Name: fertility sparing procedure using carbon dioxide fiber laser vaporization of ovarian endometrioma
Uploaded: 2022-07-06T13:00:00.000+00:00
Duration: 6 min 24 s
Description: Watch this Scientific Journal Video about Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma at JoVE.com

No external funding was either sought or obtained for this study.

All the studies were conducted in compliance with the Declaration of Helsinki, as outlined in the International Conference on Harmonization Guidelines for Good Clinical Practice. Written informed consent for data collection and anonymous publication of disease-related information is routinely obtained at the institution during patient interviews preceding surgical treatment. Women participating in the randomized controlled study signed a specific informed consent form. The Institutional Review Board of the institution approved all the studies. A diagram of the studies&#39; protocols is shown in Figure 1.
1. Patient selection
<ol>
	<li>Only include women with primary unilateral or bilateral endometriomas, with the largest cyst diameter between 3-8 cm, of reproductive age, and who have undergone surgery at San Raffaele Scientific Institute for pain or infertility.</li>
	<li>Additionally, exclude patients aged &#8805; 40 years; with previous surgery of the ovaries, unilateral oophorectomy, salpingectomy, or hysterectomy; with endocrine diseases; undergoing hormonal treatment within 3 months of ovarian reserve assessment; or with suspicion of ovarian atypical endometriosis at the pre-operative ultrasound evaluation stage.</li>
</ol>
2. Patient characteristics
<ol>
	<li>Identify the basal patient characteristics as follows. At baseline (before surgery), perform a detailed medical interview and pelvic ultrasound scan. In particular, collect data regarding age, surgical indication, offspring desire, body mass index (BMI), volume (expressed in cm3) and mean diameter (expressed in cm) of unilateral or bilateral endometrioma, and the volume of each ovary.</li>
	<li>For ovarian reserve analysis, check the antral follicular count (AFC) and antimullerian hormone (AMH) levels. At baseline (during the first 2-3 days of the menstrual cycle), evaluate the AFC by pelvic ultrasound, and collect blood samples to determine AMH levels. Assess the AFC in both ovaries, before and after surgery, by counting the number of follicles with an average diameter of 2-10 mm.</li>
</ol>
3. Surgical technique
NOTE: A team of surgeons with extensive experience in the treatment of endometriosis is required.
<ol>
	<li>First, place the patient on the operating table with their legs placed into stirrups.</li>
	<li>After administering general anesthesia, place the patient in the lithotomic position, a variation of the supine position in which the legs are separated from the midline in a 30&#176; to 45&#176; abduction with the hips flexed until the thighs form an angle between 80&#176; and 100&#176;.</li>
	<li>Establish a sterile field by cleaning the following areas with a sponge soaked in antiseptic solution: the apex of the umbilicus, the abdomen, the perineum, and the top third of the thighs. Then, scrub with a gauze drenched in iodine solution the vulva and, when possible, the vaginal interior up to the cervix and discard it. Repeat this step 3x.</li>
	<li>With a new sponge drenched in iodine solution, swab the anus twice and discard it. Dry the prepared external areas with a sterile towel and place sterile drapes. Insert a urethral catheter for continuous bladder drainage.</li>
	<li>When possible, with the use of an anterior and posterior vaginal retractor, expose the cervix and insert the uterine manipulator into the cervix. Create a pneumoperitoneum by either a Verres needle inserted at an angle of 45&#176; in non-obese patients to 90&#176; in obese patients) or using the open technique (a small, 1 cm incision is made below the umbilicus on the midline). Keep the insufflation pressure between 12 mmHg and 14 mmHg.</li>
	<li>Insert a laparoscope and inspect the upper and lower abdomen. After positioning the patient in a slight Trendelenburg position, place the other laparoscopic access (usually two or three). Perform either CO2 fiber laser ablation or stripping technique as described below.</li>
	<li>One-step CO2 fiber laser vaporization
	<ol>
