INTRODUCTION
Infertility is defined as a failure to conceive during 1 year of frequent unprotected intercourse. Apart from male factors, the main causes of female infertility include tubal pathology, ovarian disorders, uterine or cervical factors, endometriosis, infection pelvic tuberculosis, etc. In recent past, diagnostic laparoscopy (DL) was the gold standard for diagnosis as well as management of female infertility. This view was supported by the World Health Organization (WHO) guidelines,1 and also American Fertility Society recommendations. It was a custom to perform DL as an essential infertility workup by about 90% of infertility specialists in the United States of America (USA) during late 90s. The main advantage of laparoscopy is that on one hand, diagnosis can be made about anatomic pelvic defect and on the other hand, corrective surgery can be performed at the same time, along with performing hysteroscopy at the same sitting. DL also termed as exploratory laparoscopy, is usually established as the most perfect and accurate procedure to detect pelvic organ pathologies likes tubal pathology, endometriosis, fibroids, ovarian cysts and other conditions influencing fertility.2–9
COMMON INDICATIONS OF DIAGNOSTIC LAPAROSCOPY
- Patients with unexplained infertility following standard infertility screening tests usually undergo timed intercourse (TI) that coordinates the time of ovulation and coitus, controlled ovarian hyperstimulation (COH), or intrauterine insemination (IUI). If the treatment is unsuccessful, DL is performed.
- Infertility with suspected pelvic pathology detected during clinical examination or pelvic ultrasonography (USG)
- Infertile women with chronic pelvic pain
- Past history of pelvic surgery involving pelvic organs
PROCEDURE IN A NUTSHELL
Laparoscopy patients are admitted 8–12 hours before the surgery and kept in fasting. The procedure is performed in postmenstrual phase. DL is performed by standard technique under general anesthesia in lithotomy position.
The laparoscope is introduced through subumbilical incision and after CO2 insufflations. Thorough assessment is performed and findings are recorded. Methylene blue is used to check the tubal patency. The patients are discharged on next day morning.
During laparoscopy, all the pelvic organs are examined very carefully by manipulating through the second puncture instrument. A third puncture may be necessary to push the bowels upward and backward, to examine the pelvic organs thoroughly, particularly the ovarian fossa, which is a very common site of endometriotic involvement which is often missed.
COMMON APPEARANCES OF VARIOUS LESIONS IN LAPAROSCOPY
- Genital tuberculosis:
- Congestion, edema, pelvic adhesions, loculated collections of fluid in subacute stages
- Miliary tubercles, white, yellow or opaque plaques
- Chronic stages—tubo-ovarian mass, caseous nodules, encysted ascites, various types of adhesions—both flimsy, dense, perihepatic adhesions
- The fallopian tubes—normal, tubercles, retort-shaped, hydrosalpinx, caseous granuloma, beaded, tobacco pouch appearance (exudative or productive adhesive type of tubercular salpingitis).
- Chlamydia and gonococcus:
- Normal (75%)
- Violin-string adhesions and perihepatic adhesions (Fitz-Hugh-Curtis syndrome).
- Endometriosis:
- Typical black/dark blue or deep red spots or peritoneal surface
- Scarring, red flame like lesions, yellow patches, clear “bubble” like lesions, peritoneal defects and adhesions
- Chocolate cysts.
- Other lesions—fibroid, adenomyosis, uterine structural anomalies, ovarian cysts can be diagnosed well with laparoscopy.
The role of diagnostic laparoscopy in modern day fertility practice is under debate.
In mid-90s indicated that DL is not an ideal predictor of infertility. Moreover with this view, some authorities declined the need for this procedure as an essential workup of infertility.10,11 Consequently, with increase in popularity of 3in vitro fertilization (IVF) and it is cost-effectively, DL is increasingly bypassed. Moreover, DL is an invasive procedure requiring general anesthesia, patient anxiety, surgical accident like hollow viscus injury, and postoperative adhesion formation. A large Finnish follow-up study has concluded the complication rate of DL to be 0.6/1,000.12
If we want to avoid laparoscopy, we have to explore other alternative procedure which helps us to investigate infertility.
