Hysterosalpingogram (HSG), Laparoscopy & Laparotomy

Knowing the condition of the fallopian tubes is essential for proper and effective treatment of fallopian tube blockage. This is because, although you may know your tubes are blocked, you won't know which approach to take in unblocking them unless you have an idea of what type of blockage you have. Each treatment procedure addresses a specific problem hence, your doctor or your treatment provider will need at least, a general view of the condition of your tubes and the location of the blockage to be able to prescribe an appropriate action to take to relieve the blockage. There are generally three tests that are employed in determining the condition of the fallopian tubes -Hysterosalpingogram (HSG), Laparotomy and Laparoscopy. We will discuss each test individually in this article.

Hysterosalpingogram(HSG)
A hysterosalpingogram is also known as a hysterogram or an HSG and is a form of x-ray which provides a visual of the inner part of the uterus(see picture). A special liquid (dye) is injected into the cavity of the uterus which is then observed (through an x-ray of the abdominal area) as it travels into the fallopian tubes. The liquid should be seen to spill out of the ends of the fallopian tubes near the ovaries to conclude the absence of any significant blockage. However, if only some of the liquid drips out of the tube or if not a single drop falls out, a blockage automatically becomes a possibility. However, additional tests would be likely recommended as spasms from the procedure can produce a similar restriction or stoppage in the flow of the liquid from the ends of the tubes. In addition, this type of test is not advisable for pregnant women or for those with infection in the pelvic area (procedure can spread infection through the liquid contrast dye used).

Laparotomy
Laparotomy is also known as coeliotomy and is a procedure used either for diagnostic or therapeutic purposes(see picture). This procedure involves surgery, with incision made through the abdominal wall thereby providing access to the abdominal cavity which houses the organ to be checked or treated. This is an ancient procedure & is not recommended for diagnostic purposes in present-times. Diagnostic laparotomy was generally used to find out what may be wrong with a certain structure in the abdominal cavity (e.g. fallopian tubes). This was a significantly invasive form of diagnostic tool and hence women tend to choose the similar yet less invasive procedure, laparoscopy.

Laparoscopy
Laparoscopy is similar to laparotomy in that, it also involves an incision through the abdomen. However, the incision need only be large enough to accommodate a laparoscope, which is a thin telescope-like instrument (laparoscope) to be used in inspecting the organ with the problem. A visual image of the abdominal cavity and the structures in it is projected in a monitor connected to the laparoscope(see picture). The fallopian tube along with any blockages within it can be seen hence the extent, location and general characteristics of the blockage can be determined. This diagnostic tool provides approximately the same quality of diagnosis as laparotomy and is also used in treatment procedures.

Advantages and Disadvantages
All three diagnostic procedures have their benefits as well as disadvantages. A hysterosalpingogram provides minimal information about the condition of the tube and the risks associated with it makes it unavailable to pregnant women and those with pelvic infections. However, it is non-invasive and cheaper as against the two other procedures.

A laparotomy on the other hand provides the clearest access to checking the condition of the tubes but is largely invasive & is not recommended. Laparoscopy is a less invasive procedure and provides the best quality of diagnosis with a magnified image which helps in both diagnosis as well as therapeutics.

Blocked Fallopian Tubes- Treatment Options

Tubal factors are said to account for about 20 to 30 percent of all infertility cases around the world. The main contributing factor: blocked fallopian tubes. A blocked fallopian tube, although not necessarily life threatening, can be a very serious cause for concern because although conventional surgery may provide relief from the condition, damage to the tubes are generally considered irreversible and hence, subsequent pregnancy may prove almost impossible -but not quite. The fallopian tubes play a major role in conception. It is within a fallopian tube that fertilization normally occurs and the tubes serve as the pathways for the egg to travel from the ovaries towards the uterus for implantation. When the tubes are substantially blocked, the meeting of the sperm and egg may be prevented and hence, natural fertilization might be impossible. During the times when fertilization does happen, the zygote may still be unable to reach the uterus and ectopic pregnancy, a life threatening condition, could occur.

