|Year : 2019 | Volume
| Issue : 4 | Page : 1401-1405
Role of hysteroscopy and laparoscopy in evaluation of unexplained infertility
Mohamed S Gad1, Ragab M Dawood1, Mohamed S Antar1, Shaimaa E M Ali2
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Abu Kir El-Takhassossy Hospital, Alexandria, Egypt
|Date of Submission||07-Dec-2018|
|Date of Decision||25-Jan-2019|
|Date of Acceptance||26-Jan-2019|
|Date of Web Publication||31-Dec-2019|
Shaimaa E M Ali
Sidi Beshr, Alexandria
Source of Support: None, Conflict of Interest: None
To evaluate the diagnostic and therapeutic role of combined hysterolaparoscopy in female infertility.
Infertility affects approximately 10–15% of reproductive age couples. Causes of infertility in the female partner include ovulatory, tubal, uterine, cervical, and endometriosis. Owing to its noninvasive nature and low cost, hysterosalpingography (HSG) is widely used as a first-line approach to assess the patency of the fallopian tubes and uterine anomalies. We assessed hysterolaparoscopy as a one-step procedure and compared it with HSG, in the ovulatory infertile women with normal pelvic sonography, seminogram, hormonal assays, and HSG. Even in women thought to be at low risk for significant pelvic pathology affecting reproduction, the yield was high. Laparoscopy was helpful in making a decision to go to assisted reproductive technology.
Patients and methods
An observational cross-sectional study conducted on 200 women aged 20–40 years old with unexplained infertility. Methylene blue test, inspection for abnormal pelvic and intrauterine pathology, and therapeutic interventions when needed were done.
Of 200 patients, 116 had primary and 84 had secondary infertility. The patients in the secondary infertility group were older compared with the primary group. The most common intrauterine pathology was uterine septum. Adnexal adhesions and endometriosis were the most common abnormalities detected in laparoscopy. The prevalence of endometriosis and unilateral tubal block was higher in the primary group. The operative interventions, both hysteroscopic and laparoscopic, were also recorded.
Hysterolaparoscopy is a reliable method in comprehensive evaluation of infertility.
Keywords: hysterolaparoscopy, hysteroscopy, infertility, laparoscopy, unexplained infertility
|How to cite this article:|
Gad MS, Dawood RM, Antar MS, Ali SE. Role of hysteroscopy and laparoscopy in evaluation of unexplained infertility. Menoufia Med J 2019;32:1401-5
|How to cite this URL:|
Gad MS, Dawood RM, Antar MS, Ali SE. Role of hysteroscopy and laparoscopy in evaluation of unexplained infertility. Menoufia Med J [serial online] 2019 [cited 2020 Jan 19];32:1401-5. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1401/274268
| Introduction|| |
Infertility affects approximately 10–15% of reproductive age couples . It is defined as the inability to conceive after 1 year of unprotected intercourse of reasonable frequency. It can be subdivided into primary infertility, that is, no prior pregnancies, and secondary infertility, referring to infertility following at least one prior conception . Although pelvic sonography and hysterosalpingography (HSG) are good enough to exclude gross intrauterine pathology, the subtle changes in the form of small polyps, adhesions, and seedling fibroid are better picked up on magnification with hysteroscopy. Additionally, hysteroscopy-guided biopsy and therapeutic procedures like polypectomy, myomectomy, septal resection, and adhesiolysis can be done in the same sitting . Laparoscopy can reveal the presence of peritubal adhesions, periadnexal adhesions, tubal pathology, and endometriosis in 35–68% of cases even after normal HSG result . Initially hysterolaparoscopy procedure may appear to be a costlier and invasive procedure, requiring anesthesia, but in the long run, it will become more beneficial as the therapeutic interventions can be done at the same sitting. Decisions for assisted reproductive technique can be taken appropriately in time (if required). The aim of this work was to evaluate the role of combined hysterolaparoscopy in female infertility and the incidence of various pathological conditions in the female reproductive tract leading to infertility.
