Role of Laparoscopy in Unexplained Infertility  – “Never ending debate”

Diagnosing and managing unexplained infertility  still remains an enigma .  

 Infertility affects  1 in 10 couples and unexplained infertility accounts for about 20% of cases. 

Diagnosis is usually made when the female partner ovulates regularly, has patent Fallopian tubes, and has a partner with normal sperm count and function.

Hysterosalpingography (HSG), Laparoscopy, or both can be used to assess tubal patency. 

PROS-When laparoscopy is used as a standard test for tubal function, instead of HSG, the incidence of unexplained infertility may reduce from 10 to 3.5% (Drake et al., 1977).

When laparoscopy was performed for infertile patients with normal HSG findings, 21%-68% of patients had pathologic abnormalities like endometriosis, tubal disease and peritubular adhesions (Corson et al. 2000). Laparoscopy helps in detecting infertility causes in the pelvic cavity, which could then be treated, allowing postoperative pregnancies. Therefore, laparoscopy has both diagnostic and therapeutic importance.

CONS Other school of thought, Fatum et al. (2002) suggests that diagnostic laparoscopy should be omitted in patients with unexplained infertility. These patients should be treated with 3-6 cycles of ovulation Induction and IUI, and if the treatment is unsuccessful, they should be switched to Assisted Reproductive Techniques(ART), because of  (1) improved outcome of ART in today’s era, (2) lower pregnancy rate following diagnostic laparoscopy for patients with suspected unexplained infertility and normal HSG findings than following ART, and (3) lack of a contribution from diagnostic laparoscopy in the management plan for patients with suspected unexplained infertility and normal HSG findings.

Clinical history is very important for the selection of the more appropriate diagnostic tool. Its important to classify patients as high risk and low risk. High-risk patients with a past history of infection, prolonged infertility, and positive clinical findings usually warrant early laparoscopy whereas HSG is initially indicated as the less invasive procedure in low-risk patients.  Omitting laparoscopy from the infertility work-up when HSG is normal and there is no contributing past history can reduce

the cost of fertility treatment without compromising success rates.

Conclusion: Laparoscopy and laparoscopic surgery for adhesiolysis or ablation of endometriotic lesions should be reserved for cases where ART is not

easily available or covered by health care services.

References :

Corson, S.L., Cheng, A. & Guthman, J.N. (2000) Laparoscopy in the ‘normal’      

    infertile   patient : a question revisited. J. Am. Assoc. Gynecol. Laparosc., 7, 317-    

    324.

Drake, T., Tredway, D., Buchanan, G., Takaki, N. and Daane, T. (1977)

        Unexplained infertility. A reappraisal. Obstet. Gynecol., 50, 644–646.

Fatum, M., Laufer, N. & Simon, A. (2002) Investigation of the infertile couple:      

  should  diagnostic laparoscopy by performed after normal hysterosalpingography in   treating infertility suspected to be of unknown origin? Hum. Reprod., 17, 1-3.