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Procedure Can Help Find Causes of Unexplained Infertility
by Leigh Ann Woodruff, June 26, 2012
Around 10 to 15 percent of infertile couples will receive a diagnosis of unexplained infertility. This can be incredibly frustrating, even though in vitro fertilization (IVF) is typically a good treatment for the diagnosis.
"There's probalby more unexplained infertility because we're doing fewer diagnostic tests than we used to," says Brad Hurst, M.D., Director of Assisted Reproduction with the Center for Reproductive Medicine at Carolinas Medical Center's Women's Institute. He explains that during the 1990s, physicians would perform routine laparoscopy — a surgery that uses a thin, lighted tube put through an incision in the belly to look at the female pelvic organs — to diagnose infertility, and they often found endometriosis or adhesions.
"Laparoscopy wasn't a very cost effective approach," Dr. Hurst says, "and when we do laparoxopy and find and treat endometriosis, we find that we only improve the monthly pregnancy rates by 1 percent or 2 percent. So, the current standard is to do semen analysis, ovarian reserve testing, some type of means to confirm ovulation, and a hysterosalpingogram to assess the uterus and tubal patency, and if those things are normal, the couple is assumed to have unexplained infertility."
Now, however, a procedure that has been approved for use in the United States during the last year is available to better find the source of a woman's infertility: Fertiloscopy.
What Is Fertiloscopy?
The Fertiloscope was developed by the French surgeon Dr. Antoine Watrelot to provide accurate, primary screening and diagnosis of several disorders in an office setting. Dr. Hurst was one of seven U.S. physicians who traveled to France to be trained in the procedure.
"Fertilioscopy is something that has been done in Europe for the last decade," explains Dr. Hurst. "It is a type of laparoscopy where the camera, instead of being placed through the belly button, is placed through a little tiny incision behind the cervix," Dr. Hurst says. "The pelvis is filled with fluid and then the fallopian tubes and ovaries are assessed with a type of camera that can magnify the image by a factor of about 100. And when you do that, you can identify things like endometriosis and adhesions, and you can treat those conditions."
Diagnosing with Fertiloscopy
Fertiloscopy can diagnose blocked fallopian tubes, damaged tubal mucosa, adhesions, endometriosis and intrauterine lesions. "One of the amazing tings about Fertiloscopy is you can place the camera into the fallopian tube and really see the incredibly subtle abnormalities in the fallopian tube that you just can't even appreciate by doing a laparoscopy," Dr. Hurst says. "I've seen some kind of surprising abnormalities of the fallopian tube." For example, "You can see intratubal inflammation. You can prescribe antibiotics if there's inflammation, and that would be a very great and simple way of treating infertility.
"The advantage of fertiloscopy is that it's a much faster procedure than laparoscopy, and it provides diagnosis, especially for couples who are frustrated because they don't have an explanation for infertility," Dr. Hurst continues. "This is a way of getting answers."
Pelvic inflammatory disease (PID), which causes inflammation and scarring of the uterus, fallopian tubes and ovaries is a common cause of infertility; however, sometimes women may have PID with no symptoms, called subclinical PID. Recent research by the University of Pittsburgh and the University of California, Davis, evaluated women for subclinical PID via a biopsy of the lining of the uterus and investigated pregnancy rates. The scientists found that women with subclinical PID diagnosed at enrollment had a 40 percent reduced incidence of pregnancy compared with women without subclinical PID. Fertiloscopy can help in the diagnosis of this silent threat to fertility. "Anatomic abnormalities can be identified, including very subtle fimbrial or intratubal adhesions," Dr. Hurst says. "Also, macrophages (white blood cells within tissues) are stained by the blue dye used to assess tubal patency, and this staining can be detected by Fertiloscopy with the 100x zoom feature."
Fertiloscopy Used for Treatment
Fertiloscopy can also be used for treating causes of infertility. For example, it enables ovarian drilling for polycystic ovarian syndrome (PCOS), and it allows physicians to treat minor adhesions and endometriosis, and perform hysteroscopic procedures. In addition, there can be a fertility-enhancing benefit just by having the procedure.
"It's all theory, but when we do fertiloscopy, we fill the pelvis up with saline, and we do the procedure, and at the end of the procedure, we drain the saline, so we kind of flush the pelvis out," Dr. Hurst says. "And there's a lot of evidence that shows that with endometriosis, the endometriosis implants secrete toxins that can affect fertilization, egg pickup or sperm survival. It may just be that you dilute out those factors and improve fertility for a period of time after doing the procedures."
More importantly, fertiloscopy may help infertility patients make decisions about the next steps for fertility treatment. "If a patient is on the fence: Should they wait for six more months, or spend another year or two trying and save up their money for IVF, or is it just a waste of time? If you find out by doing fertiloscopy that the patient has extensive adhesions and that it would be very unlikely for them to conceive, then it may help them make the decision to move to IVF sooner."