Pregnancy in the presence of blocked tubes is often difficult but not impossible. Assisted Reproductive Technology (ART) techniques provide artificial conception or a meeting of the egg and sperm outside the woman's body. The resulting mix or the zygote is then delivered into the uterus or the unaffected fallopian tube and pregnancy can result. These techniques however, are not always successful. ART practitioners try to increase the chances of impregnation by delivering more than 1 zygote or egg-sperm mix hence, this procedure can often lead to multiple births.

Another option for pregnancy-hopeful women with blocked tubes is to resort to Endoscopic Fallopian Tube Recanalisation; which works best with proximal tubal occlusion & a method of Tactile Cannulation using Laparoscopic guidance has been pioneered by us and published in peer-reviewed journals (see pictures) . Alternative remedies have proven quite effective in helping women get pregnant. The generally accepted method of unblocking fallopian tubes was through tubal surgery which can be done through microsurgical techniques either during open abdominal surgery (laparotomy) or using laparoscopy through a small incision in the abdomen. The latter procedure however must be conducted by a surgeon trained in the field of microsurgery and has hands-on knowledge of laparoscopy. There are many different surgery techniques for unblocking fallopian tubes and the differences generally involve the length of the incision, the area affected, the type of blockage present, and the method of unblocking applied (e.g. complete removal or creation of another opening). Tubal reanastomosis involves the complete removal of the blocked portion of the tube and a subsequent joining of the healthy ends. This procedure is usually done with laparotomy or abdominal incision.

Salpingectomy involves the surgical removal of the infected or blocked fallopian tube. It is usually done on patients who have a hydrosalpinx and want to improve their chances at pregnancy through in vitro fertilization (IVF). This procedure is preferred over salpingostomy which is another surgical procedure available for dealing with hydrosalpinges (fluid-filled blocked fallopian tubes).

Salpingostomy is a procedure that requires an incision through the affected fallopian tube. In neosalpingostomy, the idea is to create a new opening in the part of the tube closest to the ovary while in linear salpingostomy the incision serves as the pathway to release the blockage. Neosalpingostomy is generally used in dealing with hydrosalpinges. This technique however more often than not merely provides temporary unblocking as it is a common occurrence for scar tissue growth to reseal the new opening created by neosalpingostomy thereby effectively blocking of the tube once more.

When the problem is a partial blockage or a scarring in the fimbriae (fingerlike projections at the end of the fallopian tube near the ovary), Fimbrioplasty is an option where the blockage or the scar adhesions are removed and the fringed ends are rebuilt such that wafting motion of the fimbriae are restored. The fimbriae move in sweeping motions such that the egg released by the ovary will be caught then guided towards the uterus.

The relative success of the surgery will depend on the health and condition of the patient and the location of the blockage. It is shown that clearing blockages near the uterus are more likely to be successful. Furthermore, the amount of tube that remains after the surgery will determine the ability of the tube to regain its normal function and hence, the subsequent ability of the woman to get pregnant.

Surgery is generally an invasive form of treatment but recent technologies already provide for less invasive procedures as against the traditional open abdominal option such as Laparoscopy. It involves the use of a laparoscope (camera or ultrasound) which is inserted into a small incision through the abdominal wall. The body part requiring surgical treatment will be seen through a monitor which, is connected to the laparoscope.

Surgery procedures also involve risks some of which are spread of pelvic infection, the formation of scar adhesions among the reproductive organs or with the abdominal cavity, and the increase in the possibility of tubal ectopic pregnancy.

Dyspareunia or Painful Intercourse

Intercourse pain can be totally debilitating. Complaints range from pain at initial penetration, to pain at deep penetration, to a combination of the two. While physicians can give varying primary or accompanying diagnoses, there is little doubt that the pain is of "mechanical" cause. In fact, the pain generally comes from adhesions or scar tissue left by a prior surgery, inflammation or trauma. In some cases, this is accompanied by an anteverted (forward tilting) tailbone.

