| Transvaginal hydrolaparoscopy(THL) was first described by Gordts et alin1998as a modification of culdoscopy to evaluate the fallopian tubes andovaries of infertile women without obvious pelvic pathology. The techniqueused saline solution as distension and added the benefits of hydroflotation tothe closer, clearer, and more detailed view of the allopian tubes and ovariesachieved by culdoscopy. Combined with hysterocsopy and chromotubation, itcould assessed the tubal patency.The ability of THL to diagnose pelvic pathology in infertile women hasbeen compared with laparoscopy, the gold standard diagnostic tool. THL has ahigh concordance rate with laparoscopy when a complete evaluation isaccomplished during THL. The appeal of THL was that it is less invasive andcan be preformed in an outpatient setting without the use of general anesthesia.THL also has been shown to have a high concordance withHysterosalpingography(HSG) for tubal patency, but THL diagnosed moreintrauterine abnormalities as well as finding adhesions and endometriosis notvisible with HSG. Thus, THL could be considered as a first-line test for theexploration of the infertile woman in place of HSG.Part1Study of transvaginal hydrolaparoscopy with hysteroscopy andchromopertubation as a first-line test in infertility womenObjectives:1To study the safety of the transvaginal hydrolaparoscopic (THL) withhysteroscopy and chromopertubation for the infertile woman as a first-lineexamination method, to understand the main explored range and the unusualsituation and the incidence of major complications.2To assess and explore the ovum retrieval ability of the fallopian tubalfimbria with the THL by the new designed score system. According to the scores, we guide the infertile women to choose the different pregnancy wayafter surgery. To analysis the pregnancy rate by spontaneously coitus,intrauterine insemination (IUI) and invitro fertilization and embryo transfer(IVF-ET) after the surgery, to explore the clinical value of THL withhysteroscopy and chromopertubation in treatment of the infertile women.Methods:1Subjects of THL with hysteroscopy and chromopertubationThere was a total of130infertile women to be operated by THL withhysteroscopy and chromopertubation at the Bethune International PeaceHospital from2010September to2013June. The mean (±SD) age was30.92±3.54years (range22~47) and body mass index (BMI) was23.04±2.67(range15.94~33.59). Primary infertility was diagnosed in76women(58.46%) and54secondary infertility. Duration of infertility was3.39±2.67years (range1~18).2Equipments of THL with hysteroscopy and chromopertubationThe THL and hysteroscopy equipments made by Karl Storz (Tuttlingen,Germany,26120BA,26129BA).3Procedure of THL with hysteroscopy and chromopertubationThe THL with hysteroscopy and chromopertubation could be performedwithin3-7days after cessation of menstruation. The operation was done underthe intravenous anesthetic of propofol in the dorsal lithotomic position. Adiagnostic hysteroscopy was carried out with a2.9mm hysteroscopy (KarlStorz, Tuttlingen, Germany). Normal saline solution was used to distend theuterine cavity at a filling pressure of120mmH2O. After completion of thehysteroscopy, a size10Foley catheter was introduced into the uterine cavityand the inflated balloon with3ml normal saline solution, then the methyleneblue dye was drop.Next, THL was performed. The posterior lip of the cervix was elevatedwith a tenaculum, and a4-mm stab incision was made1.5cm posterior to thecervix. The system made by Karl Storz Endoscopy includes a spring-loadedneedle, dilator, and sheath. The needle was placed through the dilator, which was placed through the sheath. The needle was used to enter the pouch ofDouglas through the vaginal wall fast and easily. It wasn’t withdrawn until theouter sheath was intraperitoneal when the dilator was advanced. The dilatorwas removed, a rigid endoscopy less than3mm in diameter with a30-dregreeoptical angle was placed through the sheath. Once the endoscopy wassuccessfully introduced into the pouch of Douglas,200to300mL of warmedsaline solution was drop to float the bowel out of the pelvis.Firstly, we evaluated the posterior aspect of the uterus, and the scope wasmoved laterally to identify the tubo-ovarian structures. The ovarian surfacewas inspected from the ovarian fossa to around ovaries for determiningwhether ovulation and endometriotic leision were existed. The fimbrial part ofthe fallopian tubes was inspected carefully. The methylene dye could beinjected transcervically to assess tubal patency. The pelvic sidewalls and theanterior of rectum were inspected similarly, the pelvic adhesions andendometriosis could be seen easily with the transvaginal optic scope, and laxadhesions could be removed. The vaginal incision was left to closespontaneously.4Methods of the scores for tubal fimbrial ovum retrievalAccording to the tubal fimbrial mucosa morphology and relationship withovarian, the scores were graded from5aspects respectively.