TUBAL FACTOR
Hysterosalpingography (HSG) and sonosalpingography (SSG) are the two alternative procedures to evaluate the tubal status. As the patient is exposed to radiation in HSG, many people want to avoid it and prefer to do hysterosalpingo contrast sonography (HyCoSy). It is an attractive alternative to HSG, because the patient is not exposed to X-rays or iodinated contrast media. Fallopian tubal patency is assessed using transvaginal ultrasonography (TVS) and a galactose microbubble contrast medium. The concordance rates on the assessment of tubal patency between HyCoSy and HSG are similar, making this ultrasound (US)-diagnostic tool an attractive option for the outpatient screening for tubal patency. The accuracy of HSG or HyCoSy so far pregnancy rate (PR) is concerned, are similar.13 The other disadvantages of HSG are abdominal pain and discomfort, pelvic abscess, and peritonitis. The technique of HSG has several possible adverse effects. Lower abdominal pain and discomfort are commonly experienced by patients undergoing HSG, and can be remembered for years afterward as one of the most painful outpatient examinations in gynecology. An HSG can induce or exacerbate pelvic inflammatory disease (PID), leading to peritonitis, pelvic abscess and very exceptionally, even to death.14 Uterine perforation and post-examination hemorrhage are a possibility. Other complications include granuloma formation and vascular intravasation. Hypersensitivity reactions to iodine exist with any of the HSG media, but allergic reactions are rare. Finally, the ionizing radiation used for HSG can be detrimental to an undiagnosed early pregnancy. A multicentre randomized controlled trial (RCT) comparing cumulative PRs (CPRs) in a group where HSG was followed by DL versus a group where DL alone was performed, showed no significant difference in CPR at 18 months.15 HSG can detect luminal problem of tube and uterus. But peritubal adhesion and other mild pelvic adhesion can only be detected by laparoscopy.
TUBO-PERITONEAL FACTOR
Minimal and mild endometriosis are better diagnosed by laparoscopy. According to a meta-analysis by Jacobson and coworkers,16 the ablation of endometriotic lesions with adhesiolysis to improve fertility in minimal and mild endometriosis is effective compared to DL alone. This recommendation is based upon a systematic review of two similar but contradictory RCTs 4performed in Italy17 and in Canada,18 comparing laparoscopic ablation or excision and adhesiolysis of endometriotic lesions versus DL alone. The fact that these two RCTs have been assembled into one meta-analysis has been criticized,19 because the Italian study had some methodological limitations.19 Some authorities have used TVS to detect mild to moderate endometriosis in the pouch of Douglas (POD), by detecting thickening of POD. This procedure is not popularized yet.20
Minor tubal defects may pass unnoticed during laparoscopic procedure. Six types of minor tubal defects had been presented by Chatterjee et al.21 Correction of these problems at the same sitting resulted in improvement of PRs in case of unexplained infertility, which is comparable to IVF PR for same type of problems.
LAPAROSCOPY AND OVULATION
During performing DL, ovulatory stigma may be visible. In matured preovulatory follicle or Graafian follicle with some straw-colored fluid collection in POD might indicate the ovulatory status. This is not a routine practice and USG-folliculometry and serum progesterone estimation are the standard practices for detecting ovulation. Laparoscopy before ovulation induction (OI) is not an essential step, but finding endometriosis or minimal adhesion (peritubal and periovarian) might indicate that OI may be useless to achieve a pregnancy unless the adnexae are made free. Whether minimal or mild endometriosis must be treated before OI is an unresolved question but proper OI with or without gonadotropin, IUI may be a proper step to treat ovulatory infertility.
LAPAROSCOPIC OVARIAN DRILLING
Laparoscopic ovarian drilling (LOD) is another way of treating polycystic ovarian disease (PCOD) particularly for clomiphene-resistant cases (20% of PCOD cases). In a recent Cochrane review,22 the efficacy of laparoscopic drilling of the ovarian capsule (laparoscopic ovarian diathermy, LOD) by diathermy or laser in clomiphene-resistant polycystic ovarian syndrome (PCOS) has been compared to gonadotropin treatment based on a total of 15 RCTs. Only six trials were included for further analysis. The primary outcome parameters were live birth rate, ovulation rate and ongoing PR. The secondary outcome parameters included rate of miscarriage, multiple PR, ovarian hyperstimulation syndrome (OHSS) and the total cost of the respective treatments. There was no evidence of difference in the live birth rate or ongoing PR or miscarriage rate between LOD and the gonadotropin. However, the multiple PRs were lower with ovarian drilling than with gonadotropin. The reviewer's conclusion is that there is no difference in the live birth rate and the miscarriage rate in women with clomiphene-resistant PCOS undergoing LOD, when compared with gonadotropin treatment.22 However, the reduction in multiple PRs in women undergoing LOD makes this option attractive.5
LAPAROSCOPY BEFORE INTRAUTERINE INSEMINATION
Intrauterine insemination is an effective fertility enhancement treatment in cases of cervical factor, unexplained infertility and mild male factor infertility. The role of laparoscopy before IUI is not yet specified23 and studies also could not conclude whether laparoscopy before IUI influences the success rate. Scientific evidence suggests that minimal and mild endometriosis, treated surgically before starting COH (COH and IUI may increase the cycle PR and reduce the time to pregnancy).24 Indeed, in a retrospective cohort study, D'Hooghe and coworkers24 recently showed data suggesting that it is useful to treat minimal and mild endometriosis before starting COH and IUI.25 The study observed that surgical treatment prior to IUI restores the clinical PR after COH and IUI in women with minimal to mild endometriosis to the same level, as that in women with unexplained infertility. This is in contrast with previous studies where the cycle PR and CPR seemed to be lower in patients with surgically untreated minimal to mild endometriosis than those with unexplained infertility.24 Randomized trials are needed to verify this conclusion, which might have important implications.