During the course of life, the female reproductive tract may be subjected to numerous traumas, infections, inflammations, and surgeries, which can lead to adhesions and scar tissue. Some women absorb these repetitive traumas and stresses to the pelvis without experiencing symptoms or negative side effects. However, some women experience significant, long lasting symptoms including anorgasmia (the inability to have an orgasm or reach a full orgasm), decreased desire (libido) and dyspareunia (intercourse pain).

Endometriosis and adhesions are major causes of painful intercourse. Painful sexual intercourse is a condition that plagues millions of women worldwide. For some, the pain may occur at first penetration. This is often a very sharp and specific pain in one location, often at or near the opening of the vagina. For others, the pain is experienced at deep penetration. This is often described as a broader, deeper pain, and has been described as if “it feels like my partner is hitting something” and in many cases, he is (see picture). Some women may even experience a combination of the two.

Surgery or a fall can pull your tailbone forward, creating a physical block in your body. This can cause chronic constipation,
or pain during intercourse. In cases of pain or tightness at the opening, we find that adhesions, tiny or large, have formed at some time in the past. As the body heals from infection, inflammation, surgery or trauma, it develops tiny adhesions, which are often invisible to the naked eye. These adhesions can form on the surface of the labia, at the vaginal opening or within its delicate inner tissues. These adhered tissues are stretched at the commencement of intercourse, creating a pull on nerves and other sensitive structures. This pull causes pain at just the time when you should be experiencing great pleasure. The irritation can cause pelvic spasms, which in turn causes more pain and dysfunction, perpetuating the process.

Pain at deeper penetration is often associated with a trauma or repetitive stress to the tailbone (coccyx), generally caused by a fall on the hip, back, or tailbone. Other causes may include pelvic surgery (such as an appendectomy or D&C), inflammation (such as endometriosis), or infection (bladder, yeast, etc.). Abuse and repetitive stresses (such as sitting for long periods of time) are other common causes of this pain. When any of these occur, internal tissues may shorten, pulling the tailbone out of its normal position. The tailbone then acts as a physical block to your partner during intercourse, causing you to experience a deep pain during or after sex. Similar conditions can occur at the cervix, or other vaginal tissues.

Intercourse should be a time of great pleasure. Because the female reproductive organs are susceptible to adhesions and tailbone trauma over time, intercourse can become a time of pain and embarrassment. Our endoscopic surgeons at the Aesculap Academy, Mumbai (www.testtubebabyclinic.com) have with pelvic adhesiolysis & peri-rectal dissection of endometriotic implants, decreased pain, increased sexual function, and restored the pleasures of intimacy and intercourse for most of the women we treat with intercourse pain. In doing so, we enrich their lives and those of their partners.

Intrauterine Insemination is the First Line Treatment For Infertility

Intrauterine insemination (IUI) is a procedure in which sperm are placed directly into the uterine cavity through a catheter near the time of ovulation. This procedure is most commonly performed when there are problems with the sperm, such as low count or low motility, or an incompatibility between the sperm and the cervical mucus. It can also be performed to overcome problems associated with a man's inability to ejaculate inside the woman's vagina due to impotence, premature ejaculation or other medical conditions.It is the most common procedure-in fact, the first line therapy for unexplained infertility. IUI increases the chances of pregnancy because the sperm are placed directly in the uterus, bypassing the cervix and improving the delivery of the sperm to the egg.
IUIs can be performed either with the partner's sperm or with donor sperm. It is recommended that the patient abstain from sexual intercourse for two to three days before the procedure. In some cases, it may be necessary for the female to take medication to induce ovulation if her cycles are not regular. The male will provide a semen sample one to two hours before the procedure is to be performed. The semen will be washed, a procedure in which the sperm is separated from the seminal fluid and the quality of the sperm is analyzed. Following the wash, it is time for the insemination procedure, which only takes a few minutes and does not cause much, if any, discomfort for the female. The doctor will insert a small catheter into the uterine cavity through the cervix and inject sperm directly into the uterus. The patient is able to resume normal activity immediately following the IUI procedure. If pregnancy does not result from the initial IUI, the procedure may be repeated during the following cycles.
We expect a 15% chance of success with IUI cycles combined with clomiphene citrate or letrozole. The success rates go up by nearly 10% with use of gonadotrophins (Fertility Injections). At Rotunda, from 1992, we must have performed over 5000 IUI cycles for in-house patients & over 12,000 IUI cycles for referred cases, who are monitored by their respective gynecologist & walk in only for the IUIs.

