The investigation of infertile couples should be: Rapid inexpensive using minimally invasive tests (Gomel and McComb2010) The focus of treatment for infertility has shifted from the systematic correction of each identified factor to applying the most efficient therapy, which may be ART (Speroffand Fritz 2011).

Basic investigations of infertility: ovulation HSG Conventional semen analysis. Infertility is described as ‘unexplained’ when standard investigations are normal(NICE, 2013)

Laparoscopy reserved for further diagnosis or may be used in combination with endoscopic surgery ART: may be performed on suboptimally investigated couples. reduced the need for reproductive surgery as a primary surgical treatment of infertility.

DIAGNOSTIC LAPAROSCOPY

Laparoscopy as a diagnostic tool in infertility has diminished markedly Today, we rarely perform diagnostic laparoscopy in infertile women. (Tulandi, 2017) 1.The benefit of diagnostic laparoscopy with no risk factors for intra-abdominal adhesions: small 2.Treatment of stage I or II endometriosis: small increase in PR. 3.Alternative treatments of infertility are available Superovulation with IUI IVF.

Indications

3. Three cycles of superovulation with IUI are unsuccessful. 1.Abnormal HSG or US 2.Young women with history or symptoms suggestive of pelvic disease. Even if HSG indicates patency in one or both tubes a.A history of PID, b.Ectopic pregnancy. c.Pelvic surgery. d.Chronic pelvic pain 3. Three cycles of superovulation with IUI are unsuccessful. diagnostic laparoscopy or IVF treatment (ASRM, 2012; TulandiT 2017) 4. After failed IVF

Laparoscopy after failed IVF:(Littman et al.,). Pathology in 50% endometriosis or adhesions No RCTs have confirmed this rate.

Diagnostic laparoscopy can be avoided in 1.Older women 2.Multiple infertility factors. 3.Severe ♂factor. a. These women are better served by IVF, instead of a surgical approach to treatment b.The presence of endometriosis and adhesions does not markedly influence the effectiveness of IVF

Laparoscopy should be omitted in couples with unexplained infertility Laparoscopy may reveal minimal or mild endometriosis or Peri tubal adhesions Surgery or medical thas not been proven to improve fecundity.

Treatment indicated if duration > 2 y age >35 y 3 cycles of Gnt & IU I if unsuccessful : IVF(Bhattacharya et al.,; Collins et al.,) This approach most cost effective efficient treatment protocol. (Fatum, et al . 2002; Balasch2000; Badawyet al 2008) As a result, laparoscopy is not routine work-up for infertility. The role of diagnostic laparoscopy in the management of infertility is limited.

Findings and benefits: 1.General view of the pelvic organs 2.Minimal and mild endometriosis not detected on TVS or HSG treated laparoscopically 3.Bowel and/or pelvic peritoneal adhesions 4.Milder forms of distal tubal occlusive disease 1.Fimbrial agglutination 2.Fimbrialphimosis determine fimbrial function in addition to the patency of tubes, which is vital for ovum retrieval(Speroff and Fritz 2011). 5. Confirmation of tubal patency: Spillage of the dye from each tube

HSG Vs Laparoscopy: false-negatives are more tubal blockages are often false-positives obstructions diagnosed by laparoscopy are most likely true positives. Prognosis of a tubal obstruction (unilateral and/or bilateral) is poorer when diagnosed with laparoscopy than with HSG

OPERATIVE LAPAROSCOPY

Reproductive surgery 1.Treatment of infertility 2.Enhance the pregnancy outcome of IVF 3.Preservation of fertility

4.Uterine: 1.Endometriosis 2.Ovarian: OD 3.Tubal: 1.Moymectomy TREATMENT OF INFERTILITY 1.Endometriosis 2.Ovarian: OD 3.Tubal: 1.Adhesions: adhesolysis 2.Obstructions: Tubal reanastomosis 3.Distal tubal obstruction 4.Hydrosalpinx 4.Uterine: 1.Moymectomy 2.Adenomyomectom

.ENDOMETRIOSIS

Operative Laparoscopy (Jozwiaket al, 2015) an efficient method most effective particularly at stage III

Endometriosis: excision or ablation of the endometriosis lesions adhesiolysis can be ablated or excised using Scissors electrocoagulation, laser ultrasonic cutting and coagulation device (eg, Harmonic Scalpel) Excision: more complete removal than electrocoagulation, which is especially important for women with pelvic pain(

does not decrease ovarian reserve. Medical therapy of an endometrioma larger than 1 cm not effective [Donnezet al, 2001] Aspiration Not effective recurrence rate of 88% at six months follow-up [SalehA, Tulandi, 2000]. ultrasound-guided sclerotherapy. Using absolute alcohol low recurrence rate compared with surgery does not decrease ovarian reserve. In a meta analysis of 18 studies, CPR after IVF were similar for women treated with sclerotherapy and surgery [Cohen et al, 2017].

