MIAMI BEACH — Physicians investigating a patient's persistent infertility should not underestimate the value of combined laparoscopy and hysteroscopy for allowing the most thorough work-up, according to Liselotte Mettler, Prof. Dr. Med.
Other common methods of investigating tubal patency, such as hysterosalpingogram (HSG), are valuable in that they are minimally invasive and can be performed in the office. But none of these methods offers as revealing a view of the ovaries and uterus as the combination of laparoscopy and hysteroscopy, according to Dr. Mettler, who is professor of obstetrics and gynecology and the head of gynecology, endocrinology and reproductive medicine at the University of Kiel, (Germany).
Speaking at a congress on laparoscopy and minimally invasive surgery, Dr. Mettler outlined her study of 120 patients investigated for tubal patency over a 2-year period.
The patients were examined using one of six available methods: hysterosalpingogram, hysterosalpingo contrast sonography (HyCoSy), laparoscopy with chromopertubation and hysteroscopy, transvaginal hydrolaparoscopy, air-contrast sonohysterography, or CO2 pertubation.
In assessing each of these approaches, Dr. Mettler explained that all six proved safe and were associated with only minor side effects.
The cheapest method is air-contrast sonohysterography, which is performed in much the same way as regular sonohysterography, except that a balloon catheter is used.
In this procedure, as well as in CO2 pertubation, contrast dye is forced into the fallopian tubes and can be painful when used in women with occlusions, she said.
HsCoSy is the second least expensive investigation. In this procedure, a transcervical balloon catheter is passed through the internal cervical os and inflated, and then a transvaginal probe is used to visualize the uterine cavity.
This maneuver is made possible with the injection of contrast solution, which allows the physician to evaluate tubal flow.
The main drawback of this and many of the other investigations is that no treatment can be performed at the time pathology is diagnosed, she said during the meeting, which was sponsored by the Society of Laparoendoscopic Surgeons.
With HSG, although tubal patency can be tested, no pelvic pathology can be assessed.
Although transvaginal hydrolaparoscopy can be used to evaluate tubal patency, it is quite traumatic and can assess only a small part of the lower pelvis, she said.
In laparoscopy the entire pelvis can be assessed, and—with the addition of chromopertubation—tubal patency can be evaluated at the same time. Adding hysteroscopy to this procedure allows assessment of the internal uterus, and if immediate therapy is necessary, it can be easily done while the patient is still under anesthesia, she said.
“When we see patients, they have been through many, many work-ups already, so we don't hesitate to go straight to laparoscopy,” Dr. Mettler told this newspaper.
“It is important to distinguish between outpatients and hospital patients. In our case, we are in a hospital and have access to operative techniques,” Dr. Mettler noted.
She said physicians who are not in a position to offer this type of investigation to patients with persistent infertility should refer them immediately to someone who can.
“After a certain amount of time, there is no point in confirming tubal patency by HSG in a woman only to find out 2 years later at laparoscopy that she has extensive adhesions. Tubal patency alone is not the only important factor,” she said.