Modern Wonders of India

India's rise as a 21st century global economic force is mirrored in a new building boom of corporate campuses, shopping malls, movie studios, and skyscrapers, many of which reflect a growing trend of sustainable architecture. Just as the classic Indian wonders of the world—from the elegant Taj Mahal to the spectacular temples at Khajuraho—evoke a characteristically South Asian style, India's newest wonders distinguish themselves from other nations' contemporary building types.
International powerhouse companies headquartered in India, such as Tata Consultancy Services, Wipro, and Infosys, are planning and constructing show-stopping offices that recall and update traditional Indian edifices, rather than mirror the generic glass boxes of Silicon Valley. Here are 10 examples of the new Indian architecture, by a spectrum of designers based around the world and in India. All of these superlative projects share one thing: They bridge India's rich history and bright economic future.
The latest available statistics from the World Bank indicate that India's gross domestic product has seen annual growth of 8.5%—more than doubling the 4% of 2000. Reflecting this growth and the country's increasing presence on the international stage as an IT and economic powerhouse, the nation's leading companies, including Wipro (WIT ), Infosys (INFY ), and Tata Consultancy Services are constructing new corporate campuses. Similar to China's architectural boom , India's forthcoming wave of slick contemporary architecture, even beyond offices, symbolizes the Asian nation's rocketing economy, which first began to open up 15 years ago. Via a series of superlative skyscrapers, shopping centers, and residences that are the tallest, the largest, the "greenest," or the first of their kind, the country is quickly presenting itself as a 21st century global power.
In 2005, for example, Infosys Technologies opened its $65.4 million Global Education Center in Mysore. Located on a 270-acre, $119 million campus, the facility is the largest IT training center in the world, accommodating 4,500 trainees at any given time and hosting up to 15,000 per year. The center is being expanded to handle double the number of employees. While its glassy, futuristic design might evoke corporate buildings in Silicon Valley, the campus also features an Indian touch: a cricket pitch. Software, engineering, and management-consulting giant Wipro commissioned Indian architect Vidur Bhardwaj to design an office in Gurgaon based on the traditional structure, the haveli (a house built around an open-air courtyard). Meanwhile, Tata Consultancy Services, a division of mega-conglomerate Tata Group, will soon see a sprawling, $200 million campus in Chennai designed by noted Uruguayan architect Carlos Ott (a nod to Tata's expansion into Latin America). Buildings will feature a step-like structure recalling those found in centuries-old South Indian temples—only these are rendered in ultra-contemporary glass. It's scheduled to be completed next year and will boast the tallest tower in Southern India.
New York architects Tod Williams and Billie Tsien, have designed a new Bombay campus for Tata Consultancy Services (to be completed by 2010) that incorporates elements such as a jali, a traditional carved screen used for centuries as both sunshade and ventilated wall. Williams and Tsien's jali is more angular and contemporary and less florid than screens of the past. But it serves as a nod to Indian architectural history as well as providing an eco-friendly way to keep offices cool using natural shade and ventilation. Projects such as Williams and Tsien's design for Tata make use of natural light and ventilation, cutting down on energy consumption that contributes to air pollution. Vidur Bhardwaj's haveli design for Wipro is not only an homage to traditional Indian buildings, but also provides cost-effective cooling—via the open-air public courtyard — that's necessary for hot Indian days. Carlos Ott's forthcoming Chennai campus for Tata Consultancy Services uses these ideas and also recycles waste water to conserve resources, following the lead of the 2003 CII—Sohrabji Godrej Green Business Center in Hyderabad. This 20,000-square-foot minimalist office building became the only structure outside of the U.S. to receive the LEED (Leadership in Energy & Environment Design) Platinum ranking when it opened.
Will the new forms of Indian architecture endure as long as the spectacular Elephanta rock-cut temples (built circa 600 A.D.) or the elegant Taj Mahal (a wonder of the world dating back to the 17th-century Mughal era)? Only time will tell.

