Michael L. Moore, MD

Transvaginal hydro         laparoscopy (THL) is a new approach to pelvic anatomic evaluation in the         infertile woman. In this procedure a dilating trocar is inserted through         the osterior vaginal wall for endoscopic pelvic examination. Normal         saline is used to float the bowel out of the pelvis so that one can         evaluate the distal Fallopian tubes, ovarian surfaces, pelvic sidewalls,         and the cul-de-sac. The THL procedure makes in-office pelvic endoscopy,         hysteroscopy, and dye hydrotubation a reality.[1]         

For many years there has been a debate         over the accuracy of hysterosalpingography (HSG) when compared to         laparoscopy as the gold standard. False positive and false negative         rates for HSG are in the range of 15-38% and 13-57%, respectively. In a         meta-analysis of studies comparing HSG to laparoscopy, Swart reported         that HSG had a sensitivity of .65 and a specificity of .83.[2] The         author's conclusion was that HSG was good for diagnosing tubal         obstruction but poor at predicting peritoneal pathology. Most authors         recommend 3 to 10 months of therapy following a normal HSG because of         the expense of laparoscopy, which can account for as much as 70% of the         cost of the infertility work-up.[3]

This article discusses the role of THL         and HSG in the cost-effective evaluation of infertility.

New diagnostic technologies that may         improve the accuracy and cost-effectiveness of infertility services are         being explored. Currently, couples have a basic evaluation involving         semen analysis, HSG, and postcoital and ovulatory testing. If the HSG is         normal, couples undergo various therapies, including intrauterine         insemination and ovulation induction prior to laparoscopy. Chlamydial         antibody testing can help in detecting those patients who have a higher         likelihood of tubal disease and who should undergo laparoscopy sooner.

Hysteroscopy, in our hands, has been         more accurate than HSG for diagnosing submucosal fibroids and polyps.         Office diagnostic hysteroscopy can be done with minimal discomfort and         is sometimes recommended even after a normal HSG. Sonohysterography (SHG)         has been shown to be very accurate in uterine cavity evaluation.[4] SHG         may be of value in diagnosing tubal obstruction, and can be incorporated         into a screening ultrasound examination. Diagnostic microlaparoscopy[5]         and THL are new endoscopic advances for minimally invasive, visual         pelvic evaluation.

Microlaparoscopy has been proposed as a         cost-effective method to obtain accurate pelvic anatomic information.         Microlaparoscopy can be performed in the office with conscious sedation         for diagnostic purposes. The need for Trendelenberg position, CO2         insufflation, and organ manipulation makes microlaparoscopy an         uncomfortable procedure for many patients.

THL is performed in dorsal lithotomy         position, and uses a fluid distending medium as opposed to CO2.         Generally patients can tolerate this procedure with less discomfort than         microlaparoscopy. The pelvic structures tend to float in the fluid, so         the scope can be guided around the surface of the organ of interest. In         expert hands THL can be performed with only local anesthesia and no         significant sedation.[1] For the physician with less experience, THL may         require IV or oral conscious sedation.

Preceding laparoscopy, couples usually         undergo 3 to 10 months of therapy. These therapies involve both monetary         and emotional costs. Approximately 50% of apparently normal infertile         patients undergoing laparoscopy will have pelvic pathology.[6]

Endometriosis, which affects 25-35% of         infertile women, is associated with a lower monthly pregnancy rate.         Laparoscopic treatment of minimal or mild endometriosis significantly         improves the pregnancy rate compared to expectant management.[7] Women         with moderate to severe distal tubal adhesions, whether from advanced         stages of endometriosis, infection, or prior surgery, may be better         served by in vitro fertilization (IVF) than operative laparoscopy. THL         is a diagnostic endoscopic procedure with greater accuracy than HSG and         can be done in the office with conscious sedation. Initial or early         evaluation with THL, as a more precise critical pathway, may help reduce         fertility costs.

Substituting THL for HSG in the         infertility work-up requires combining THL with diagnostic hysteroscopy         and dye hydrotubation. Patients who would not be candidates for THL are         those with a pelvic mass, a fixed retroverted uterus, or suspicion of an         obliterated cul-de-sac. Women with an enlarged uterus filling the pelvis         would also not be candidates. A vaginal infection should be treated         before attempting THL, and transvaginal sonography should be performed         before considering THL. Contraindications found on ultrasound include         submucosal fibroids, endometrial polyps, endometrioma, dermoid,         suspected ovarian neoplasia, or any other pelvic mass that suggests the         need for operative intervention. Since blood can obscure the view, THL         may not be possible in the presence of hemoperitoneum. THL may not be         advisable in morbidly obese patients. In the initial infertility         evaluation, THL, hysteroscopy, and dye hydrotubation are feasible in the         majority of patients.

