Laparoskopie bei Infertilität, Tubenpathologie, Endometriose und vor ART

Zusammenfassung Auch wenn der Laparoskopie (LSK) im Rahmen der Diagnostik der ungewollten Kinderlosigkeit der Status eines Goldstandards zuerkannt wird, haben assistierte Reproduktionstechniken einen Paradigmenwechsel eingeleitet, viele Schritte im Fertilisationsprozess werden technisch assistiert. Es stellt sich die Frage, welche Evidenzen für den Einsatz der LSK bei verschiedenen Sterilitätsursachen existieren. Es ist die LSK, die den Anteil sog. ungeklärter Sterilitäten niedrig hält und die unmittelbar zur operativen Intervention erweitert werden kann. Bei den Tubenpathologien führen laparoskopische Salpingoovariolysen bei erhaltener Tubenpassage zu Ergebnissen, die den assistierten Reproduktionstechniken (ART) überlegen sind. Unter den Myomtypen FIGO (Fédération Internationale de Gynécologie et dʼObstrétique) 0, 1, 2, 2–5, 3, 4, 5, 6 entfalten die dem Cavum uteri anliegenden Myome den höchsten fertilitätsblockierenden Effekt, welcher auch für die Myomtypen 3, 4, 5, 6 angenommen werden muss, obwohl das Cavum nicht distorsiert wird. Die Myomtypen 0, 1, 2 sind eine Domäne hysteroskopischer Operationstechniken, alle anderen Myome können erfolgreich laparoskopisch operiert werden, solange ein ausreichend hohes Planum zwischen Optiktrokar und Objekt für die Insertion der Arbeitstrokare existiert. Bei den verschiedenen Endometriosemanifestationen besteht eine Priorität zur laparoskopischen Intervention bei therapieresistenten Schmerzen. Insbesondere stenosierende Prozesse im Bereich des harnableitenden Systems und des Darms indizieren die LSK. Bei Hydrosalpingen ist ein Nutzen durch die laparoskopische Salpingektomie vor In-vitro-Fertilisation (IVF) gesichert. Für die Endometriose existieren Subgruppen, die von dem Prinzip „surgery first“ vor ART profitieren. Abstract Even if laparoscopy is awarded the status of a gold standard in the diagnosis of involuntary childlessness, assisted reproductive techniques (ART) have initiated a paradigm shift and many steps in the fertilization process are technically assisted. The question arises as to what evidence exists for the use of laparoscopy for the various causes of sterility. It is laparoscopy that keeps the proportion of so-called unexplained sterility low and that can be immediately expanded to include a surgical intervention. In the case of tubal pathology, laparoscopic salpingo-ovariolysis with preserved tubal patency leads to results that are superior to ART. Among the Fédération internationale de gynécologie et dʼobstétrique (FIGO) myoma types 0, 1, 2, 2–5, 3, 4, 5, 6, the myomas adjacent to the cavity of the uterus develop the highest fertility-blocking effects, which must also be assumed for the myoma types 3, 4, 5, 6, although the cavity is not distorted. Myoma types 0, 1, 2 are a domain of hysteroscopic surgical techniques, all others myomas can successfully be operated on laparoscopically as long as there is a sufficiently high plane between the optical trocar and the object for the insertion of the working trocars. For the various phenotypes of endometriosis, priority is given to laparoscopic intervention in cases of treatment-resistant pain. In particular, stenosing processes in the urinary tract and the intestines are indications for laparoscopy. In cases of hydrosalpinx, a benefit is ensured by laparoscopic salpingectomy before in vitro fertilization (IVF). 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Kleinstein gibt an, dass kein Interessenkonflikt besteht. Für diesen Beitrag wurden von dem Autor keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien. Additional information Redaktion Heribert Kentenich, Berlin QR-Code scannen & Beitrag online lesen Rights and permissions About this article Cite this article Kleinstein, J. Laparoskopie bei Infertilität, Tubenpathologie, Endometriose und vor ART. Gynäkologische Endokrinologie 20, 15–20 (2022). https://doi.org/10.1007/s10304-021-00424-4 Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s10304-021-00424-4