Tiger Woods in Ireland

On a golf tour in Ireland , Tiger Woods drives his BMW into a petrol station in a remote part of the Irish countryside.

The pump attendant, who knows nothing about golf, greets him in a typical Irish manner completely unaware of who the golfing pro is.

"Top of the morning' to yer sir'", says the attendant.

Tiger nods a quick "Hello" and bends forward to pick up the nozzle.

As he does so, two Tees fall out of his shirt pocket onto the ground.

"What are those ?'" asks the attendant.

"They're called tees," replies Tiger.

"well, what on good God's earth are they for?" inquires the Irishman.

"They're for resting my balls on when I'm driving"' says Tiger.

"Fooking Jaysus," says the Irishman, "BMW thinks of everyting........"

PCOS - A Brand New Approach To Treating This Metabolic Disorder

Women with polycystic ovary syndrome who are hoping to conceive have reasons for both hope as well as concern. I hope this article will introduce you with newer treatment options and educate you to choose well prior to entering into any infertility treatments. When I order the anovulation Profile (a series of blood tests), I simply want to determine if responsibility for your ovulatory disturbance lies with another condition such as thyroid disorders, diabetes, age related ovarian failure, stress infection, ovarian cysts, or pituitary or ovarian tumors. Once these conditions have been ruled out and a normal semen analysis and tubal patency has been confirmed, a treatment plan can be considered.
Traditionally, the first step has been clomiphene therapy regardless of whether or not PCOS was diagnosed. Studies report ovulation rates of up to 80% and pregnancy rates in approximately half those who ovulate have demonstrated in the literature using this method. However, in women with PCOS, miscarriage rates once conception occurs have been higher than normal, running as high as 60% loss in those women with a history of a prior loss. Multiple birth rates may be higher and ovarian hyperstimulation more frequent when using clomiphene therapy.
However, it appears that ovulation therapy in Hyperinsulinemic PCOS patients with metformin when combined with a low glycemic diet and a moderate exercise program may provide much better results and provide significant health benefits. Ovulation rates by three months of metformin therapy appear similar to clomiphene, yet the rates of multiple births, miscarriage and gestational diabetes may all be reduced. Added health benefits may include normalization of elevated blood pressure, weight loss, normalization of blood lipids, and better sugar control in diabetics.
First do no harm. That means , before starting the Metformin therapy, please confirm if your PCOS patient has Insulin Resistance. I ask for a 12 hour fasting Serum Insulin Test. If this value is more than 10, I consider the patient Hyperinsulinemic. My approach to metformin therapy is to start the medication gradually. During the first week a single tablet of the Metformin 850 mg is taken with a full glass of water toward the end of a meal. After a fortnight an additional tablet is added with another meal. This gradual introduction of the 1700mg full dose adds to patient compliance with minimal upset stomach or diarrhea, the usual transient side effects when starting this medication.
But, what happens if this approach does not restore fertility? At that point I will consider use of ovulation induction with or without intrauterine insemination. Clomiphene or the oral anti-estrogen medicine letrozole which is administered in a fashion similar to clomiphene are the first medications considered. Despite the failure to respond in prior attempts at clomiphene therapy when combined with metformin, the effectiveness of these oral medications is greatly enhanced. I must stress the importance of ultrasound monitoring at the start of each cycle to avoid significant ovarian hyperstimulation (OHSS). Many doctors don't realize that OHSS can occur even on clomiphene and don't bother to check the ovaries at the start of each treatment cycle. These women have a progressive increase in pain with each month of therapy and show up at the clinic with grapefruit-sized ovaries which require months off therapy to allow them to return to normal size before considering additional treatment. One last caveat is that if you have not conceived after three months of a particular therapy, it is time to meet with your physician to review your case and determine whether other therapies may be more appropriate.