①the fallopiantubal mucosa morphology: Tubal fimbrial interdigitating had a clear imageand normal color which was2points, the atrophic mucosa and interdigitatingadhesion into mass or vanished were0point, it was1point between in twoconditions;②the flexibility of tubal fimbria: fimbrial ciliums swung pliableand flexible under natural states and interdigitating could separated and foldedlikely umbrella shape, it was2points. Ciliums was thickened andinterdigitating couldn’t swing or be separated, and had not actions as “retrievaloocyte” for0point, it was1point between in two conditions;③the openingof tubal fimbria: the methylene blue flew from the fallopian tube. It could beobserved clearly under the THL through the adjusted direction of lens. If itwas unobstructed, the around interdigitating was not adhesive and could spread, the methylene blue could be seen flowing from the opening position. Ifits diameter was small, the around interdigitating was adhesive and couldn’tspread totally, the methylene blue flew from the side. These conditions were1and0piont respectively.④the relationship or distance between tubal fimbriaand ovary: It was1point that tubal fimbria could be touched the homolateralovary through swinging in the natural state, and which was0point that itcouldn’t be touched because the fallopian tube was fixed and anfractuous orfar, even a "back to back" relationship with ovary.⑤the surroundings of tubalfimbria and ovary: There were natural channel and without adhesion betweenthe tubal fimbria and ovary, or slight adhesion scope less than1/2, it was1point. When the fibrous adhesion or film adhesion scope was1/2, and therewas adhesive barrier between tubal fimbria and ovary, it was0point. Totalscore was from0to7. When the score was more than4, it was deemed thatthe retrieval oocyte ability was good. When it was less than3, it was poor.5Statistical analysisStatistical analysis of the data was performed by Student’s t-test andchi-square test using SSPS17.0, and when p was less than0.05, it wasconsidered to be statistically significant.Results:1Safety and findings in the operation of THL with hysteroscopy andchromopertubation1.1Success rate and complications of THL with hysteroscopy andchromopertubationIn130patients,127patients were probed successfully, the success ratewas97.7%(127/130).Among the127patients, There were2cases of rectalperforation and1case of uterine injury. The average total operation time was35.6±10.03min (range18min～60min), the hysteroscopic time was12.7±6.7min (5min~30min). The hysteroscopy took shorter time but hysteroscopicsurgical operations such as polyp’s electricity cutting, the intrauterine adhesionseparation and the uterine septum resection took longer time. 1.2Findings by the hysteroscopyA total of130infertile women were operated by the hysteroscopy.Fifty-eight patients were detected uterine disease findings the detection rate44.6%. There were22diagnosed from the uterine polypus,8the intrauterineadhesion,1the cervical adhesions,2the submucous myoma,2the septateuterus and1the unicornous uterus, but they weren’t detected before operation.There was one case suffering from the endometrial atypical hyperplasia.Endometrial inflammation changes and Congestion points could be foundunder the hysteroscope.1.3Findings in the operation of THLIn127women, there were62(48.82%) cases having a normal pelvic,51cases having pelvic adhesions,11cases having endometriosis co-existing withadhesion. The Mild and moderate-serious pelvic adhesions were33and18cases respectively. In25cases, the superficial endometriotic lesions weredetected on the ovarian surface (10) and the peritoneum of the lateral pelvicwall (15). Most the endometriotic lesions were very small. All of them wereclassified as stage I or II endometriosis according to the revised AFSclassification (American Fertility Society,1985).1.4The scores of the tubal fimbria in the THLThe rate of completely evaluated tubo-ovarian structures was122(96.1%).In122(96.1%) patients, bilateral tubal patency, unilateral tubalpatency and bilateral tubal obstruction and invisibility were95,22,8and2cases respectively. There were2cases whose bilateral tubo-ovarian structurescouldn’t be visualized, and3whose unilateral tubo-ovarian structures couldn’tbe visualized due to the extensive adhesions.There were81women scored more than4and36cases less than3. Thewomen with at least one side tube patency had good capability scores for tubalfimbrial retrieval oocyte, and they were advised to be pregnant by spontaneouscoitus or intrauterine insemination (IUI), the others by vitro fertilization andembryo transfer (IVF-ET).Conclusions:1THL with hysteroscopy and chromopertubation is a feasible and safe method and may be considered as a first-line test for the infertile woman.2Pelvic genital organs can be invisible clearly in saline medium, whichincludes of the posterior aspect of the uterus, the pelvic sidewalls, the ovaries,fallopian tubal fimbria and so on. The pelvic adhesion and tiny lesions such asovary and pelvic endometriosis could be found under THL.3In the outpatient, pelvic and uterine can be probed completely at onceby THL combined with hysteroscopy. Some abnormal uterine cavity can befound, especially some microlesions such as endometrial polyps, mildintrauterine adhesions, the submucous myoma, the septate uterus, theunicornous uterus and so on, which can’t be found by ultrasonic inspection.4The infertile woman could choice a suitable treatment after THL underthe guide of the new scoring system and avoids unnecessary waiting, surgeryand excessary ART.Part2Effectiveness of the Hysterosalpingography and laparoscopy,transvaginal hydrolaparoscopy on the tubal patencyObjective:To compare and analysis the influence to the tubal patency between theHysterosalpingography(HSG) and laparoscopy(Lap), transvaginalhydrolaparoscopy with chromopertubation (THL), To understand thecoincidence rate of two methods and assess the sensitivity and specificity ofthe tubal patency.Methods:1SubjectsThere were43and76infertile women to be operated respectively byTHL and Lap who had HSG prior to the process at the Bethune InternationalPeace Hospital from2010September to2013June.The mean (±SD) age in Lap group was28.71±4.24years (range20~40),and duration of infertility was3.4±2.5years (range1~11). Primary infertilitywas diagnosed in38women (50%) and38secondary infertility.The mean (±SD) age in THL group was30.87±4.24years (range22~41)and duration of infertility was3.45±2.07years (range1~11). Primary infertility was diagnosed in23women (53.5%) and20secondary infertility.2Equipments of THL and LapThe THL and hysteroscopy equipments made by Karl Storz (Tuttlingen,Germany,26120BA,26129BA) and Lap equipments made by Olympus.3Procedures of HSG, Lap and THLThe HSG could be performed within3-7days after cessation ofmenstruation. The procedure was done in the dorsal lithotomic position. A size12uterus radiography catheter for drainage was introduced into the uterinecavity and the inflated balloon with1～2ml76%meglumine diatrizoatesolution, then the meglumine diatrizoate solution was drop. Then the wholeprocess of throughout the uterine and fallopian tubes into the pelvis diffusionwas observed in the X-ray, the orthostatic radiography was done after40minutes again to assess the pelvic dispersion.The Lap was done under the tracheal intubation anesthesia in the dorsallithotomic position. A diagnostic hysteroscopy was carried out with a2.9mmhysteroscopy (Karl Storz, Tuttlingen, Germany), a size10Foley catheter wasintroduced into the uterine cavity, and then the Lap was performed. The scopewas moved in pelvic cavity to identify the tubes and ovarian structures, and toexplore whether adhesions and endometriosis around the pelvic genital organs.The methylene dye could be injected transcervically to assess tubal patency.The pelvic adhesions were given adhesiolysis, and endometriosis could bedone cystectomy and ablation corresponding.THL procedure was same as part1.Results:1Fallopian tube patency between HSG and Lap, THL.In Lap group, the coincidence rate was80.79%(122/151), the sensitivity,specificity, positive and negative predictive values of HSG was83.52%(76/91),76.67%(46/60),84.44%(76/90)，75.41%(46/61) respectively. There