ervi(al mu(us is thin, pro,use, (lear and stret(hy, like ra! egg !hites. A,ter ovulation, the mu(us be(omes thi(k, ta(ky, s(anty and sti(ky. Jou (an learn to appre(iate this (hange in your mu(us "by seeing and ,eeling it$ and this allo!s you to predi(t !hen ovulation o((urs <uite a((urately. Jou (an learn the te(hni<ue ,or tra(king your (ervi(al mu(us in the +hapter on )he +ervi(al Fa(tor.

4bdominal pain
Appro&imately #E per(ent o, !omen may e&perien(e a pain on one side o, the abdomen that is asso(iated !ith ovulation. )his is (alled mittels(hmer5 "a 2erman !ord, !hi(h means mid(y(le pain$ and is usually related to the release o, an egg ,rom the rupturing ,olli(le. 1t is a good idea to mark the date !hen it o((urs sin(e this in,ormation is help,ul in determining !hen ovulation o((urs.