The value of substituting THL for HSG         in the initial work-up may be controversial. However, there is support         that performing THL before laparoscopy reduces infertility costs. Campo         reported on 70 infertility patients who underwent THL.[8] Thirty-three         (47%) had no adnexal pathology and did not go on to laparoscopy.         Assuming the cost of laparoscopy (anesthesiologist, hospital, surgeon)         is $5,580[3] and the cost of THL is $1,000, this approach represents a         savings of $114,170 ($1,631/patient). Applying this same cost model to         Marcoux's[7] study on laparoscopic treatment of endometriosis provides         additional considerations. Assume 30% of patients have minimal or mild         endometriosis.[6] HSG costs $400, THL is $1,000, and laparoscopy is         $5,580 (see Table 1).

All women with minimal or mild         endometriosis will have a normal HSG; after 9 months 17.7% are pregnant         (rate for untreated controls); and the rest undergo laparoscopy. THL         diagnoses all patients with endometriosis, each is treated with         laparoscopy, and 30.7% are pregnant at 9 months (treated rate). The cost         per pregnancy is $28,585 for the HSG group and $21,457 for the THL         group. These models support the economic value of THL.[6,7]

A pilot study of the cost-effectiveness         of THL was conducted at our institution on 11 patients who underwent THL         instead of laparoscopy. Eight patients had a previous normal HSG, one         had an abnormal HSG (unilateral distal disease), and 2 had historical         factors without previous HSG. THL was adequate in all patients. Based on         THL findings laparoscopy was recommended in only 4 patients (36%),         saving $28,060 ($2,551/patient - see Table 2). The contralateral side         and the rest of the pelvis was normal in the patient with the abnormal         HSG. Both of the women with no previous HSG had a normal pelvis. Three         of the 8 patients with a normal HSG had a normal THL. Four of the other         5 were candidates for operative laparoscopy, and IVF was suggested for         the other patient. The cost of therapy in the 5 women that had a normal         HSG but an abnormal THL was $13,725 ($2,745/patient - see Table 3). If         THL was used initially instead of (or in combination with) HSG, patients         who would benefit from IVF or laparoscopy could be identified sooner.

There is a learning curve for THL. One         must become familiar with a narrower field of vision and a view of the         pelvis from a different angle. In laparoscopy we are used to a broad         panoramic view. Physicians experienced in office microlaparoscopy know         that with a conscious patient, there is less CO2 distention, and the         panoramic view is decreased. The closeness of the pelvic organs and the         smaller field of vision associated with THL are similar to the smaller         field of view in hysteroscopy. A physician comfortable with in-office         hysteroscopy should be able to master THL.

The THL trocar system (Figure 1) is         designed to minimize the risk of complications. The occurrence of         infection, puncture of the uterine parametrium, rectal perforation, and         other bowel injury are thought to be similar to the risk of other         transvaginal needle procedures such as ovum retrieval and culdocentesis.         Careful exclusion of patients with contraindications is one way to avoid         complications. It is wise to perform THL in the hospital at the time of         laparoscopy to develop a comfort with the procedure before attempting it         in the office.

Until recently, THL has been solely a         diagnostic procedure. Instrumentation has been developed for operative         applications (see CIRCON Update, below) such as treatment of minimal to         mild endometriosis. Other uses of THL may include pain mapping for         chronic pelvic pain, lysis of adhesions, tubal sterilization, and         ovarian cystectomy.

Based on our experience, THL appears to         be an efficient, cost-effective procedure that can be performed in the         office setting and is well tolerated by patients. However, further         prospective trials are necessary to fully assess its role in pelvic         assessment for infertility.

    1. Gordts S, Campo R, Rombauts L, et al. Transvaginal hydro laparoscopy as an outpatient procedure for infertility investigation. H Repro. 1998;13:99-103.

    2. Swart P, Mol BWJ, Van der Vee F, et al. The accuracy of hysterosalpingography in the diagnosis of tubal pathology, a meta-analysis. Fertil Steril. 1995;64:486-491.

    3. Bates GW, Bates BR. The economics of infertility; developing an infertility managed-care plan. Am J Obstet Gynecol. 1996;174:1200-1207.

    4. Gaucherand P, Piacenza JM, Salle B, et al. Sonohysterography of the uterine cavity: preliminary investigations. J Clin Ultrasound. 1995;23(6):339-348.