was astatistically significant in the diagnosis of the tubal patency between HSG andLap in the same patients(X2=69.21，P﹤0.05)In THL group, the coincidence rate was82.6%(71/86), the sensitivity, specificity, positive and negative predictive values of HSG was86.3%,61.5%,92.6%,44.4%respectively. There was a statistically significant in thediagnosis of the tubal patency between HSG and THL in the samepatients(X2=107.40，P﹤0.05).2Abnormal findings in Lap and THLIn the Lap group, the abnormality rate in pelvic cavity was71.05%(54/76). Including pelvic adhesion in23cases and15cases of endometriosis;in the THL group, the abnormality rate in pelvic cavity was72.1%(31/43),including pelvic adhesions in23cases and10cases of endometriosis.Conclusions:1There were higher sensitivity and lower specificity in evaluationfallopian tube patency by HSG compared with Lap and THL. That showedHSG was not the perfect method to evaluate the fallopian tube patency.2THL provided more accurate tubal patency surroundings, also couldgive additional information about the pelvic cavity as Lap that could not beobtained through HSG, and may be considered as a first-line test for theexploration of fallopian tube patency.Part3Body stress response to the THL with hysteroscopy andchromopertubation and HSG.Objectives:1To compare body stress response, trauma and influence to the bodyafter the operation of the THL with hysteroscopy and chromopertubation andHSG.2To evaluate the pain by the visual analogue scale (VAS) at2hours afterthe performed operation between the THL with hysteroscopy andchromopertubation and the HSG, to explore the tolerability of two kinds ofoperation on infertile women.Methods:1SubjectsThirty women were chosen to be performed THL with hysteroscopy andhydrotubation as the study group, and30women to be performed HSG as the control group correspondly at the same period. The mean (±SD) age in studygroup was30.37±0.68and28.53±0.84in control group, Duration of infertility2.98±0.31vs2.88±0.28, body mass index (BMI)23.20±0.76vs,22.55±0.57.Primary infertility was18women and12secondary infertility in study group,while21and9in control group.2Method and indicator of the body stress response to THL withhysteroscopy and hydrotubation and HSGBoth groups’ average artery pressure (MAP), heart rate (HR), plasmaadrenocor ticotropic hormone (ACTH), noradrenaline (NA), angiotensin (AII),cortisol (Cor), insulin(INS), C reactive protein(CRP) and glucose (GLU) weremeasured respectively. The blood sample was obtained by a consecutive seriesof30patients of each group. We collected elbow vein blood3ml at three timesand rapidly put into the precooling vitro containing20ul EDTA, aftercentrifugal separated for5minutes at4°C, then the plasma was preserved in-20°C refrigerator to be measured. GLU was measured by glucose oxidasemethod and the other markers were used radioimmunoassay. Equipment wasmade by Siemens IMMULITE2000and reagent kit was provided by SiemensCompany.3Method of VAS after the THL with hysteroscopy and hydrotubation andHSGTo evaluate the Tolerance of THL and HSG,60consecutive patients wereasked to score their most intense pain experience during THL and HSG on a10cm visual analog pain scale2hours after the operation. The VAS scoreswere from0(no pain, perfectly acceptable) to10(unbearable pain, completelyunacceptable).Results:1Comparison of the body stress response to THL with hysteroscopy andhydrotubation and HSGIn a consecutive series of30patients, plasma Cor in THL and HSG athalf hour before and after the surgery were187.78±19.74ng/ml and183.00±25.77ng/ml versus197.20±22.28ng/ml and201.05±22.41ng/ml respectively, which significantly increased after the both operations(p＜0.05),the others were no statistically significant (p＞0.05).2The VAS scoresThe VAS scores had statistically significant between two groups but wereboth lower (p＜0.05). The average pain score was1.73(SD±1.01) in THL andno women marked a score above5and2.47(SD±1.33) in HSG. Theappropriate anesthesia would reduce the pain and increase the tolerationduring the operation.Conclusions:1Our study has demonstrated that there was microtrauma to body byTHL with hysteroscopy and chromopertubation as same as HSG, it couldrecovered in24hours.2The two groups VAS score were below the mild pain, and it wasaccepted better and tolerated both procedure. |
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