The fertiloscope is a type of laparoscope, modified to make it suitable for trans-vaginal application, which is used in the diagnosis and treatment of female infertility.
This relatively new surgical technique is used for the early diagnosis and immediate treatment of a number of disorders of the female reproductive organs and can be considered one of the first standard NOTES (Natural Orifice Transluminal Endoscopic Surgery) procedures. A large body of published research is available on the application of this surgical technique using the device.
Fertiloscopy provides a minimally invasive, potentially office-based procedure for the clear diagnosis of two major causes of infertility in a manner enabling rational choices at the start of infertility treatment.
Published evidence indicates improvement in pregnancy rates with reductions in costs.Watrelot A, Dreyfus J M. "Fertiloscopy: Review of a 1500 Continuous Case Series." JSLS, Journal of the Society of Laparo-endoscopic Surgeons. Volume 10, Number 3
Literature review The published evidence into the use of Fertiloscopy falls into two categories; those studies linked with the original research into the technique itself, and the later (post 2002) evaluations of the product after it was fully developed.
The original technique was a development of a surgical procedure called culdoscopy which was widely used in the 1960s and 1970s. This was a transvaginal technique performed via the vagina with a conventional laparoscope. This fell out of general use, in most countries most probably because culdoscopy could not offer any advantages over laparoscopy. A modified laparoscope was the original instrument used for a "transvaginal hydrolaparoscopy".Watrelot A., Gordts S., Andine J.P., Brosens I. Une nouvelle approche diagnostique : La Fertiloscopie Endomag, 1997,21,7-8Gordts S, Campo R, Rombauts L, & Brosens I. Transvaginal hydrolaparoscopy as an outpatient procedure for infertility investigation. Human Reproduction 13, 99-103. 1998.Brosens I, Campo R, & Gordts S. Office hydrolaparoscopy for the diagnosis of endometriosis and tubal infertility. Current Opinion in Obstetrics and Gynecology 11, 371-377. 1999.Campo R, Gordts S, Rombauts L, & Brosens I. Diagnostic accuracy of transvaginal hydrolaparoscopy in infertility. Fertility and Sterility 71, 1157–1160. 1999.A.Watrelot, J.M.Dreyfus and J.P.Andine Centre de Recherche et d'Etude de la Sterilite´, 85 cours Albert Thomas-69003, Lyon, France. Evaluation of the performance of fertiloscopy in 160 consecutive infertile patients with no obvious pathology . Human Reproduction vol.14 no.3 pp.707–711, 1999 An integral member of the initial teams working on the technique, Watrelot decided to develop a disposable instrument with extended capabilities that make a more comprehensive procedure possible. He included in the device a conventional hysteroscope so that the total procedure includes not only the transvaginal laparoscopy, but also hysteroscopy, and the so-called "laparoscopy and dye" test for tubal patency. This device became known as the Fertiloscope and from it is derived the name for the current technique that uses it; Fertiloscopy. There is a recent review of alternative methods of assessing tubal patency by Papaioannou, Afnan and Jafettas in 2007 that makes clear that "lap and dye" is the gold standard procedure for assessing tubal patency.S. Papaioannou, M. Afnan, J. Jafettas. Heart of England NHS Foundation Trust, Birmingham, UK; Birmingham Women's Health Care NHS Trust, Birmingham, UK; 32nd Department of Obstetrics and Gynecology, Aristoteleion University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece. Symposium: Tubal disease and fertility outcome. Tubal assessment tests: still have not found what we are looking for. Vol 15. No 4. 2007 376-382 Reproductive BioMedicine Online Watrelot also recommends the use of a special type of scope with a 30-degree chamfered end which makes it possible to examine the inside of the fallopian tubes and visualise the depths of the folds under 100 fold magnification, so that mucosal damage can be assessed. Watrelot and Dreyfus (2000),Watrelot A & Dreyfus J. Explorations intra-tubaires au cours de la fertiloscopie. Reproduction Humaine et Hormones 13, 39-44. 2000. Watrelot and Grudzinskas (2003) Watrelot A, Hamilton J, & Grudzinkas J. Advances in the assessment of the uterus and fallopian tube function. Best Practice & Research in Clinical Obstetrics & Gynaecology 17, 187-209. 2003. Watrelot, Dreyfus and Cohen (2002),Watrelot A, Dreyfus J, & Cohen M. Systematic salpingoscopy and microsalpingoscopy during fertiloscopy. A 500 cases report. J Am Ass Gynae Lap 9, 117-123. 2002. Swart, van Beurden, Mol, Redekop, van der Veen and Vossuyt (1995)Swart P, van Beurden M, Mol B, Redekop W, van der Veen F, & Bossuyt P. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertility and Sterility 64, 486-491. 1995. and Yablonski Sarge and Wild (1990)Yablonski M, Sarge T, & Wild R. Subtle variations in tubal anatomy in infertile women. Fertility and Sterility 54, 455-458. 1990. have published on the value of visualisation of the tubal mucosa under magnification (microsalpingoscopy). Watrelot, Nisolle, Chelli, Hocke, Rongieres and Racinet (2003)Watrelot A, Nisolle M, Chelli H, Hocke C, Rongieres C, Racinet C; International Group for Fertiloscopy Evaluation. Centre de Recherche et d'Etude de la Sterilite, 69003-Lyon, France. [email protected]. Human Reproduction, Vol. 18, No. 4, 834-839, April 2003. Is laparoscopy still the gold standard in infertility assessment? A comparison of fertiloscopy versus laparoscopy in infertility. Results of an international multicentre prospective trial: the 'FLY' (Fertiloscopy-LaparoscopY) study. is a comparison of the results obtained by the "gold standard" methodology of lap and dye and Fertiloscopy in a series of patients who underwent both procedures (by two surgeons, blind to each other's results). This study showed that there is a high degree of concordance between laparoscopy and fertiloscopy in the identification of adhesions and endometriosis. Further papers such as those by Watrelot and Dreyfus have reported in the Journal of the Society of Laparoendoscopic Surgeons 2007 a retrospective analysis of over 1500 patients. Watrelot received a medal from the society for this publication, in October 2006.Watrelot A, Dreyfus J M. Fertiloscopy: Review of a 1500 Continuous Case Series. JSLS, Journal of the Society of Laparoendoscopic Surgeons. Volume 10, Number 3 2007 The use of the technique has broadened over the past few years with further publications examining effectiveness in standard clinical practice,Nohuz E, Pouly J-L, Bolandard F, Rabischong B, Jardon K, Cotte B, Rivoire C, & Mage G. "Fertiloscopie : l'expérience clermontoise". Gynécologie Obstétrique & Fertilité 34(10): 894–899. 18 May 2006. as well as those reporting on new applications such as ovarian drilling for Polycystic Ovarian Syndrome (PCOS).