		<li>Firstly, mobilize both adnexa to restore the normal anatomy of the pelvis. Then, by using an aspiration or irrigation device, drain the cyst content and irrigate and inspect its inner wall. Take a biopsy of the cyst wall using scissors and send it for routine histological examination to confirm the diagnosis of endometriosis.</li>
		<li>Select the basic operation mode and set the device to fiber laser mode with the continuous wave and constant timed-exposure mode at a power density of 13-15 W13.</li>
		<li>Evert the cyst with grasping forceps in order to expose the inner cystic wall and completely vaporize the inner wall with a CO2 fiber laser in a radial way, starting from the center to the periphery, keeping the tip of the fiber at a distance of at least 1 cm from the cystic surface (see Table of Materials).</li>
		<li>Do not suture the ovary after vaporization. Carefully control any source of bleeding at the end of the procedure using the water test (i.e., washing the bleeding sites to visualize and achieve hemostasis selectively) or by slightly reducing the pneumoperitoneum.</li>
	</ol>
	</li>
	<li>Cystectomy
	<ol>
		<li>Start with adhesiolysis in order to free the ovaries from the surrounding structures. Make a sharp cortical incision on the thinnest part of the cyst, just enough to identify the correct cleavage plane. Avoid making the incision close to the fallopian tube or fimbriae.</li>
		<li>Take the edges of the incision with two grasping forceps and strip out the cyst from the healthy ovarian parenchyma by delicate traction and counter traction maneuvers.</li>
		<li>After removal of the cyst, perform selective hemostasis with bipolar coagulation using the water test, mainly on the edges of the ovary, to reduce the risk of ovarian damage13.</li>
	</ol>
	</li>
	<li>At the end of the surgery, carefully remove the uterine manipulator if positioned. Suture the fascia with a medium absorption rate braided suture size 0 and the skin with a quick absorption rate suture size 3-0. Place patches on all the incisions and remove the urethral catheter the day after the surgical procedure.</li>
</ol>
4. Post-operative follow-up and testing
<ol>
	<li>Identify the endometriosis stage. Perform endometriosis staging according to the revised American Society for Reproductive Medicine (r-ASRM) classification17. Calculate the lesion score and total score at the end of surgery based on the surgery report, according to the standards of the r-ASRM classification, and report these as the r-ASRM score.</li>
	<li>Follow-up 30 days after the surgical procedure. After surgery, refer the patient to the endometriosis outpatient clinic for follow-up. In the case of patients with no immediate pregnancy intention, prescribe hormonal therapy (progestins or estroprogestins).</li>
	<li>Assess recurrence rate. 
	NOTE: To assess the recurrence rate, the minimum follow-up duration is 12 months.
	<ol>
		<li>Perform periodic gynecological examinations at intervals ranging from 3-12 months, according to patients&#39; offspring desire or onset of symptoms (i.e., dysmenorrhea, chronic pelvic pain, dyspareunia).</li>
		<li>At every follow-up, perform a gynecological examination as well as a transvaginal ultrasound to check for recurrence of the endometriotic cyst. In case of the identification of a cyst with a typical sonographic aspect and a diameter of more than 10 mm arising on the operated ovary, confirmed by transvaginal ultrasound, consider it as cyst recurrence. Assess the symptoms of cyst recurrence by interviewing the patient.</li>
	</ol>
	</li>
	<li>Assess pregnancy outcomes. Allow patients wishing to conceive to attempt spontaneous conception for a period of 6-9 months in the case of CO2 fiber laser vaporization and for a period of 12 months after cystectomy. If spontaneous conception fails, refer the patients immediately for assisted reproductive techniques (ART). 
	NOTE: Pregnancy is defined as the evidence of a vital embryo in utero by transvaginal ultrasound at 6 weeks of pregnancy. As suggested by usual clinical practice, in case of the absence of fetal cardiac activity at 6 weeks of pregnancy, wait for at least 7-10 days to diagnose a pregnancy loss. The time taken for spontaneous conception is defined as the interval between surgery and spontaneous conception (or the first IVF when natural conception fails). Do not include patients who become pregnant following oocyte donor-IVF.</li>
</ol>

