Infertility Work-Up Should Include Examination With TVL, Expert Says


LONDON — The modern infertility work-up should include a transvaginal hydrolaparoscopic exploration of the tubes and ovaries, said Stephan Gordts, M.D., of the Leuven (Belgium) Institute for Fertility and Embryology.

He pioneered transvaginal hydrolaparoscopy (TVL) in 1998 (later, another group named the procedure “fertiloscopy”) and said he's since abandoned tubal assessment by hysterosalpingogram (HSG).

Whereas the HSG can explore tubal patency only, “with TVL you have a more complete exploration of the patient,” he told this newspaper.

Speaking at the annual congress of the International Society for Gynecologic Endoscopy, Dr. Gordts explained that TVL can evaluate both the inside and outside of a patient's reproductive organs and can evaluate adhesions and endometriosis by incorporating hysteroscopy, transvaginal hydrolaparoscopy, salpingoscopy, and tubal patency testing.

TVL can be done in an ambulatory setting, under local anesthetic, and requires only an oocyte aspiration room, rather than a full operating theater. The procedure is performed with the insertion of a needle transvaginally into the pouch of Douglas followed by infusion with saline. An endoscope can be introduced, allowing visualization of the outside of the uterus, the ovaries, and the distal part of the fallopian tubes. The scope can be introduced a few centimeters into the distal end of the fallopian tube for evaluation of the ampulla and the inside of the distal tube. A biopsy can reveal the presence or absence of normal cilia movement.

At the same time, a hysteroscope can be passed through the cervix, allowing evaluation of the inside of the uterus, and infusion of dye through the fallopian tubes to assess their patency.

The presence of saline makes adhesions and subtle endometriotic lesions float, allowing for easier identification. “This pathology is often masked under the high intraabdominal pressure of laparoscopy,” Dr. Gordts said.

Although it's primarily a diagnostic procedure, TVL can be used to perform adhesiolysis, treat mild to moderate endometriosis, and drill ovaries in patients with polycystic ovarian disease.

Unlike Dr. Gordts, Jacques Donnez, M.D., said he believes there is still a place for HSG in the fertility work-up—and the combination of HSG and TVL might offer the most thorough tubal assessment.

Although TVL can visualize a few centimeters of the inner distal fallopian tube, and evaluate patency by confirming spillage of dye infused through the cervix, it offers no other information about the status of the proximal tube, said the professor and head of gynecology at Catholic University of Louvain in Brussels.

“You can see if the dye is not going through, but if this happens you have no idea of the location of the blockage or if there is some diverticuli or anomalies in the proximal tube,” he said in an interview.

HSG can identify the location of proximal blockages, some of which can be easily catheterized.

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