| Patients and Methods|| |
This cross-sectional study was conducted on 200 women attended the infertility clinic at Alexandria Maternity University Hospital in the period from July 2017 to March 2018 after approval of committee of research ethics. A written consent was taken from all patients. Patients between 20 and 40 years of age with infertility either primary, had never conceived before, or secondary, had at least one prior conception, irrespective of the outcome, were included in this study. All patients had normal infertility hormonal profile, HSG, and seminogram of the husband. Hormonal profile included basal fertility hormonal profile (days 2–5 of menstruation), serum follicle-stimulating hormone, serum luteinizing hormone, and serum E2 and serum prolactin. Patients with active genital infections, bleeding, hormonal abnormalities known to cause anovulation, or any contraindications to operation were excluded. Hysterolaparoscopy was performed in early follicular phase in all the patients. The data of the prevalence of different lesions were collected to be analyzed.
Statistical analysis of the data
Where N = minimum sample size.
Z = 1.96 at 95% confidence interval obtained from standard statistical.
P = estimated prevalence of the event in a given population (15% obtained from previous literature).
Q = (1–P = 85%).
E = margin of error (0.05).
So N = 195.
Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0 (SPSS statistics, IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Significance of the obtained results was judged at the 5% level. The used tests were χ2 test, Fisher's exact or Monte Carlo correction, and Mann–Whitney test.
| Results|| |
Of 200 patients, 116 (58%) women had primary infertility and the rest 84 (42%) had secondary infertility. The patients in secondary infertility group were elder compared with the primary infertility group (32.82 ± 4.22 vs. 29.09 ± 4.47 years). The duration of infertility was longer in the primary group (5.16 ± 2.73 vs. 4.17 ± 2.83 years) with significant difference between the two groups. Abnormal laparoscopic findings were seen in 62.9% of primary infertility group (73 of 116 patients) and 54.8% of secondary infertility (46 of 84 patients). Abnormal hysteroscopy findings were seen in 49.5% of primary infertility group (51 of 103 patients) and 35.4% of secondary infertility (29 of 82 patients), with significant difference (P = 0.05) [Figure 1].
|Figure 1: Comparison between the two studied groups according to procedure done.|
Click here to view
Endometriosis and pelvic adhesions were the most common abnormalities detected in laparoscopy in two groups (30 and 41%, respectively), as shown in [Table 1] and [Table 2]. Myoma is seen in 8.5% of cases, ovarian pathology in 16%, tubal pathology in 37%, fimbrial agglutination in 7.5%, and unilateral tubal block by chromopertubation test in 13.5% of cases. Surgical intervention was done to manage pelvic abnormalities such as endometriosis: electro-cauterization in 28%, adhesiolysis in 34%, tubal ligation in 14.5%, fimbrioplasty in 6.5%, ovarian cyst aspiration in 2%, myomectomy in 1.5%, and ovarian cystectomy and laparoscopic ovarian drilling in 1% of cases.
|Table 1: Incidence of abnormal laparoscopic findings in infertile patients|
Click here to view
|Table 2: Comparison between the two studied groups according to different findings by hysteroscopy|
Click here to view
By hysteroscopy, the septate and subseptate uterus had the highest incidence (26.5%) with significant difference (P = 0.024), being higher in the primary group, followed by endometritis (12.43%), with significant difference (MCP = 0.020), being higher in the secondary group [Table 2]. Surgical hysteroscopic intervention was done as shown in [Figure 2] in the form of metroplasty (reconstructive hysteroscopic maneuver to regain normal shape of endometrium especially in septate, subseptate, and arcuate uterus) in 29.2%, myomectomy/polypectomy in 9.2%, septal resection in 5.4%, removal of abnormal endometrial tissue (e.g., the diffuse polyposis, endometrial hypervascularization, strawberry pattern, mucosal elevation, and endometrial defects ,) in 4.3%, adhesiolysis in 2.2%, and endometrial scratching in 1.1% (to improve endometrial receptivity, also some cases were prepared for in-vitro fertilization).
|Figure 2: Comparison between the two studied groups according to procedure done by hysteroscopy.|
Click here to view
We used 185 patients in hysteroscopy because eight cases of 200 were difficult hysteroscopic insertion and seven cases had dropped out.