<ol>
	<li>Bafort, C., Beebeejaun, Y., Tomassetti, C., Bosteels, J., Duffy, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+surgery+for+endometriosis.">Laparoscopic surgery for endometriosis.</a> The Cochrane Database of Systematic Reviews. 10 (10), (2020).</li><li>Somigliana, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+excision+of+endometriomas+and+ovarian+reserve:+a+systematic+review+on+serum+antim&#252;llerian+hormone+level+modifications.">Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antim&#252;llerian hormone level modifications.</a> Fertility and sterility. 98 (6), 1531-1538 (2012).</li><li>Uncu, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+assessment+of+the+impact+of+endometriomas+and+their+removal+on+ovarian+reserve+and+determinants+of+the+rate+of+decline+in+ovarian+reserve.">Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve.</a> Human Reproduction. 28 (8), 2140-2145 (2013).</li><li>Alborzi, S., Keramati, P., Younesi, M., Samsami, A., Dadras, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+impact+of+laparoscopic+cystectomy+on+ovarian+reserve+in+patients+with+unilateral+and+bilateral+endometriomas.">The impact of laparoscopic cystectomy on ovarian reserve in patients with unilateral and bilateral endometriomas.</a> Fertility and Sterility. 101 (2), 427-434 (2014).</li><li>Muzii, L., Bianchi, A., Croce, C., Manci, N., Panici, P. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+excision+of+ovarian+cysts:+is+the+stripping+technique+a+tissue-sparing+procedure.">Laparoscopic excision of ovarian cysts: is the stripping technique a tissue-sparing procedure.</a> Fertility and Sterility. 77 (3), 609-614 (2002).</li><li>Sanchez, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+distinguishing+cellular+and+molecular+features+of+the+endometriotic+ovarian+cyst:+from+pathophysiology+to+the+potential+endometrioma-mediated+damage+to+the+ovary.">The distinguishing cellular and molecular features of the endometriotic ovarian cyst: from pathophysiology to the potential endometrioma-mediated damage to the ovary.</a> Human Reproduction Update. 20 (2), 217-230 (2014).</li><li>Benaglia, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rate+of+severe+ovarian+damage+following+surgery+for+endometriomas.">Rate of severe ovarian damage following surgery for endometriomas.</a> Human Reproduction. 25 (3), 678-682 (2010).</li><li>Muzii, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Histologic+analysis+of+specimens+from+laparoscopic+endometrioma+excision+performed+by+different+surgeons:+does+the+surgeon+matter.">Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: does the surgeon matter.</a> Fertility and Sterility. 95 (6), 2116-2119 (2011).</li><li>La Torre, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ovarian+blood+flow+before+and+after+conservative+laparoscopic+treatment+for+endometrioma.">Ovarian blood flow before and after conservative laparoscopic treatment for endometrioma.</a> Clinical and Experimental Obstetrics &amp; Gynecology. 25 (1-2), 12-14 (1998).</li><li>Loh, F. H., Tan, A. T., Kumar, J., Ng, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ovarian+response+after+laparoscopic+ovarian+cystectomy+for+endometriotic+cysts+in+132+monitored+cycles.">Ovarian response after laparoscopic ovarian cystectomy for endometriotic cysts in 132 monitored cycles.</a> Fertility and Sterility. 72 (2), 316-321 (1999).</li><li>Candiani, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ovarian+recovery+after+laparoscopic+enucleation+of+ovarian+cysts:+insights+from+echographic+short-term+postsurgical+follow-up.">Ovarian recovery after laparoscopic enucleation of ovarian cysts: insights from echographic short-term postsurgical follow-up.</a> Journal of Minimally Invasive Gynecology. 12 (5), 409-414 (2005).</li><li>Donnez, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Large+ovarian+endometriomas.">Large ovarian endometriomas.</a> Human Reproduction. 11 (3), 641-646 (1996).</li><li>Candiani, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+ovarian+reserve+after+cystectomy+versus+'one-step'+laser+vaporization+in+the+treatment+of+ovarian+endometrioma:+a+small+randomized+clinical+trial.">Assessment of ovarian reserve after cystectomy versus 'one-step' laser vaporization in the treatment of ovarian endometrioma: a small randomized clinical trial.</a> Human Reproduction. 33 (12), 2205-2211 (2018).</li><li>Candiani, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fertility+outcome+after+CO2+laser+vaporization+versus+cystectomy+in+women+with+ovarian+endometrioma:+a+comparative+study.">Fertility outcome after CO2 laser vaporization versus cystectomy in women with ovarian endometrioma: a comparative study.</a> Journal of Minimally Invasive Gynecology. 28 (1), 34-41 (2021).</li><li>Ottolina, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ovarian+responsiveness+in+assisted+reproductive+technology+after+CO2+fiber+laser+vaporization+for+endometrioma+treatment:+preliminary+data.">Ovarian responsiveness in assisted reproductive technology after CO2 fiber laser vaporization for endometrioma treatment: preliminary data.</a> Minerva Endocrinologica. 45 (4), 288-294 (2020).