IVF 1. Age ≥38 y 2. Infertility is long lasting. 3 IVF 1.Age ≥38 y 2.Infertility is long lasting. 3.Diminished ovarian reserve 4.Tubal function is compromised 5.Male factor infertility 6.Bilateral endometriomas 7.Other treatments have failed. 8.Prior surgical treatment In patients who failed to conceive spontaneously after surgery: ART is more effective than repeat surgery. {GPP; Polatet al, 2015) After surgery{cumulative endometriosis recurrence rates are not increased after COS for IVF/ICSI}(D’Hooghe et al., 2006; Benaglia et al., 2010;Coccia et al., 2010; Benaglia et al., 2011). {C}

2. Surgery Stage I/II: Operative laparoscopy rather than diagnostic laparoscopy only, to increase PR(Nowrooziet al., 1987; Jacobson et al., 2010).{A

Endometrioma Pre cycle resection of endometriomas: does not have benefit should only be performed for gynecologic indications. deleterious impact on ovarian reserve and response.(Surrey, 2015)

Hormonal treatment Before surgery to improve spontaneous PR No For pain Yes After surgery to improve spontaneous PR No

Treatment for anovulatory infertility in PCOS 1.Weight reduction. 1.Lifestyle modifications 2.Pharmacological 3.Bariartricsurgery 2.Oral anti-estrogens . 1.CC 2.Letrozole 3.Tamoxifen 4-Gonadotropins 3-Insulin sensitizers 1.Metformin 2.Myoinsitol 3.. laparoscopic ovarian drilling .4. IVF and ICSI

Indications: 1.Failure of ovulation despite an adequate trial of CC and metformin 2.Normal weight{often unsuccessful in obese women} 3.Absence of other causes of infertility

Tubal surgery

Classification of Tubal disease British Fertility Society Minor Proximal occlusion without tubal fibrosis Distal occlusion without tubal distension Healthy mucosal appearance at HSG, salpingoscopy Flimsy peritubal/ovarian adhesions. Intermediate Unilateral severe tubal damage Limited dense adhesions of tubes & ovaries Severe Bilateral severe tubal damage Extensive tubal fibrosis Tubal distension >1.5 cm Abnormal mucosal appearance Bipolar occlusion Extensive dense adhesion

Tubal infertility: corrective surgery or IVF. (ASRM, 2015) Tubal infertility: corrective surgery or IVF?(ASRM, 2015) .Age of the woman .Number of children desired .Patient preference. .Ovarian reserve .Number and quality of sperm in the ejaculate .Presence of other infertility factors .Site and extent of tubal disease .Experience of the surgeon .Success rates of the IVF program .Cost

Surgery may be considered for young women mild distal tubal disease{if successful, one surgical procedure: several pregnancies where as IVF

IVF is more likely than surgery to be successful in women with: bilateral hydrosalpinx older women women with severe disease severe hydrosalpinx extensive and dense adhesions both proximal and distal tubal occlusion {PR after reconstructive surgery in women with bipolar tubal blockage: 12 % at 2.5 years follow-up}

IVF vs tubal surgery (ASRM,) delayed conception increased ectopic PR IVF: higher per-cycle PR. ectopic pregnancy 1.8 % which is similar to that in the general population. The IVF ectopic rate, however, doubles in those with tubal factor. PR per cycle after IVF: 40.6%.

WHY? Negative effect on PR, IR, early pregnancy loss & Treatment of hydrosalpinx before IVF Negative effect on PR, IR, early pregnancy loss & WHY? The fluid of hydrosalpinx: 1.Mechanical barrier to implantation: embryo to float 2.Deficient to support the developing embryo 3.Toxic to the developing embryo

Irreparable not candidates for corrective tubal surgery Hydrosalpinx: Mild: The evidence is fair to recommend Laparoscopic fimbrioplasty or Neo salpingostomy in young women no other significant infertility factors Irreparable not candidates for corrective tubal surgery There is good evidence for recommending laparoscopic salpingectomy or proximal tubal occlusion to improve IVF pregnancy rates

4. Uterine 1. Myomectomy

2. Failed natural conception or IVF: repeat IVF 3. Failed IVF: Adenomyomectomy Management of women with adenomyosis-associated infertility(Tsuiet al, 2015). 1.Routine infertility investigation Normal: long agonist protocol and natural conception Abnormal: IVF 2. Failed natural conception or IVF: repeat IVF 3. Failed IVF: conservative surgery IVF after 3 m

radiation therapy for malignancy PRESERVATION OF FERTILITY in young women at risk of premature ovarian failure, such as those undergoing chemotherapy or radiation therapy for malignancy