[Table 3] shows the incidence of complications with both hysteroscopy and laparoscopy, which were minimal and happened in 10 (5%) cases only.
|Table 3: Comparison between the two studied groups according to complications in hysteroscopy and laparoscopy|
Click here to view
| Discussion|| |
Hysterolaparoscopy may appear to be invasive, but it may become more beneficial, as diagnosis and therapeutic interventions can be done at the same sitting ,. Therefore, we conducted this cross-sectional study. In general, abnormal laparoscopic findings were more common than the hysteroscopic ones, being more prevalent in the primary group. They accounted for approximately 63% in primary group and 55% in the secondary one. The hysteroscopic ones were approximately 50% in the primary infertiles and 35% in the secondary ones.
In agreement with our results, Kabadi and colleagues reported 52% abnormal laparoscopic findings and 31% abnormal hysteroscopy, Ramesh and colleagues reported higher incidence of approximately 75% abnormal hysterolaparoscopy findings, Vaid and colleagues reported 62% abnormal laparoscopy and 32% abnormal hysteroscopy findings, and Nigam and colleagues found similar laparoscopic abnormalities and less rate of hysteroscopic ones (13%). Nayak and colleagues found also lower results of approximately 33% abnormal laparoscopy and 20% abnormal hysteroscopy findings ,,,,. This is accepted because of fallacies of HSG. It has sensitivity of 65% and specificity of 85% . Many studies had near results to ours ,,. In infertile couples, laparoscopy revealed abnormal findings in 45–68% of the cases after normal HSG results according to multiple studies ,,,.
Among the abnormal laparoscopic findings, pelvic adhesions and endometriosis were the most noted (41 and 30%, respectively).
Moreover, Ramesh and Kurkuri  reported the prevalence of adnexal adhesions and endometriosis in 41.6% of patients in a retrospective analytical study on 250 infertile patients in India in 2016.
Badawi et al.  found no significant difference between the two groups in the incidence of pelvic adhesions or endometriosis, which is in disagreement with other more studies, including ours.
Tubal disease was found in 34.5% women with primary infertility and 40.5% women with secondary infertility, which is higher than other similar studies that have found tubal disease ranging from 23 to 30% in both groups ,,,.
Ovarian pathology was observed in approximately 16% of cases. This was similar to the results by Zhang et al.  and slightly more than that of Y. M. Kabadi and Harsha .
Uterine factors may be associated with primary infertility or with pregnancy wastage and premature delivery. Uterine factors can be congenital or acquired. They may affect the endometrium or myometrium and are responsible for 4–5% of infertility cases .
HSG failed to detect uterine pathology in approximately 50% of primary infertile patients, and 35% of secondary infertile patients, with a specificity of 50.5%. The agreement between HSG and hysteroscopy was 50%. Results with higher rates were demonstrated by Kabadi and Harsha . Lesser results have been documented, such as 32.12% of patients in a study by Vaid et al.  and approximately 12% by Hourvitz et al. ,.
Among the abnormal findings that were detected on hysteroscopy, uterine septum had the highest incidence (26.5%), followed by endometrial abnormalities (18.5%), mainly endometritis. The most common intrauterine pathology in both the groups was uterine polyps (10.3%). This result is higher than those observed by Ramesh and Kurkuri , Kabadi and Harsha , Zhang , Nayak et al. , and others.
The abnormal findings that were detected on hysteroscopy and laparoscopy were dealt with therapeutically at the same sitting. This was a significant advantage of hysteroscopy over HSG.