</li><li>Candiani, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recurrence+rate+after+&amp;#34;one-step&amp;#34;+CO2+fiber+laser+vaporization+versus+cystectomy+for+ovarian+endometrioma:+a+3-year+follow-up+study.">Recurrence rate after &amp;#34;one-step&amp;#34; CO2 fiber laser vaporization versus cystectomy for ovarian endometrioma: a 3-year follow-up study.</a> Journal of Minimally Invasive Gynecology. 27 (4), 901-908 (2020).</li><li>American Society for Reproductive Medicine. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Revised+American+Fertility+Society+classification+of+endometriosis:+1996.">Revised American Fertility Society classification of endometriosis: 1996.</a> Fertility and Sterility. 67 (5), 817-821 (1997).</li><li>Hart, R. J., Hickey, M., Maouris, P., Buckett, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Excisional+surgery+versus+ablative+surgery+for+ovarian+endometriomata.">Excisional surgery versus ablative surgery for ovarian endometriomata.</a> The Cochrane Database of Systematic Reviews. (2), (2008).</li><li>Daniell, J. F., Kurtz, B. R., Gurley, L. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laser+laparoscopicmanagement+of+large+endometriomas.">Laser laparoscopicmanagement of large endometriomas.</a> Fertility and Sterility. 55 (4), 692-695 (1991).</li><li>Sutton, C. J., Ewen, S. P., Jacobs, S. A., Whitelaw, N. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laser+laparoscopic+surgery+in+the+treatment+of+ovarian+endometriomas.">Laser laparoscopic surgery in the treatment of ovarian endometriomas.</a> The Journal of the American Association of Gynecologic Laparoscopists. 4 (3), 319-323 (1997).</li><li>Donnez, J., Pirard, C., Smets, M., Jadoul, P., Squifflet, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+endometriosis.+Best+practice+&amp;+research.">Surgical management of endometriosis. Best practice &amp; research.</a> Clinical Obstetrics &amp; Gynaecology. 18 (2), 329-348 (2004).</li><li>Sutton, C. J., Jones, K. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laser+laparoscopy+for+endometriosis+and+endometriotic+cysts.">Laser laparoscopy for endometriosis and endometriotic cysts.</a> Surgical Endoscopy. 16 (11), 1513-1517 (2002).</li><li>Roman, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ovarian+endometrioma+ablation+using+plasma+energy+versus+cystectomy:+a+step+toward+better+preservation+of+the+ovarian+parenchyma+in+women+wishing+to+conceive.">Ovarian endometrioma ablation using plasma energy versus cystectomy: a step toward better preservation of the ovarian parenchyma in women wishing to conceive.</a> Fertility and Sterility. 96 (6), 1396-1400 (2011).</li><li>Muzii, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Histologic+analysis+of+endometriomas:+what+the+surgeon+needs+to+know.">Histologic analysis of endometriomas: what the surgeon needs to know.</a> Fertility and Sterility. 87 (2), 362-366 (2007).</li><li>Roman, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vaporization+of+ovarian+endometrioma+using+plasma+energy:+histologic+findings+of+a+pilot+study.">Vaporization of ovarian endometrioma using plasma energy: histologic findings of a pilot study.</a> Fertility and Sterility. 95 (5), 1853 (2011).</li><li>Donnez, J., Wyns, C., Nisolle, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+ovarian+surgery+for+endometriomas+impair+the+ovarian+response+to+gonadotropin.">Does ovarian surgery for endometriomas impair the ovarian response to gonadotropin.</a> Fertility and Sterility. 76 (4), 662-665 (2001).</li><li>Vanni, V. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Flexible+CO2+laser+fiber:+first+look+at+the+learning+curve+required+in+gynecological+laparoscopy+training.">Flexible CO2 laser fiber: first look at the learning curve required in gynecological laparoscopy training.</a> Minerva Ginecologica. 70 (1), 53-57 (2018).</li><li>Pados, G., Tsolakidis, D., Assimakopoulos, E., Athanatos, D., Tarlatzis, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonographic+changes+after+laparoscopic+cystectomy+compared+with+three-stage+management+in+patients+with+ovarian+endometriomas:+a+prospective+randomized+study.">Sonographic changes after laparoscopic cystectomy compared with three-stage management in patients with ovarian endometriomas: a prospective randomized study.</a> Human Reproduction. 25 (3), 672-677 (2010).</li><li>Tsolakidis, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+impact+on+ovarian+reserve+after+laparoscopic+ovarian+cystectomy+versus+three-stage+management+in+patients+with+endometriomas:+a+prospective+randomized+study.">The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study.</a> Fertility and Sterility. 94 (1), 71-77 (2010).</li><li>Roman, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Postoperative+recurrence+and+fertility+after+endometrioma+ablation+using+plasma+energy:+retrospective+assessment+of+a+3-year+experience.">Postoperative recurrence and fertility after endometrioma ablation using plasma energy: retrospective assessment of a 3-year experience.</a> Journal of Minimally Invasive Gynecology. 20 (5), 573-582 (2013).</li><li>Carmona, F., Mart&#237;nez-Zamora, M. A., Rabanal, A., Mart&#237;nez-Rom&#225;n, S., Balasch, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ovarian+cystectomy+versus+laser+vaporization+in+the+treatment+of+ovarian+endometriomas:+a+randomized+clinical+trial+with+a+five-year+follow-up.">Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up.</a> Fertility and Sterility. 96 (1), 251-254 (2011).</li></ol>