The noncontrolled retrospective evidence in this study stresses the importance of referring patients with severe endometriosis to a center with the necessary expertise,26 in which case even after several failed IVF cycles, radical and appropriate surgery may still be beneficial to their reproductive outcome. It is clear that further randomized controlled studies are needed to support this view on laparoscopic treatment of severe endometriosis after failed IVF cycles.
LAPAROSCOPY IN ADVANCED ENDOMETRIOSIS
Laparoscopy can diagnose advanced endometriosis and sometimes, some definitive surgery is added to it in anticipated cases, mostly to alleviate pain. Adnexal endometriotic involvement like endometrioma may need laparoscopic procedure even before IVF treatment. The restoration of pelvic anatomy may increase spontaneous PR but in India, this rise is negligible because of presence of associated adenomyosis.27 No definite data regarding the benefit of laparoscopy in endometriosis is available. There seems to be a negative correlation between the stage of endometriosis and the spontaneous CPR after surgical removal of endometriosis based upon the evidence of three studies,28,29 but statistical significance for this statement was only reached in one study.27 Laparoscopic surgery for advanced endometriosis may technically be very demanding, time consuming, and high risk with significant post TI morbidities and needs tremendous expertise. Laparoscopy for the treatment of endometriosis in failed IVF patients if performed by very experienced surgeon might increase a PR. A non-controlled retrospective study stressed the importance of such procedure in very experienced hand.266
DEBATE OF LAPAROSCOPY AND IN VITRO FERTILIZATION
This is true that the progresses of IVF technology have made the need for laparoscopic procedures less important in the treatment of infertility. However, there is a fair degree of consensus that in selected adnexal pathologies, such as hydrosalpinx and ovarian endometriotic cysts, still have to be treated by laparoscopic surgery prior to IVF.
With respect to hydrosalpinx, two RCTs have demonstrated increased implantation and PRs in IVF cycles after salpingectomy for ultrasonically visible hydrosalpinges.30,31 Both these trials have been included in a recent Cochrane review.32 The Scandinavian trial31 reports a delivery rate per started cycle of 27% in IVF patients undergoing salpingectomy prior to IVF treatment versus 17% in the control group without salpingectomy. The adverse effect of hydrosalpinx on assisted reproductive technology (ART) success rates can be explained by several mechanisms: the direct toxic effect of tubal fluid on the embryos, the negative effect of tubal fluid on the endometrium by flushing out embryos, dilution of implantation factors and prevention of normal embryonic-endometrial apposition.33 Some authors like Puttemans et al. have warned against the indiscriminate and blind victimization of the fallopian tube and have advocated selective salpingostomy in selected cases.34 A RCT of reconstructive tubal surgery versus salpingectomy and IVF in women with hydrosalpinx is needed to define the position of both treatment strategies in everyday clinical practice, but can only be done in countries with a high prevalence of PID.25 Ovarian endometrioma or chocolate cyst should be considered crucially. Small endometrioma of less than 3 cm may not hinder IVF result and treating them may kill the time as well as inappropriate surgery may reduce ovarian function. Larger symptomatic endometrioma if removed, improves fertility rate, oocyte pickup (OPU) rate and reduces the recurrence rate.35–37 With respect to endometriosis and ART, the recent European Society of Human Reproduction and Embryology (ESHRE) guidelines state that IVF is appropriate treatment especially if tubal function is compromised, if there is also male factor infertility and if other treatments have failed.26
The IVF PR is lower in patient with advanced endometriosis as compared to other factors.
CONCLUSION
Diagnostic laparoscopy, which was at one time essential step for evaluation and treatment of infertility, is gradually losing ground due to more and more advancement of ART procedures. The routine use of diagnostic laparoscopy for evaluation of all cases of female infertility is currently under debate. Laparoscopy performed after several failed cycles of OI in unexplained infertility cases may detect significant proportion of pelvic pathology amenable to treatment, but many authorities deny that because they think correction of those pathologies 7like mild and minimal endometriosis do not increase PR. LOD in clomiphene citrate-resistant PCOS is at least as effective as gonadotropin treatment, and the only advantage being reduction of multiple PRs. The role of diagnostic laparoscopy before IUI is controversial. In case of definite tubal pathology like hydrosalpinx or large ovarian endometrioma, laparoscopy improves the PR through IVF. The evidence of benefit of laparoscopic surgery in moderate and severe endometriosis is still lacking. Though its role has generally been accepted, the use of laparoscopy should be individualized and should not be used randomly in the treatment of infertility.
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