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

As a pure diagnostic tool the place of laparoscopy has recently been questioned in the exploration of the female pelvis. First, techniques of three-dimensional ultrasound and hystero-contrast sonography have been introduced and are routinely used. However, this approach still provides insufficient information on peritoneal and minimal ovarian endometriosis, presence of adhesions and tubal disease. It is therefore questionable whether the diagnosis of unexplained infertility can be made without proper endoscopic exploration. Second, standard laparoscopy is not an innocuous procedure, and for diagnostic purposes it is rather invasive, requiring the necessary skills and infrastructure. Complications, although rare, can be life threatening. Transvaginal laparoscopy is performed as a simple needle puncture technique of the pouch of Douglas (Gordts et al. Hum Reprod 1998;13:99–103) A watery distension medium (Ringer lactate) avoids the high intra-abdominal pressure caused by the CO2 pneumo-peritoneum at standard laparoscopy. Accuracy for detecting peritoneal and ovarian endometriosis, subtle lesions and tubo-ovarian adhesions is higher when compared with standard laparoscpy (Brosens et al. Fertil Steril 2001;75:1009–12). The ovaries can be inspected over their total surface without any extra manipulation. At standard laparoscopy, inspection of the anterior ovarian site and the fossa ovarica requires manipulation to lift the ovaries, occasionally causing rupture of adhesions with bleeding in the fossa ovarica. With the endoscope in the same axis as the fallopian tube, fimbrial inspection and salpingoscopy can be performed. With the exception of the immediate area around the place of entry of the endoscope, inspection of the pouch of Douglas can be performed by turning the 30° angled 2.9-mm endoscope around his axis. Transvaginal laparoscopy is intended to be a minimally invasive diagnostic procedure in women without obvious pelvic pathology (normal vaginal examination, normal vaginal ultrasound). Complications are a failure of access in 3% and the risk of perforation of the rectum (0.3%). These have to be considered as minimal complications because they are all treated by a conservative treatment with antibiotics without further consequences (Gordts et al. Gynecol Surg 2008;5:187–91). Minimal operative procedures like ovarian drilling for polycystic ovarian syndrome, drainage of small endometriotic cysts or adhesiolysis can be performed, but in the absence of a panoramic view there is no place for major surgical procedures (Gordts et al. RBMonline 2002;4:72–5). The advantages of the diagnostic capacities of transvaginal laparoscopy are obvious and far superior to standard laparoscopy. Instead of avoiding an endoscopic exploration of the pelvis by standard laparoscopy because of its invasive nature, the transvaginal approach offers a minimally invasive tool easily performed in a day-case setting under local anaesthesia or sedation. A complete and accurate visualisation of the pelvis is of benefit to the patient because it results in an accurate diagnosis and accurate treatment. Full disclosure of interests 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.