The authors have no conflicts of interest to disclose.

The aim of this method is to provide a comprehensive overview of our experience with CO2 fiber laser technology at San Raffaele Scientific Institute since 2015, when the use of this technique first started for the surgical management of endometriomas. Since endometriosis is a chronic benign gynecological condition affecting women of reproductive age with potential offspring desire, surgical techniques need to be as fertility-sparing as possible.
A Cochrane review18...

The best surgical treatment for ovarian endometriosis, especially when fertility preservation is a priority for women with a desire for offspring, is still a matter of debate. Although cystectomy is still the recommended technique1, previous studies have raised some concerns about its possible detrimental effect on ovarian reserve and reproductive outcomes due to the inadvertent removal of healthy ovarian parenchyma2,3,4.
Indeed, unlike non-endometriotic cysts, endometrioma is a pseudocyst not surrounded by a real anatomic capsule5, in which inflammation caused by free iron and reactive oxygen species (ROS) plays a role in the substitution of the surrounding normal ovarian cortical tissue with fibrous tissue6. Thus, the absence of a clear cleavage plan may lead to an increased risk of removing healthy ovarian parenchyma, even when cystectomy is performed by experienced surgeons7,8.
Moreover, cystectomy-mediated injuries could lead to compromised vascularization due to the diffusion of thermal damage to the surrounding healthy ovarian parenchyma during coagulation, as shown by previous findings where adverse changes in the ovarian artery blood flow were reported after cystectomy9,10,11.
At our institution, concerns about ovarian damage after cystectomy led to the introduction of CO2 fiber laser technology since in 2015. This surgical procedure, which can deliver energy with a controlled tissue penetration depth and little thermal spread, was inspired by the work of Jacques Donnez more than 20 years ago12.
Although ablative techniques involving CO2 fiber laser technology do not represent a novelty in the surgical management of endometrioma, many surgeons may not feel confident with the procedure. Indeed, only a few studies have investigated the impact of this technique on ovarian reserve, pregnancy outcome, and the rate of recurrence of endometriosis. The aim of this protocol is to provide an overview of the promising results obtained using the CO2 fiber laser technology since its introduction in 2015 and to describe the simplicity and reproducibility of this technique.
Firstly, in order to assess the impact of CO2 fiber laser vaporization and cystectomy on ovarian reserve markers, a multicenter randomized trial was conducted between 2017 and 2018. A total of 60 patients were randomly assigned either to Group 1 (cystectomy: 30 patients) or Group 2 (CO2 laser vaporization: 30 patients) at a ratio of 1:1, by using a computer-generated randomization list that used the simple randomization method13. To investigate postoperative spontaneous conception, a prospective observational study was conducted between 2015 and 2019 on 142 women, comparing cystectomy and laser vaporization14. When pregnancy was not achieved after CO2 fiber laser vaporization, patients were referred to in-vitro fertilization (IVF) clinics and were then included (n = 26) in a prospective observational study to investigate ovarian responsiveness to controlled ovarian stimulation15. Following this, a retrospective analysis of a larger sample size study population (n = 125, women with or without offspring desire), who were treated between 2015 and 2018 and whose follow-up lasted at least 12 months, was performed to assess the recurrence rate of a cyst and/or pain symptoms after both the surgical techniques16.

<table><tbody><tr><td>CO2 fiber laser</td><td>UltraPulse Duo system, Lumenis Ltd</td><td>AC-1059590</td><td></td></tr><tr><td>Insufflation Needle</td><td>Covidien</td><td>10065003</td><td></td></tr><tr><td>Laparoscopic Forceps</td><td>Erbe Elektromedizin GmbH</td><td>20195-133</td><td></td></tr><tr><td>Manipulator</td><td>Lumenis Ltd</td><td></td><td></td></tr><tr><td>UltraPulse Duo</td><td>Lumenis Ltd</td><td>GA-2000000</td><td>CO2 laser system</td></tr><tr><td>VIO 3</td><td>Erbe Elektromedizin GmbH</td><td>10160-000</td><td>electrosurgical unit</td></tr><tr><td>Voluson S8</td><td>GE Healthcare</td><td>186958SU5</td><td>ultrasound scan voluson system 8</td></tr></tbody></table>

fertility sparing procedure using carbon dioxide fiber laser vaporization of ovarian endometrioma