One alternative that appears effective is laparoscopic ovarian drilling. For women who have a specific indication for diagnostic laparoscopy, this procedure should be considered. We prefer to use a monopolar needle placed into each ovary six to eight times. An electrical current is placed through the needle and ultimately destroys some of the male hormone (androgen) producing tissue in the central portion of the ovary. It is thought that excess androgen production interferes with normal follicle development. Those who demonstrate a normalization of male hormone levels after this procedure have the greatest benefit, while the procedure appears less effective in those who smoke. Despite successfully restoring ovulation in up to 80% of women, the expense and surgical risks make injectable therapy and IVF appropriate considerations.
In order to understand present day management with injectable medications, you must first understand a bit of the history surrounding these drugs. The first group of medications in this class were urinary derived hMG (Menogon, GMH), a mixture of two hormones, FSH and LH. FSH stimulates development of the follicle cells and the conversion of male hormones to estrogen. LH stimulates the production of male hormones and assists in the maturation of the egg. As the number of women in treatment increased, the demand for these drugs increased so drug companies were forced to consider alternative means to generate a sufficient supply of drug to meet the demand. This required large investments to produce pure recombinant (genetically engineered) forms of FSH (Gonal-F). Studies revealed that most women responded well to treatment protocols that included only FSH. They found that the body produced, on its own, sufficient LH to generate healthy eggs. It was surmised that since women with PCOS had high LH levels, they would do best using an FSH only product and avoiding LH entirely. We now know that may not be the case.We now do most of the treatment cycles using Menogon or GMH.
Let's look at this a bit closer. But first, a bit more basic review of the ovulatory process. Hormones work by attaching to the receptor on the outside of the cell and triggering some action inside the cell. In the early follicle phase (prior to ovulation), small follicles only have FSH receptors and therefore respond to FSH only. There are no follicular cell receptors for LH at this early stage. As the follicles grow FSH levels decrease and the follicles develop receptors for LH (approximately 12-14mm in size) and thus are able to respond to either FSH or LH by increasing the cellular levels of the chemical cyclic AMP. Smaller follicles lack LH receptors and as FSH levels drop, these smaller follicles die off. This fact has lead to a novel approach to ovulation induction that appears promising.
Initial work by Italian physician, Dr. Marco Filicori, has revealed that adequate continued growth and maturation of larger follicles can occur in the absence of FSH. He has shown that a switch to low dose hCG (equivalent to LH) promotes satisfactory follicular growth while smaller follicles die off. Well- designed studies will confirm whether this approach reduces the risk of ovarian hyperstimulation and multiple births. Additional studies will be required to determine whether this approach is appropriate for IVF patients where in many cases we find that "more is better" when it comes to the number of follicles that develop to maturity. We have found this result promising in a few patients whose prior cycles generated hyperstimulatory responses. I will consider this protocol in any patient who, during the course of stimulation, appears to develop an excessive number of follicles of varying sizes. We give micro-doses of hCG ranging from 50 IU to 200 IU. In addition to low dose hCG during the late follicular phase, follicular reduction (removal of eggs) or conversion to IVF with GnRH antagonist administration are alternatives to consider if excessive follicular development is noted.
These new therapeutic options offer exciting alternatives. Hopefully, well- designed studies will allow prediction of the best approach for each patient. Until that data is available, it is important that you consult your fertility physician to understand all possible alternatives and options prior to making treatment decisions.