Fertiloscope - The Fertiloscopy Procedure

The Fertiloscopy Procedure

Fertiloscopy combines Lap and Dye, Salpingoscopy and Microsalpingoscopy (MSC) and Hysteroscopy in two instruments presented as a single kit. It uses for the entire procedure a single narrow scope (Hamou 2, from Storz or equivalent) that has a 30 degree chamfer which enables a panoramic view by rotating the scope, and a zero to 100X magnification controlled by a rotating knurled knob:

1. The basis of the procedure is a laparoscopy performed under local anaesthesia via the vagina and the pouch of Douglas rather than via the abdominal wall and the peritoneal cavity. The benefit of this route of entry for the patients is that the procedure is minimally invasive, with no scar. Because it is carried out under local anaesthesia it is well accepted by patients who can go home in two hours.

   The doctor can carry out the procedure with a single hand, which can lead to savings in time and cost. Fertiloscopy is deemed to be safe because of the use of saline solution instead of Carbon dioxide, because of no requirement to use the head down position, and because the procedure is carried out entirely below the peritoneum, eliminating the risk of peritonitis if the bowel is inadvertently punctured. In addition the procedure is carried out without disturbing the position of the internal organs, thus allowing the detection of abnormalities normally not seen during conventional laparoscopy.

   Published data show that injury to major blood vessels is practically impossible and there are very few other minor complications when performed in the right manner. This one risk has been reported: that if a thorough physical examination of the pelvic space between vagina and rectum is not carried out, and if in fact the patient has severe endometriosis causing a fixed retroverted uterus, then there is a risk of rectal puncture. Proper training in the technique makes sure that patients with severe endometriosis and fixed retroverted uterus are excluded, and this minimises this risk. The paper by Nohuz, Pouly, Bolandard, Rabishong, Jardon, Cotte, Rivoire and Mage (2006) confirms this

2. During the procedure, dye is introduced via the uterus into the fallopian tube and observed appearing (or not) in the pouch of Douglas. MSC is then performed using the same scope as for the laparoscopic investigation in order to identify and assess damage to the mucosa. The natural position of the tubes allows an easy approach (unlike the Lap and Dye procedure)
3. At the end of the procedure a full hysteroscopy is performed

Published papers show that Fertiloscopy, even without its inherent salpingoscopy, is fully equivalent to full laparoscopic investigation. The most important of these is by Watrelot, Nisolle, Chelli, Hocke, Rongieres, Racinet (2003). But because the full procedure includes a dye test and full salpingoscopy/microsalpingoscopy, it produces all the information that could only otherwise be provided by a combination of HSG, plus Lap and Dye, plus Salpingoscopy and Microsalpingoscopy. As we have previously discussed, such a combination is not otherwise practicable, and is never performed.

Clinical decisions following fertiloscopy

1. When the fallopian tube is abnormal, the modern tendency is to choose IVF in all cases, but formerly it was the practice to repair the tubes where possible by surgery. This remains a rational option for a number of reasons: firstly the procedure is cheaper than IVF and secondly, if successful, it permits as many future pregnancies as desired, whereas IVF has to be used for every future pregnancy.
2. The problem here is that HSG or HyCoSy do not provide sufficient information to make an informed choice between either "expectant management or IUI", and "tubal surgery or IVF", or (in the latter case) between tubal surgery and IVF. Currently, this would only be achieved by a laparoscopic inspection, and as we have seen, this is not normally performed
3. Under what we may now call the "Fertiloscopy paradigm" if the Dye test does not produce a good flow of dye into the pouch of Douglas, or if the mucosa show the characteristic staining patterns associated with damage, then the patient will rarely become pregnant using IUI.
4. Similarly, patients with significant adhesions or endometriosis are unlikely to become pregnant using IUI.
5. For these people (40% of the total), a choice is required between immediate IVF, or pelvic surgery followed by either expectant management, IUI or IVF as appropriate. There are clear criteria for this decision, as described in the literature
6. If none of these are seen, the patient is treated expectantly or by IUI as appropriate. This applies to approximately 60% of patients in developed countries.