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated with a potential reduction in the ovarian reserve due to the inadvertent removal and thermal damage of healthy ovarian tissue. New ablative techniques with reduced tissue penetration depth and less thermal spread to the surrounding parenchyma may represent a viable alternative to cystectomy. For these reasons, the aim of this manuscript is to demonstrate the ablation of the endometrioma capsule using a CO2 fiber laser technique and discuss the clinical outcomes. Once the cyst has been drained and washed, a biopsy is taken. After cyst eversion, vaporization of the inner surface of the cyst is performed using a CO2 fiber laser. The technique is simple and reproducible as even young surgeons without any surgical experience were more confident in performing laser CO2 vaporization instead of cystectomy. The positive effects of CO2 technology are reported in a randomized controlled trial, where the postoperative changes in the antral follicular count (AFC) and antimullerian hormone (AMH) levels were compared between patients who had their endometrioma excised (cystectomy) and those who had undergone endometrioma vaporization with CO2 laser. The patients treated with CO2 laser showed significantly increased AFC without a reduction in serum AMH levels as compared to the cystectomy group, in which both parameters were significantly reduced. The postoperative pregnancy rate was also assessed, and comparable pregnancy rates were found after both treatments. On the contrary, patients treated with the CO2 fiber laser technique had more favorable in-vitro fertilization (IVF) outcomes compared to cystectomy.
In conclusion, the CO2 fiber laser technique may represent a viable alternative to cystectomy in the surgical treatment of endometrioma in terms of ovarian preservation, pregnancy rates, and IVF outcomes. Moreover, it has the advantage of being independent of the surgeon's skills and personal experience.

The details of the outcomes of the included studies are shown in Table 1.
Ovarian reserve after one-step laser vaporization versus cystectomy in the treatment of ovarian endometrioma13 
The aim of this randomized controlled study was to compare the two surgical procedures for endometrioma treatment (cystectomy versus CO2 laser vaporization) in terms of their impact on ovarian reserve markers (AFC and serum AMH concentrat...

Watch this Scientific Journal Video about Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma at JoVE.com

Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated ...

fertility-sparing-procedure-using-carbon-dioxide-fiber-laser

Research

JoVE Journal

Medicine

4.6K Views.  San Raffaele Scientific Institute. In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

Video: Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

Epidural Intracranial Pressure Measurement in Rats Using a Fiber-optic Pressure Transducer

Elevated intracranial pressure (ICP) is a significant problem in several forms of ischemic brain injury including stroke, traumatic brain injury and cardiac arrest. This elevation may result in further neurological injury, in the form of transtentorial herniation1,2,3,4, midbrain compression, neurological deficit or increased cerebral infarct2,4. Current therapies are often inadequate to control elevated ICP in the clinical setting5,6,7 . Thus there is a need for accurate methods of ICP measurement in animal models to further our understanding of the basic mechanisms and to develop new treatments for elevated ICP.
In both the clinical and experimental setting ICP cannot be estimated without direct measurement. Several methods of ICP catheter insertion currently exist. Of these the intraventricular catheter has become the clinical 'gold standard' of ICP measurement in humans8. This method involves the partial removal of skull and the instrumentation of the catheter through brain tissue. Consequently, intraventricular catheters have an infection rate of 6-11%9. For this reason, subdural and epidural cannulations have become the preferred methods in animal models of ischemic injury. 
Various ICP measurement techniques have been adapted for animal models, and of these, fluid-filled telemetry catheters10 and solid state catheters are the most frequently used11,12,13,14,15. The fluid-filled systems are prone to developing air bubbles in the line, resulting in false ICP readings. Solid state probes avoid this problem (Figure 1). An additional problem is fitting catheters under the skull or into the ventricles without causing any brain injury that might alter the experimental outcomes. Therefore, we have developed a method that places an ICP catheter contiguous with the epidural space, but avoids the need to insert it between skull and brain. 
An optic fibre pressure catheter (420LP, SAMBA Sensors, Sweden) was used to measure ICP at the epidural location because the location of the pressure sensor (at the very tip of the catheter) was found to produce a high fidelity ICP signal in this model. There are other manufacturers of similar optic fibre technologies13 that may be used with our methodology. Alternative solid state catheters, which have the pressure sensor located at the side of the catheter tip, would not be appropriate for this model as the signal would be dampened by the presence of the monitoring screw. 
Here, we present a relatively simple and accurate method to measure ICP. This method can be used across a wide range of ICP related animal models.

A novel technique to record the pressures within the skull is described. The minimally invasive method uses a fibre-optic pressure sensing system to accurately measure intracranial pressure (ICP) in anaesthetized rats without causing significant brain trauma. The technique may be used in a wide range of experimental models.

Elevated intracranial pressure (ICP) is a significant problem in several forms of ischemic brain injury including stroke, traumatic brain injury and ...

Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method.
This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture&#8217;s morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures.
Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels.
Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.

Here we present a method to stabilize sternal fractures by using locked titanium plates in a low profile design. Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates provides a safe surgical way.

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the ...

