Transvaginal, rather than traditional, laparoscopy should be used for the assessment of infertility

Transvaginal laparoscopy (TVL) was introduced in 1998 (Gordts et al. Hum Reprod 1998;13:99–103) but its uptake has been slow. Globally, very few centres offer it as an alternative to traditional laparoscopy. There are reasons for this. First, the diagnostic capability of TVL is inferior to that of traditional laparoscopy. It cannot visualise the uterovesicle pouch, the superior aspects of the ovary and the abdominal cavity. Moreover, the greater degree of distension achieved with carbon dioxide in the case of traditional laparoscopy permits movement of mobile structures such as the uterus, ovary, Fallopian tubes and bowel by the use of a palpiteur to enable a more thorough inspection of these structures. Second, the therapeutic capability of TVL is limited to a few simple operations compared with the much wider range of operations permitted by traditional laparoscopy such as ovarian cystectomy, myomectomy, salpingostomy, salpingectomy, tubal anastomosis, excision of peritoneal endometriotic lesions and suturing, all of which are not possible with TVL. As a consequence, it is more difficult for TVL to implement a see-and-treat policy. Third, although it is still unclear if there is any significant difference in complication rate between the two types of laparoscopy, when complication does occurs, it is far easier to deal with using traditional laparoscopy than TVL. Haemostasis during TVL relies exclusively on a small bipolar diathermy instrument whereas a wider range of management options are available during traditional laparoscopy, namely mono- or bipolar diathermy, suturing and the application of haemostatic agents such as Floseal (Watrowski Arch Gynecol Obstet 2014;290:411–15). Neither traditional laparoscopy nor TVL is indicated in the routine, initial investigation of women presenting with infertility. Refined imaging techniques such as three-dimensional ultrasonography in conjunction with hystero-salpingo contrast or saline infusion sonography have emerged as noninvasive and less expensive alternative options that have largely replaced hysterosalpingography and endoscopic examination as the initial investigations of choice to assess pelvic anatomy. Neither TVL nor traditional laparoscopy should be employed as a screening test for subtle lesions (such as fimbrial cyst and accessory fimbriae), as the possible benefit, if any, of diagnosing and treating these subtle lesions has not yet been confirmed by clinical trials. Endoscopic examination of the pelvis is considered necessary only when either symptoms, clinical findings on examination, or initial investigation by the use of one of the currently available imaging techniques suggest that pelvic pathology is likely to be present. The choice of traditional laparoscopy or TVL will depend on the likely pathology to be encountered and whether traditional laparoscopy is deemed desirable for a more thorough examination of the pelvic and abdominal cavity and necessary to complete the required surgical treatment. Second, it will depend on the local availability of necessary equipment to support TVL. In the end, local practice including the expertise and preference of the specialist providing the care will influence the final decision. Given the above considerations, it is no wonder why the vast majority of practicing specialists prefer traditional laparoscopy to TVL. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.