    5. Palter SSF, Olive DL. Office microlaparoscopy under local anesthesia for chronic pelvic pain. J Am Assoc Gynecol Lap. 1996;3:359-364.

    6. Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility. Baltimore, MD: Williams & Wilkins; 1998.

    7. Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Engl J Med. 1997;337:217-222.

    8. Campo R, Gordts S, Rombauts L, Brosens I. Diagnostic culdoscopy in infertility: study of 400 out-patient procedures. Infertil Reprod Med Clin N Am. 1999;161-175.

Dr. Moore is an assistant clinical professor at the University of Colorado Health Sciences Center, and medical director, Advanced WomenÂ¹s Institute, in Denver, CO.

Articles

Transvaginal hydro laparoscopy (THL) is a new approach to pelvic anatomic evaluation in the infertile woman. In this procedure a dilating trocar is inserted through the osterior vaginal wall for endoscopic pelvic examination. Normal saline is used to float the bowel out of the pelvis so that one can evaluate the distal Fallopian tubes, ovarian surfaces, pelvic sidewalls, and the cul-de-sac. The THL procedure makes in-office pelvic endoscopy, hysteroscopy, and dye hydrotubation a reality.

Transvaginal Hydro Laparoscopy: Preliminary Assessment of Cost-Effectiveness

 Hi, I am  Barbara Nesbitt, I am the editor of OBGYN.net and I am here with one of our  editorial advisors, Dr. Michael Moore, of Denver, Colorado. Hello, Dr. Moore.
 
 

 We are going to talk about  sexual dysfunction in the female patient following hysterectomy and the new  things that Dr. Moore has read about worldwide and what they are doing for it. 
 
 

 Thank you, Barbara. Thank  you for the invitation to talk about a very important topic. 
 
 The uterus is a reproductive organ and it is part of your sexual organs as a  woman, so when you have a problem that requires hysterectomy, there is going to  be some potential impact on sexual functioning. A lot of information is  available today in the lay literature that talks about hysterectomy and a lot of  women come in having read these and they are scared to death of a hysterectomy  because of all the information or, should I say misinformation that is out there  about the loss of sexual function that follows hysterectomy. 
 
 The history, because I just got through doing a lecture on sexual function and  hysterectomy, has enlightened me with new knowledge. I set out to gather  information for this talk and much of the information that I was aware of in the  early ‘90s indicated that you could anticipate a woman would have a 20% to 30%  chance of sexual dysfunction following a hysterectomy and the literature  attributed that to the hysterectomy itself because we know uterine contractions  occur during orgasm and so, because of that, removal of the uterus was perhaps  felt to affect sexual function. All the older literature, which is mostly  retrospective information, was going along with that. 
 
 Now, what you have to realize from retrospective data is that they identify,  say, 100 women who have had a hysterectomy in the past. Now they send those  ladies a questionnaire and it might be a year, two, three years after their  hysterectomy. You have got to then wait for these questionnaires to come back.  Now, if you get 70 out of 100 questionnaires back, you are doing really well.  But who are going to be the ladies who respond? Maybe more who are unhappy with  the procedure and are not happy with the outcome. In the ‘90s, there are about  eight or nine really good prospective cohort studies. Now, prospective means the  information was gathered before the hysterectomy about sexual dysfunction and  then sexual information was gathered six months or a year or eighteen months  after the hysterectomy. It is a cohort because it is a group of women who then  have the operation and we compare their questionnaire results beforehand and see  their questionnaire results afterward. There is no control group and it is a  very important part of scientific studies to have a control group. So that gives  us some indication as to how women might do. 
 
 A very, very good study of about 150 women with 18 months of follow-up not only  looked at the women’s sexual function, as well as the quality of the experience,  which I think was unique to most of the studies - I think that is what drew me  to this one particularly - and it looked at psychological parameters. It  indicated, at least the authors drew the conclusion that the women’s sexual  functioning before the hysterectomy dictated to some degree her sexual function  afterward.
 
 The majority of women who have hysterectomy notice no difference in sexual  function. There is a group of women who actually find it has improved. They were  starting to have pain with intercourse because of an enlarged fibroid uterus,  now they can have comfortable intercourse and that does improve the quality of  the experience. But some women also develop problems afterward and this  represents a challenge. Who can we anticipate might develop problems afterward?  Something that appears in the literature, speculated on by many authors, is the  woman who does not want to have a hysterectomy at all who is the woman who has a  problem. 
 