Assessing Ovarian Reserve in Young Patients Using Z-Scores for Follicle Density

Z-Scores for Assessing Ovarian Reserve in Young Patients Undergoing Fertility Preservation

Women are born with a non-renewable pool of ovarian follicles, referred to as the ovarian reserve. This reserve consists of primordial follicles in the ovaries and can be affected by many factors, such as genetic and endocrine disorders, medical interventions, and endocrine disruptors. Fertility preservation is recommended when gonadotoxic treatments are necessary. The preferred options for women are oocyte and embryo cryopreservation. However, in very young, sexually immature patients, ovarian tissue cryopreservation is the only option. Knowing the follicular density of cryopreserved tissue samples is essential in fertility counseling for young patients. This protocol demonstrates the use of Z-scores for cortical follicle density as a tool to evaluate the quality of ovarian tissue in girls and young women aged 25 years and below who are undergoing fertility preservation. Follicle density in patient samples is compared to age-normalized reference standards, developed by Hassan et al. to estimate possible deviations from the standard. The follicle density is measured through histological quantification. For this, a small piece of ovarian cortical tissue (~2 mm x 2 mm x 2 mm) is fixed in either Bouin&#39;s or formaldehyde solution, embedded in paraffin, sectioned at 4 &#181;m thickness, stained with hematoxylin and eosin, and digitized using a slide scanner. Follicular stages present in the cortex range from primordial to primary follicles. The cortical area was 1 mm from the surface epithelium on histological sections. Follicle density is calculated using a modified formula presented by Schmidt et al., and the Z-score is determined using the reference mean and standard deviation. The Z-score indicates how much the measured value deviates from the reference mean, determining&#160;reduced (&#60;-1.7 Z-score) ovarian reserve. With this method, follicle densities can be used as a valuable measure of ovarian reserve for young patients requiring fertility preservation.

Author Spotlight: Advancing Fertility Assessment with Z-Score-Based Follicle Density Evaluation in Cryopreserved Ovarian Tissue

The present protocol describes a method for assessing ovarian reserve in patients under 25 years old who require fertility preservation through ovarian tissue cryopreservation. This method involves: (1) histological assessment of ovarian reserve in cortical samples, (2) comparison to a reference dataset, and (3) calculation of Z-scores.

Women are born with a non-renewable pool of ovarian follicles, referred to as the ovarian reserve. This reserve consists of primordial follicles in the ...

Developmental Biology

Introduction of Intracapsular Rotary-cut Procedures (IRCP): A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For patients desiring pregnancy, laparoscopic intracapsular myomectomy (LM) is an alternative surgery option. Although LM is widely accepted to treat fibroids, it is technically demanding with risk of excessive bleeding and difficult suturing, especially in cases with large fibroids or tumors in unusual locations. Therefore, we developed an intracapsular rotary-cut procedure (IRCP) as a modification of laparoscopic intracapsular myomectomy, with the intention to minimize risks of LM and help uterine healing. A summary of the improvements to the IRCP is described: 1) making an incision at the site of the fibroid with a length of one-third to one-half of the fibroid&#39;s diameter at a depth reaching the fibroid&#39;s surface; 2) holding the fibroid stably and making rotary cuts on the fibroid at a depth of 0.5&#8211;1 cm within its pseudo-capsule while pulling it outward slightly, making sure not to cut off any pieces of the fibroid; and 3) repeating the cutting-and-pulling until the longest dimension of the fibroid is outside the incision. The multiple cuts are to minimize the diameter and extend the length of the fibroid. When the multiple cuts cause half of the fibroid body to &#34;shrink&#34;, the fibroid is squeezed out by contraction of the surrounding myometrium. Evaluation of the outcomes of IRCP showed that the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were significantly lower in the IRCP group than the LM group. As for reproductive outcomes, the full-term live birth rate of the IRCP group was significantly higher than that of LM group. However, there was no difference in delivery modes between the two groups. In conclusion, IRCP significantly benefits fertility preservation by minimizing damage to the uterus, protecting myofibers of the pseudo-capsule, and resulting in a shallower residual cavity, which eases stitching and causes less bleeding. It is worthwhile to adopt IRCP in younger patients who desire preservation of their fertility.

Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Here, we present a protocol for performing an intracapsular rotary-cut procedure (IRCP), a modified laparoscopic intracapsular myomectomy that promotes fertility preservation.

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For ...

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. Historical treatments were invasive and had adverse effects on the endometrium. Hysteroscopically guided laser therapy is easy and effective for endometrial cysts resection, with no deleterious effects for the endometrium.
A 110 cm long and 1.0 cm wide endoscope is sterilely introduced in the uterus through the open cervix of an estrous mare after vulvar cleaning. The uterus is slowly infused with less than 1 L of physiologic solution and the laser fiber is inserted in the biopsy canal of the endoscope. Cysts are then cauterized with the 980 nm diode laser with a contact fiber set at 20&#8210;2 5W in continuous mode. Each cyst is punctured&#160;until complete voiding of the cyst and shrinking of the cyst wall around the fiber. Uterine lavages with sterile saline solution are performed directly after the surgery and for one or two days as non-inflammatory fluid can be observed.
This procedure is easy and quickly performed, with no obvious deleterious effects. Cysts resection makes ultrasound pregnancy diagnosis easier and, in some cases, could restore proper embryo migration in the uterine horns between day 6.5 and 17. However, this treatment does not improve the underlying histological lesions related to endometriosis. These considerations should be clearly expressed to the breeder before this procedure.