| Conclusion|| |
Combined hysterolaparoscopy is a safe, effective, and reliable method in comprehensive evaluation of infertility. Correctable structural abnormalities in pelvis may be unfortunately missed by routine pelvic examination and imaging procedures. It is a very useful tool in detecting these missed pelvic abnormalities in patients with the normal ovulation and husband semen analysis and normal HSG findings. It can be considered as a definitive day care procedure for evaluation of female infertility. Owing to low complication rate, minimal time requirements, therapeutic intervention at the same sitting, a negligible effect in the postoperative course, and significant advantage over HSG, hysterolaparoscopy should be considered as a definitive day care procedure for evaluation and treatment of female infertility.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dyer SJ. International estimates on infertility prevalence and treatment seeking: potential need and demand for medical care. Hum Reprod 2009; 24
Chandra A, Stephen EH. Infertility service use among U.S. women: 1995 and 2002. Fertile Steril 2010; 93
Nayak PK, Mahapatra PC, Mallick J, Swain S, Mitra S, Sahoo J. Role of diagnostic hystero-laparoscopy in the evaluation of infertility: a retrospective study of 300 patients. J Hum Reprod Sci 2013; 6
Jahan S. Role of laparoscopy in infertility: review article. BIRDEM Med J 2012; 2
Grimbizis GF, Gordts S, Di Spiezio-Sardo A, Brucker S, De Angelis C, Gergolet M, et al
. The ESHRE-ESGE consensus on the classification of female genital tract congenital anomalies. Gynecol Surg 2013; 10
Grimbizis GF, Gordts S, Di Spiezio-Sardo A, Brucker S, De Angelis C, Gergolet M, et al
. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod 2013; 28
Jain G, Khatuja R, Juneja A, Mehta S. Laparoscopy: as a first line diagnostic tool for infertility evaluation. J Clin Diagn Res 2014; 8
Pande B, Dora S, Pradhan Sh, Tiwary B. Role of hysterolaparoscopy for the evaluation of primary infertility: an experience from a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol 2017; 6
Vaid K, Mehra S, Verma M, Jain S, Sharma A, Bhaskaran S. Pan endoscopic approach 'hysterolaparoscopy' as an initial procedure in selected infertile women. J Clin Diagn Res 2014; 8
Ramesh B, Kurkuri S. Role of combined hystero-laparoscopy in the evaluation of female infertility as one step procedure. Int J Reprod Contracept Obstet Gynecol 2016; 5
Kabadi YM, Harsha B. Hysterolaparoscopy in the evaluation and management of female infertility. J Obstet Gynaecol India 2016; 66 (Suppl 1
Nigam A, Saxena P, Mishra A. A comparison of hysterosalpingography and combined laparohysteroscopy for the evaluation of primary infertility. Kathmandu Univ Med J 2015; 281
Jahan S. Diagnostic laparoscopy in infertility. Delta Med Coll J 2016; 4
Shamim S, Farooq M, Shamim R. Diagnostic laparoscopic findings in infertile patients in the Saudi population. Pak J Med Health Sci 2010; 4
Bulletti C, Panzini I, Borini A, Coccia E, Setti PL, Palagiano A. Pelvic factor infertility: diagnosis and prognosis of various procedures. Ann N
Y Acad Sci 2008; 1127
Tsuji I, Ami K, Mujazaki A, Hujinami N, Hoshiai H. Benefit of diagnostic laparoscopy for patients with unexplained infertility and normal hysterosalphingography finding. Tohaku J Exp Med 2009; 219
Badawi IA, Fluker MR, Bebbington MW. Diagnostic laparoscopy in infertile women with normal hysterosalpingograms. J Reprod Med 1999; 44
Fatnassi R, Kaabia O, Laadhari S, Briki R, Dimassi Z, Bibi M, et al
. Interest of laparoscopy in infertile couple with normal hysterosalpingography. Gynecol Obstet Fertil 2014; 42
Corson SL, Cheng A, Gotman JN. Laparoscopy in the normal infertile patient: a question revised. J Am Assoc Gynecol Laparosc 2000; 7
Aziz N. Laparoscopic evaluation of female factors in infertility. J Coll Physicians Surg Pak 2010; 20
Zhang E, Zhang Y, Fang L, Li Q, Gu J. Combined hysterolaparoscopy for the diagnosis of female infertility: a retrospective study of 132 patients in China. Mater Sociomed 2014; 26
Khan F, Jamaat S, Al-Jaroudi D. Saline infusion sonohysterography versus hysteroscopy for uterine cavity evaluation. Ann Saudi Med 2011; 31
Hourvitz A, Lédée N, Gervaise A, Fernandez H, Frydman R, Olivennes F. Should diagnostic hysteroscopy be a routine procedure during diagnostic laparoscopy in women with normal hysterosalpingography? Reprod Biomed Online 2002; 4
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]