MEDICINSKI GLASNIK

12
Medicinski Glasnik, Volumen 9, Number 1, February 2012
of early stage Chlamydial infection, as the most
important etiological factor in the development
of pelvic inflammatory disease (2). It is believed
that 25 % of infertile patients have a tubal factor
as a cause of infertility (14).
Phymosis of abdominal ostia, proximal and distal
occlusion can now be easily differentiated.
Diagnostic laparoscopy of tubal lesions can be
easily continued as therapeutic (5) .
Tuboovarial adhesions, tubal occlusion and hydrosalpinx
occur most frequently as a consequence of
PID (15). Pelvic inflammatory disease occurs in
85 % of cases after sexually transmitted diseasesadhesions
in the pelvic region as a result of chronic
inflammation are multiple damaging factors
for reproductive capacity of a female (16).
Johnson et al. conducted two Cochrane systematic
reviews recommending laparoscopic salpingectomy
before the IVF procedure, making unilateral
or bilateral surgery, depending on the extension of
the process, after which probability of intrauterine
pregnancies rises up to 95 % (15,17).
They also recommend that salpingostomy be considered
if damage is of smaller or medium grade.
The treatment outcome in salpingostomy is defined
by successful intrauterine pregnancy rate of
33-42% and extra uterine pregnancy rate of 7%. In
case of phimosis of abdominal orifice, deglutination
of fimbriae or fimbrioplasty is performed.
But in 2010 report, Johnson leaves a possibility
of laparoscopic tubal agglutination as an alternative
to other procedures (15,17).
In case of infertility our primary task is to remove
any adhesions that interfere with reproductive
physiology (ovulation, transport of oocyte or
conceptus) (17).
In cases of chronic pelvic pain it is necessary
to remove all possible adhesions and mobilize
all pelvic organs . Pelvic adhesions are usually
a consequence of pelvic inflammatory diseases,
endometriosis or surgical procedures (18). Reappearance
of adhesions after laparoscopic adhesiolysis
can be seen in 12 %, while after laparotomy
it can appear in 50 % of patients (19).
ROLE OF LAPAROSCOPY IN TREATMENT OF
MINIMAL AND MILD ENDOMETRIOSIS
Prevalence of endometriosis in infertile patients
is between 26-68% and is higher than among
general population of reproductive age, where
prevalence ranges between 2.5-3.3 % (20).
Middle and severe stages of endometriosis lead
to malformations of normal pelvic topography
and damage reproductive function. Minimal
and mild endometriosis reduce fertility by other
mechanisms including toxic factors in peritoneal
fluid which reduces folliculogenesis and luteal
function. In stages I and II monthly fecundity rate
is approximately 7% (21). Although connection
between minimal and mild endometriosis and
fertility might be considered coincidental, there
are many arguments in favour of the thesis that
there is in fact a strong relation between I and II
grade endometriosis and infertility (22).
Different stages of pathology and different clinical
signs can also demand different levels of
interventions. Endometriosis can be considered
symptomatic and asymptomatic and by clinical
classification it can be divided into endometriosis
without palpable lesions (Sampson syndrome) or
endometriosis with palpable lesions (Cullen syndrome).
Depending on the presence of palpable
lesions further preoperative diagnostics and preparations
for wider and more extensive surgical
procedure will be considered necessary (23).
There is a positive correlation between a level of
endometriosis and serum value of tumour marker
Ca 125 which can also be considered as a preoperative
predictor. One of the modern diagnostic
tests is CCR 1 mRNA (chemokine related receptor
1 mRNA) in peripheral blood as a blood test
for endometriosis. CCR is a specific receptor for
the surface of neutrophiles/mononuclear leukocytes.
It is elevated in pregnant women, acute
PID and in endometriosis (24).
First randomized study of a Canadian collaboration
group compared infertility and endometriosis.
In the first group laparoscopic resection or
ablation was performed in minimal and mild endometriosis,
while in the second group only a diagnostical
laparoscopy was performed. The first
group had the pregnancy rate of 31 %, while the
second group had pregnancy rate of 18% (25).
The European Society for Human Reproduction
and Endocrinology (ESHRE), special group for
endometriosis recommended in its guidelines
surgical treatment of minimal and mild endometriosis
in infertile women (26).