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. ...

Fertility Preservation Through Oocyte Vitrification: Clinical and Laboratory Perspectives

Preserving female fertility is crucial in a multifunctional healthcare system that takes care of patients' future quality of life. Oocyte cryopreservation is recognized by several international scientific societies as the gold standard for fertility preservation in postpubertal women, for both medical and non-medical indications. The main medical indications are oncologic diseases, gynecologic diseases such as severe endometriosis, systemic diseases compromising the ovarian reserve, and genetic conditions involving premature menopause. This paper describes the whole clinical and laboratory work-up of a fertility preservation treatment by outlining recommendations for objective and evidence-based counseling. Furthermore, it focuses on the effectiveness of the procedure and describes the most appropriate strategies to fully exploit the ovarian reserve and maximize the number of oocytes retrieved in the shortest possible time. The evaluation of the ovarian reserve, the definition of an ideal stimulation protocol, as well as oocyte retrieval, denudation, and vitrification procedures have been detailed along with approaches to maximize their efficacy, efficiency, and safety.

Oocyte cryopreservation is recognized by several international scientific societies as the gold standard for fertility preservation in postpubertal women. Appropriate clinical and laboratory strategies ensure maximum efficacy, efficiency, and safety of fertility preservation treatments.

Preserving female fertility is crucial in a multifunctional healthcare system that takes care of patients' future quality of life. Oocyte cryopreservation ...

Fertility Preservation in Patients with Severe Ovarian Dysfunction

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, chemo- and radiation-therapies, as well as ovarian surgeries. In unmarried women with severe ovarian dysfunction, fertility preservation is important for future pregnancies. Although oocyte cryopreservation is an established method for fertility preservation, these patients could only preserve a limited number of oocytes even after ovarian hyperstimulation, leading to repeated stimulations to ensure sufficient oocytes to guarantee future pregnancy. To solve this issue, we have recently developed a drug-free in vitro activation (IVA) procedure, which enable us to stimulate early stages of ovarian follicles to develop to the preantral follicle stage. These preantral follicles can respond to the unique protocol of gonadotropin stimulation, resulting in increased number of retrieved oocytes per ovarian stimulation for cryopreservation. The drug-free IVA comprised from the surgical approach and ovarian stimulation. We removed a part of cortex from one or both ovaries from patients under laparoscopic surgery. The ovarian cortical tissues were cut into small cubes to disrupt the Hippo signaling pathway and stimulate the development of early stage follicles. These cubes were grafted orthotropically into remaining ovaries as well as beneath the serosa of both Fallopian tubes. We have already published the surgical procedure of the drug-free IVA and the protocol of subsequent ovarian stimulation, but herein we present the details of laboratory methods required for drug-free IVA.

We present details of laboratory procedures for drug-free in vitro activation (IVA) of ovarian follicles for patients with severe ovarian dysfunction. This method could increase the number of retrievable oocytes per ovarian hyperstimulation and benefit fertility preservation for those patients.

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.
When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 &#176;C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.
In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.

A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, ...

Hysteroscopic Technique with Micro-Scissors and Forceps for Polyp Removal

Improved Hysteroscopic Resection of Endometrial Polyps Using 6-Fr Micro-Scissors and Forceps

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. Numerous resection methods are available, with the most used and cost-effective options being cold resection employing micro-scissors or hot resection using an electric loop. However, both methods involve sharp resection, posing a challenge in achieving complete polyp removal while avoiding damage to the uterine endometrium. To address this issue, this study proposes an innovative approach: the combined use of the 6 Fr micro-scissors and forceps under hysteroscopy. The method entails utilizing 6 Fr micro-scissors to initially remove large polyps, followed by using 6 Fr micro-forceps to extract the remaining polyp tissue expeditiously and bluntly near the basal layer of the endometrium. This approach not only prevents surgical damage to the basal layer of the endometrium but also mitigates the risk of residual polyps resulting from incomplete resection. This method is particularly suitable for women with fertility requirements, offering additional considerations for the selection of treatment options for endometrial polyp resection.

Author Spotlight: A Reproductive Hysteroscopy Approach for Complete Endometrial Polyp Removal and Enhanced Endometrial Receptivity

The novel technique presented here employs a combination of 6-Fr micro-scissors and forceps for hysteroscopic treatment of endometrial polyps, demonstrating encouraging outcomes for infertile patients afflicted with this condition.

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. ...