More than 200 women have benefited from a scarless procedure that can check on the fallopian tubes more easily
An X-ray showed that Ms Tan (not her real name), a 30-year-old teacher, had a blockage in her right fallopian tube. Maybe that was why she had had no success in getting pregnant. She feared she would have to undergo a procedure in which cuts would be made to her abdomen and a laparoscope inserted to confirm if there was a blockage.
Luckily, KK Women’s and Children’s Hospital (KKH) offered a new test that could examine the fallopian tubes without the need for any incisions on the belly. This procedure, called transvaginal hydrolaparoscopy (THL), is done by inserting instruments with cameras through the vagina. Ms Tan’s test last December proved the X-ray wrong.
She did not have a blockage, but a different condition, called endometriosis, in which tissue from the uterus grows outside of it. This abnormal tissue behind her right ovary was removed with surgery during the same procedure. She said: “I was pleasantly surprised that I came out of surgery with no incision and happy that my fallopian tube was not blocked.” But the stork has yet to visit her. So next month, she will be having her husband’s sperm placed inside her uterus to help her conceive, in a process called intrauterine insemination. Since 2009, 228 women at KKH, including Madam Tan, have had their fallopian tubes checked – and minor problems treated – through THL.
Of the 28 cases performed by Dr Tan Heng Hao, a consultant at the department of reproductive medicine at KKH, 15 had problems that were picked up by the procedure. The procedure, called fertiloscopy when it is done using disposable instruments instead of re-usable ones, has also been offered at Pacific Healthcare Specialist Centre in Paragon by Dr Law Wei Seng this year. He performed about 200 of them in KKH when he was a consultant at its minimally invasive unit. Dr Suresh Nair, the medical director of Parkway Fertility Centre in Mount Elizabeth Hospital, has performed THL on 30 patients in the last decade. He does not routinely offer this because most of his patients are older and have more advanced diseases affecting fertility. Mind Your Body understands that these are the only centres here offering the procedure, which is an addition to doctors’ arsenal to pinpoint causes of infertility.
MORE ACCURATE CHECK ON FALLOPIAN TUBES
An infertility assessment usually includes a check of the fallopian tubes, which are important for conception. Every month, one of the ovaries releases a mature egg into the fallopian tube nearer to it. The egg travels along the tube to be fertilised by the sperm. The fertilised egg, or embryo, then travels towards the uterus for implantation, “pushed” along by hair-like projections called cilia on the walls of the tube. Infection may cause scar tissue to form and block the tube, preventing the egg from reaching the uterus. A hysterosalpingogram – an X-ray of the uterus and fallopian tubes – can indicate a blockage in a fallopian tube. But in up to 25 per cent of cases, the X-ray may show a blockage where there is none. To confirm the blockage, a laparoscope is inserted in the abdomen to see if dye injected into the vagina spills out of the fallopian tubes into the abdomen. Any blockage is then cleared with tubal surgery. But KKH has found the new and less invasive method to be just as good. In THL, a dye is also injected into the uterus through the vagina. The tube is clear if the dye flows out from the other end of the fallopian tube. Studies have shown it is just as accurate as laparoscopy in diagnosing conditions of infertility.
They include a study published in 2003 that used fertiloscopy first, and then laparoscopy, on 92 women from 14 hospitals in France, Belgium and Tunisia. Only one woman’s condition of ovarian endometrioma was missed by fertiloscopy. In eight cases, laparoscopy was not able to detect subtle lesions seen during fertiloscopy, the authors noted. They concluded that “fertiloscopy should replace diagnostic laparoscopy in the routine assessment of infertile women” without obvious lesions in the ovaries. Even if the tube is not blocked, the quality of its inner lining can have an impact on fertility.
This is where THL has an advantage, as it can assess the lining more easily than laparoscopy can. Overseas studies show that up to 20 per cent of the women who have had fertiloscopy had damaged lining detected, said Dr Law. Since no treatment is available for this condition, they will then know that they may have to undergo in-vitro fertilisation (IVF), which entails combining a woman’s eggs with her husband’s sperm in a test tube in a laboratory, to have a baby. Otherwise, they might waste time trying other types of fertility treatment in vain.
SAFER AND LESS PAINFUL
In a paper published in The Internet Journal Of Gynecology And Obstetrics last year, Dr Law pointed out that there are “significant risks” to laparoscopy. In every 1,000 procedures, there are three complications such as injury to the blood vessels, resulting in haemorrhage and blood loss; or injury to the bowel or ureter, the paper noted. Dr Law said the complication rate for fertiloscopy may be similar, but the injuries, such as piercing of the wall of the uterus and vaginal hernia, are less serious.
During fertiloscopy, a patient’s risk of injury to the blood vessels and peritoneum (membrane lining the abdominal cavity) is “almost zero”, he said. There are no sensory nerves in the vagina mucosa so the new procedure is relatively painless, said Dr Law. Even the small cuts made in laparoscopy do result in pain and take up to two weeks to heal. Ms Tan said she went out for dinner with her husband, a 28-year-old technician, after her THL procedure. She recalled: “There was no pain at all and I could walk out of the hospital unaided.” Dr Law estimated that fertiloscopy in his clinic will cost below $5,000, cheaper than laparoscopy, which costs between $5,000 and $8,000. At KKH, THL costs between $1,500 and $3,500, depending on a patient’s eligibility for subsidy. Up to $2,150 can be used from Medisave.
Not every woman who cannot conceive will undergo THL. Those with obvious pelvic abnormalities, such as cysts and fibroids, are better treated laparoscopically, said Dr Tan. In other cases, women or their partners may have “pressing reasons requiring IVF”, such as a low egg supply or severe sperm abnormalities, he said. Dr Nair emphasised that THL plays only a “complementary role” to other tests in infertility assessment. He said: “It offers a limited view of the pelvis and the surgeon cannot see the entire uterus.” The danger is that conditions such as adhesions or endometriosis growing on one side of the uterus may be missed, he explained. It was for this reason that an earlier and similar technique called culdoscopy was later abandoned in favour of laparoscopy, said Dr Christopher Chen, director of Gleneagles IVF Centre, who had used it in the 1970s.
Dr Yong Tze Tein, a senior consultant at the department of obstetrics and gynaecology of Singapore General Hospital, noted that the appearance of the lining of the fallopian tube alone may be insufficient to determine its ability to “sweep” the egg along. Dr Paul Tseng, the medical director of the Centre for Assisted Reproduction at Paragon Medical, felt that THL is good only for academic purposes. He said: “It is nice to know what may be causing the infertility but there is very little that one can do to correct the problem and a woman will still have to rely on alternative methods to achieve a pregnancy.”