 There have been several randomized control trials looking at the effect of  hysterectomy on sexual function. These are good because they have a control  group, as well as the treatment group, and that becomes very important because  then you can say, here’s a group of women who didn’t have a hysterectomy, had an  endometrial ablation procedure, and that group is compared to a group of women  who entered the study - all of these women enter the study at the same, so 200  women entered the study - 100 randomly are assigned to non- hysterectomy  treatment, i.e. endometrial ablation. The other half is assigned to  hysterectomy, but they all went in knowing they were going to get one or the  other. They all had the same set of information and what the studies do not tell  us is how many women interviewed and then once they heard all that decided not  to. That’s very important because these ladies were prepared for this and,  indeed, at one year and two studies that looked at non- hysterectomy treatment  versus hysterectomy, the sexual functioning is the same in both groups. There  was no difference in preserving the uterus and just removing the uterine lining  versus removing the uterus. 
 
 Even with removal of the cervix, because there is a lot about supracervical  surgery these days: keep the cervix preserve sexual function. Two randomized  control trials, one to two years of follow-up, again, no differences in sexual  function if you keep the cervix or you take it. Now there was a small group of  women who did develop deep pain with intercourse if their cervix is removed  compared to the women who did not. So there may be some effect in terms of pain  if you remove the cervix. Unfortunately, we do not have 20 year data and that  may become very important, but I think it is really important for a woman who  recognizes inside when she hears that “H” word come out that she really take the  “how does it feel” approach because not every woman wants a hysterectomy to take  care of their problems.
 
 A 45-year-old patient came to see me just the day before I came to AAGL. She had  never had children but she said, I do not plan on having children. She had a  couple fibroids and when she got the report back over the phone that is when she  first heard it. She really felt inside that this was not good and she had the  courage to sit down with her doctor and say, this is not for me, I do not want a  hysterectomy to take care of this problem. Unfortunately, the doctor had  presumed that because she was over 40, did not plan on having children, that  that would be the best thing for her. On the other hand, as we sat down and  talked and she shared that with me, it did not make me feel good that I always  approach patients with never presuming that. With fibroid tumors especially,  there are three really good treatments. One is hysterectomy, and if it can be  done laparoscopically even better because there is less pain and a much faster  recovery. There is also the ability to do laparoscopic myomectomy, so you can  remove the fibroids instead of removing the uterus and for a woman over 45, she  is liable not to have any other intervention and can go to menopause and not  have anything else done and her goals have been met: she did not have a  hysterectomy, she has not had an adverse effect on her, whether it is  psychological function, urinary function, bowel function, sexual function.
 
 The type of woman who accepts hysterectomy, as a good procedure will do well,  but the woman who does not accept that premise will not do well. She is going to  have problems because she is going to blame it on that hysterectomy she did not  want. The third option we offer women who do not want to have a period, but they  are sick and tired of the heavy bleeding and they do not want a hysterectomy.  There, we can combine a technique where we can remove the fibroids and the  uterine lining - this can all be done laparoscopically and the woman will go  home the day of her surgery. Our average patient is back at work in ten to  fourteen days and they are sexually active again in approximately three weeks,  on average. These laparoscopic surgeries work very, very well to cut down on  pain in recovery. 
 
 A properly counseled woman should be told, yes, there could be a change in  sexual function, but if the doctor explores her sexuality with her and prepares  her for that and discusses the alternatives to hysterectomy that are appropriate  for her, then that woman will guide the doctor to what procedure is right for  her because she will not allow herself to undergo a procedure that  psychologically attacks her defense mechanisms. So I always discuss three  alternatives when women have fibroids. Now with endometriosis, pelvic pain,  sometimes non-hysterectomy alternatives are not good choices. For pelvic  prolapse, we know you do not have to have a hysterectomy to have your prolapse  corrected, so always discuss keeping your uterus if you want to and I let the  woman make her choice. Some women, they are ready for it, they find it is a good  operation; they do not have certain feelings about it. Other women do and you  have got to respect a woman’s feelings, just like I would want someone to  respect my feelings.
 
 

 Now, I had a hysterectomy  years ago and I have not had any problems, it was abdominal and I was extremely  fortunate and also had a really good GYN who did it. So what you are saying is  that if a woman is a little nervous or reticent prior to having it done, she is  probably more apt to not be completely happy afterward.
 
 

 Everything is not explained  and she is not comfortable with the whole thing, she might be more apt to be one  that is unhappy post-surgery.
 
 

 Unless that woman can  voice that concern to the physician, just say ‘I don’t want that.’
 