Rationale If, for the purposes of this discussion, female infertility is considered the main issue (while also considering male infertility where it relates to this particular subject), the huge majority of subfertile women have either:
Problems of ovulation (30-40%), Tubo-peritoneal abnormalities such as: tubal blockage (15%), tubo-ovarian adhesions (20%), abnormal tubal mucosa with patent tubes (20%) Abnormalities in the uterine cavity (10%)
Note that the percentages add up to more than 100% because of overlap where a single patient may have more than one problem.
In order to deal with all these causes, there are four main categories of treatment: Stimulation of the ovaries, starting usually with clomiphene, and then if unsuccessful, quickly moving to gonadotropins, which are more effective IVF (or ICSI if there is also a male problem) Corrective (laparoscopic) surgery of the pelvic organs Corrective surgery of uterine abnormalities (hysteroscopically or laparoscopically)
For any woman, the correct choice of treatment depends on correctly identifying the problem. However, although there are diagnostic procedures that make it possible to make rational choices between these treatments, the full range of these tests is rarely carried out at the start of treatment. As a result, many women receive inappropriate treatment, and only achieve pregnancy after unnecessary delay, and after many cycles of inappropriate treatment that was, in fact, doomed to fail from the start.
Fertiloscopy makes it possible to simultaneously identify, in any women, the case for either: Conservative treatment by either continuation of normal intercourse or IUI IVF, or Corrective surgery
Methods of diagnosis without fertiloscopy At the present time, the initial diagnostic testing that is carried out is limited. Diagnosis of ovulatory problems is routinely carried out at an early stage and is not mentioned further in this paper.
Physical abnormalities of the fallopian tubes, including blockage and mucosal damage, and in the pelvic cavity, including endometriosis and adhesions, are not generally subjected to a comprehensive diagnosis in most countries. The same applies to uterine abnormalities.
The normal diagnostic practice is as follows:
Blockage of the fallopian tubes is mainly diagnosed today by hysterosalpingography (HSG) or Hystero Contrast Sonography (HyCoSy) in which either X-ray contrast media or aqueous fluid are forced up the fallopian tube to create an image on X-ray or ultrasound. This image demonstrates (or excludes) the possibility for sperm to swim up and for ova to migrate downwards. In earlier times, a technique known as a "Laparoscopy and Dye" (Lap and Dye) test was used in which dye was forced up the fallopian tube and its presence observed in the pelvic cavity during laparoscopic surgery. The literature indicates that HSG has very poor predictive value (15% false positives and 30-35% false negatives). The relative merits of these techniques are currently being debated, but for the purposes of this document the important point is that they only diagnose the presence of a passage through the tube, and give little information about the condition of the tubal mucosa. Again, the paper by Papaiannou, Afnan and Jafettas makes useful reading in this regard.S. Papaioannou, M. Afnan, J. Jafettas. Heart of England NHS Foundation Trust, Birmingham, UK; Birmingham Women's Health Care NHS Trust, Birmingham, UK; 32nd Department of Obstetrics and Gynecology, Aristoteleion University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece. Symposium: Tubal disease and fertility outcome. "Tubal assessment tests: still have not found what we are looking for." Vol 15. No 4. 2007 376-382 Reproductive BioMedicine Online There is no convenient method for assessing the condition of the tubal mucosa (Salpingoscopy), which in theory could be carried out during laparoscopy. This is because the point of entry to the abdomen for conventional laparoscopy is such that the distal end of the fallopian tube points away from the point of entry, and is thus inaccessible. Thus Salpingoscopy can only be carried out if a second laparoscope is inserted in a different place, requiring two complete sets of equipment. For this reason the technique is unsuitable for routine use Moreover, even if Salpingoscopy is carried out in individual cases, the macroscopic examination is not fully revealing. It has been found that, on microscopic examination, cellular damage can often be seen in cases where the macro structures are intact. Obviously, this technique is not routinely used, for the same reasons as apply to Salpingoscopy This means that, at the present time tubal patency is diagnosed rather inaccurately with HSG or HyCoSy, but very few patients are assessed for the condition of their mucosa in spite of the fact that damaged mucosa affect more patients than have blocked tubes.