Page 6 - World Journal of Laparoscopic Surgery

Bamgbopa Tajudeen Kehinde

In a randomized prospective trial comparing 2 procedures cases, but outcome is far worse than in patients with mild,
for metroplasty: Resectoscopy with monopolar knife versus endometrial-type adhesions. 20
small-diameter hysteroscopy fitted with a versapoint device, The review by Kodaman and Arici concluded that diagnosis
one hundred-sixty patients with septate uterus and a history of and treatment of intrauterine adhesions are integral to the
recurrent abortion or primary infertility undergoing optimization of fertility outcomes and that favorable result in
hysteroscopic metroplasty from 2001 to 2005. Hysteroscopic terms of pregnancy and live birth rates can be expected after
resection of the uterine septum performed with either a 26F hysteroscopic adhesiolysis. Postoperative mechanical
resectoscope with unipolar knife (80 women, group A) or a distention of the endometrial cavity and hormonal treatment to
5 mm diameter hysteroscope with Versapoint device (80 women, facilitate endometrial regrowth appear to decrease the high-rate
group B). All patients were managed expectantly, with follow- of adhesion reformation. Newer antiadhesive barriers may also
up lasting 1 year. Operative parameters (operative time, fluid prevent the recurrence of intrauterine adhesions. Endometrial
absorption, complications, need for second intervention) and development can remain stunted due to a scant amount of
reproductive outcome parameters (pregnancy, abortion, term residual functioning endometrium and fibrosis. Potential
and preterm delivery, modality of delivery, cervical cerclage) pregnancy complications, especially placenta accreta, after the
were measured. Operative time and fluid absorption were treatment of intrauterine adhesions should be anticipated and
significantly greater in group A than in group B (23.4 +/– 5.7 vs discussed with the patient. 21
16.9 +/– 4.7 minutes and 486.4 +/– 170.0 vs 222.1 +/– 104.9 ml,
respectively). The cumulative complication rate was Hysteroscopic Management of Hydrosalpinges
significantly lower in group B than in group A. No difference in It is well known that the success of assisted reproductive
any of the reproductive parameters was observed between the techniques, especially IVF, for patients with tubal pathologies
2 groups: Pregnancy and delivery rates were 70% and 81.6% in such as hydrosalpinx is reduced by half compared with patients
group A vs 76.9% and 84% in group B. Nine women (18.4%) without hydrosalpinx. 22
from group B and 8 women (16%) from group B experienced Theories explaining the mechanisms behind the impaired
spontaneous abortions. Most patients (54/82) delivered by outcome of in vitro fertilization still focus on the hydrosalpingeal
cesarean section without differences according to the fluid. The negative effects of hydrosalpinx have generally been
hysteroscopic technique used for metroplasty (65% in group A attributed largely to: (i) mechanical effects of fluid washing out
vs 67.7% in group B) or to the gestational age (65.1% of term uterine contents; (ii) embryo and gametotoxicity from toxic
and 68.7% of preterm deliveries). hydrosalpinx fluid; (iii) alterations in endometrial receptivity
The study concluded that small diameter hysteroscopy with markers; or dwindled cross talk between embryoendometrium
bipolar electrode for the incision of uterine septum is as effective resulting in hindered implantation, and (iv) direct effect on
as resectoscopy with unipolar electrode regarding reproductive endometrium, leading to intrauterine fluid formation. The
outcome and is associated with shorter operating time and lower underlying mechanism explaining reduced implantation and
complication rate. 19
embryo development awaits further research. 23
The pertinent question is to determine the best mode of
Hysteroscopic Surgery for Uterine Synechiae treatment. Surgical treatment is generally advocated but a choice

Uterine synechiae precludes success in assisted reproductive has to be made between salpingectomy and proximal tubal
techniques and so need to be diagnosed and treated. While occlusion.
sonohysterography and hysterosalpingography are useful as A cochrane database systematic review carried out by
screening tests of intrauterine adhesions, hysteroscopy remains Johnson and colleagues to examine the efficacy of surgical
the mainstay of diagnosis. 1 intervention for tubal disease before IVF. Three randomized
Hysteroscopy has also become the accepted optimum route controlled trials involving 295 (or couples) were included in
of surgery, aimed at restoring the size and shape of the uterine this review. The odds of ongoing pregnancy and live birth
cavity, normal endometrial function and increasing chances at [Peto-odds ratio (OR) 2.13, 95% confidence interval (CI) 1.24 to
IVF. Treatment options range from simple cervical dilatation in 3.65] were increased with laparoscopic salpingectomy for
the case of cervical stenosis but an intact uterine cavity, to hydrosalpinges prior to IVF. The odds of pregnancy were also
extensive adhesiolysis of dense intrauterine adhesions using increased (Peto-odds ratio (OR)1.75, 95% CI 1.07 to 2.86). There
scissors or electro or laser energy. was no significant difference in the odds of ectopic pregnancy
Magos in a review concluded that patients in whom the (Peto OR 0.42, 95% CI 0.08 to 2.14), miscarriage (Peto OR 0.49,
uterine fundus is completely obscured and those with a greatly 95% CI 0.16 to 1.52) or treatment complications (Peto OR 5.80,
narrowed, fibrotic cavity present the greatest therapeutic 95% CI 0.35 to 96.79). No data were available concerning the
challenge. Several techniques have described for these difficult odds of multiple pregnancies.

4
JAYPEE