 

 When do I say this,  obviously prior to the procedure? This is new for women, younger women are  probably better at it, I am not sure, but a lot of women feel that they should  not be questioning their physicians.
 
 

 So for the women who were  born in that time or think that way, we are trying to educate and that is why  you are here. What should I say to you on that visit before we decide on which  procedure to do? I could just say to you, doctor, I’m worried about this, I’m  married or not or whatever, but I’m worried about my sex life after the  procedure. Should she just not have the courage to say that or what should she  say?
 
 

 Oh, I hope she does or at  least learn some more about what she is going to have. I encourage patients to  go to the Internet, to seek out more information, even to get other opinions  about the procedures they are considering because this is a big step and they  are going to have to live with the outcome. 
 
 Two things happen: one, I think physicians go through training, they get a  knee-jerk reflex that hysterectomy is the right operation for these problems.  Now, some physicians are not trained to do myomectomies, they are worried about  the bleeding associated with the removal of the fibroids, but not the uterus.  What we know is that the proper surgical techniques result in good outcomes,  quite frequently that big, bad, bloody cases are not usually the rule in  well-trained hands. But if you do not have that skill set, you may not offer  that to the patient and yet, if you do not offer that to the patient, then they  may not do well because they might take that other option, so we always lay out  the options and that way the patient does not have to be her own advocate. But a  woman must be aware that there are all sorts of alternatives, she should be  encouraged to look for those alternatives and look into her own heart about how  she feels because this does affect your sexual organs, and it may effect your  sexual functioning. 
 
 In the largest cohort study, about 1,200 women out of Maryland, they showed that  about 5% to 10% who did not have sexual dysfunction problems before the  hysterectomy will develop sexual dysfunctions problems. Some of those may be  relational problems: the husband or boyfriend becomes a jerk after the  operation; maybe he did not want her to have the hysterectomy. I have run into  that before, where the man has that feeling. They feel they are no longer a  woman and women feel that way, so by using patient-specific therapy and not  making the patient fit into the therapy, we will have better outcomes.
 
 

 Okay, thank you, but I just  want to throw one thing because this is what I am hearing. What I am hearing is  that there are possibly three options: hysterectomy, myomectomy or the ablation.
 
 

 So, number one, before you  even get into sexual function following a hysterectomy, a woman should ask, do  you do these, all three procedures and how often have you done them? Pose those  good questions and then when you are comfortable with the doctor who is going to  do the procedure is qualified to do more than just one and you have made your  selection that you have found a really good GYN, then you should be comfortable  in sitting down and exploring post-op problems, sexual dysfunction, but she  wants a good GYN that explains the alternatives.
 
 

 I agree, Barbara, I think  the doctor is the one who should bring this forward, not the patient, if at all  possible.
 
 

 But the patient should be  aware if she is hearing hysterectomy only, she should be starting to ask  questions, like why and maybe because it’s your only option, but he will explain  that to you and that gets a good rapport going, I think, with the patient and  the physician then they can talk about the procedures that will be done and when  I have a good rapport with you, then I can ask other things.
 
 

 I think what you said is,  make sure you have a physician who is trained in different types of  alternatives, right?
 
 

 I am not trying to put  words in your mouth, but make sure you are happy with who will be doing the  procedure and makes you comfortable in the fact that they are well qualified and  then I think the woman has this wonderful opportunity to feel comfortable and  not panic.
 
 

 You have let them all know  that there are options, they should speak up and they should be comfortable in  asking their physicians just about anything they want to ask them, that is why  they are going to them.
 
 

 That is the case. Yet a  woman should not be afraid to question the expertise of her physician because in  this day and age, there has never been such a technological gap in training.  Most physicians graduated before the age of modern laparoscopy, they do not feel  comfortable doing laparoscopic surgery, they do not have the training and  therefore they do not offer the options. They are aware of them and they should  offer therapies they do not do, that is the ethics of medicine.
 
 

 Well, I thank you and I  think this will help educate a lot of women before the procedure as well as  after. Thank you, Doctor; it has been wonderful talking to you.
 
 

 I hope so. Thank you for  taking an interest in this subject.
 
 

OBGYN.net Conference CoverageFrom the 32nd Annual Meeting of the American Association of Gynecological Laparoscopists (AAGL)

Sexual dysfunction following hysterectomy

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Michael L. Moore, MD

Articles

Transvaginal Hydro Laparoscopy: Preliminary Assessment of Cost-Effectiveness

Sexual dysfunction following hysterectomy

Sexual dysfunction following hysterectomy video