Department of Obstetrics and Gynecology, Hadassah University hospital, Ein Kerem, Jerusalem, Israel
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() |
---|
Key words: HSG/infertile couple/infertility treatment/laparoscopy/unexplained infertility
![]() |
Investigation of the infertile couple |
---|
![]() ![]() ![]() ![]() |
---|
Because the rates of spontaneous pregnancy are still considerably lower than those observed in the normal population (the cumulative pregnancy rate in normal couples within 12 months is 99% as opposed to 60% pregnancy rates after 3 years of expectant management normal infertile couples) (Simon and Laufer, 1993), it is essential to complete the standard diagnostic work-up to avoid overlooking a treatable factor. The generally accepted investigation protocol to establish the diagnosis of unexplained infertility includes semen analysis, a properly timed post-coital test, assessment of ovulation and demonstration of tubal patency (Speroff et al., 1999
).
Hysterosalpingography (HSG), laparoscopy or both can be applied to demonstrate tubal patency. HSG is also essential to exclude Müllerian tube malformations and other uterine cavity defects (Simon and Laufer, 1993). However, even when tubal patency has been demonstrated by HSG, laparoscopy has been suggested as a mandatory step to rule out the existence of peritubal adhesions as well as endometriosis as causes of infertility (Pepperell and McBain, 1985
; Simon and Laufer, 1993
). It has been estimated that using laparoscopy as a standard test of tubal function would reduce the apparent incidence of unexplained infertility from 10 to 3.5% (Drake et al., 1977
). In 24 cases of otherwise unexplained infertility, Drake et al. found abnormal findings in 18 (75%). Of these 18 subjects, unsuspected endometriosis was found in 11 (46%) and peritubal adhesions in seven (29%). They concluded that laparoscopy is, therefore, an essential final step in an otherwise negative work-up for infertility (Drake et al., 1977
). Since then, laparoscopy has traditionally been suggested to be an integral diagnostic procedure of most infertility investigatory protocols (Simon et al., 1993;Speroff et al., 1999
). It was considered a complementary procedure following normal hysterosalpingogram precluding endometriosis or peritubal non-obstructing adhesions. Several reports have documented the shortcomings of HSG in establishing the diagnosis of peritubal adhesions (Gutmann, 1992
). The sensitivity of HSG in detecting peritubal adhesions has been reported to be 3475% (Rice et al., 1986
). It was found that in 21%, adnexal adhesions and pelvic endometriosis were identified during surgery in spite of a normal HSG (Henig et al., 1991
). Therefore, it was suggested by these authors that, `the recommended interval of 6 months between normal HSG and diagnostic laparoscopy can be shortened if the HSG is normal and the etiology of the infertility is obscured.' The superiority of laparoscopy over HSG in assessing extratubular pathology has also been shown in other studies (Rajah et al., 1992
; Opsahl et al., 1993
; Cundiff et al., 1995
; Swart et al., 1995
). It has been claimed that endometriosis, regardless of its severity, rarely causes radiographic abnormalities on HSG and therefore can be diagnosed only by laparoscopy (Johnson et al., 1994
). On the other hand, discussing cost-effective infertility care, Gleicher suggested that in the case of a normal gynaecoradiological procedure, the probability of clinically relevant tubal disease or endometriosis is so low that laparoscopy does not seem warranted (Gleicher, 2000
). He states that relevant diagnostic information can be obtained more cheaply by performing a radiological procedure instead of a laparoscopy. In his view, proper utilization (or better non-utilization) of surgical procedures, usually endoscopic procedures, represents the single most significant factor in providing cost-effective infertility care. In addition, laparoscopy in normal infertile patients will ordinarily show a degree of endometriosis not requiring treatment (Speroff et al., 1999
).
Some authors stress the importance of clinical history for the selection of the more appropriate diagnostic tool. By classifying the infertile population to high and low risk infertility groups according to the patient's past history, pelvic examination and the duration of infertility, some practical conclusions were raised by Portuondo and co-authors (Portuondo et al., 1984). In the high risk group, they recommended early laparoscopy due to the greater abnormal findings encountered at both HSG and laparoscopy. In contrast, low risk infertility patients were found to have decreased abnormal findings, and consequently they recommended that HSG be initially indicated as the less invasive procedure. The authors concluded that clinical data are very valuable in the selection of infertile patients for performing early or late laparoscopy (Portuondo et al., 1984
).
Following a normal HSG and normal laparoscopy (if performed) the couple is diagnosed as suffering from `unexplained infertility' and referred to the next line of treatment. The most acceptable and successful approach is that of ovulation induction by gonadotrophins combined with intrauterine insemination (IUI) for 36 cycles (Simon and Laufer, 1993; Speroff et al., 1999
). When this treatment fails, ART is then offered to the couple.
In the minority of cases who have normal HSG, laparoscopy may reveal minimal or mild endometriosis or peritubal adhesions. In cases of minimal or mild endometriosis, neither surgery nor medical treatments have been proven to be of any benefit (Portuondo et al., 1983; Olive et al., 1985
; Hull et al., 1987
; Speroff et al., 1999
). In cases of mild endometriosis, expectant management is usually rewarded with reasonable pregnancy rates that are comparable with those obtained by either surgical or medical treatment. Others have advocated the laparoscopic resection or ablation of endometriotic lesions to treat the infertility associated with this condition. In a randomized controlled trial, it was found that laparoscopic resection or ablation of minimal and mild endometriosis enhances fecundity in infertile women (Marcoux et al., 1997
). They reported that one in eight women with minimal or mild endometriosis should benefit from resection or ablation. Nevertheless, the monthly fecundity rate among women who underwent laparoscopic surgery (6.1%) was much lower than the rate expected in fertile women (20%). Taken together, these observations on minimal and mild endometriosis justify turning to ART, which might offer a higher success rate per cycle than the relatively low pregnancy rates expected after laparoscopic surgeries.
The minority of patients with a normal HSG study, but who have peritubal adhesions by laparoscopy, might benefit from laparoscopic adhesiolysis followed by combined gonadotrophins treatment and IUI to achieve pregnancy as soon as possible after diagnosis. For those who still fail to achieve conception after several cycles of attempt, ART is called as the next line of treatment. However, low risk women for peritubal adhesions will have low abnormal laparoscopic findings as stated above (Portuondo et al., 1984). In these cases, laparoscopy will be of little benefit in determining or changing the management plan. In addition, patients with significant tubal disease will frequently have positive hysterosalpingograms and these women are best advised to proceed to IVFembryo transfer.
In a comprehensive debate article (Balasch, 2000), the role of laparoscopy as a diagnostic procedure used to investigate the infertile couple was addressed. In this debate Balasch raised the point that as the success of ART improves, clinicians increasingly believe that turning to ART is appropriate even without laparoscopy. He stresses the difficulties in persuading a woman with a normal HSG to undergo an invasive procedure such as laparoscopy. According to Balasch, this attitude towards laparoscopy from both the clinicians and patients, represents a move from a `diagnostic work-up' to a `prognosis oriented approach' in the investigation and treatment of the infertile couple (Balasch, 2000
).
In our daily practice, with the improved success rates of ART and the relatively low contribution of diagnostic laparoscopy in the decision as to the next step in treating patients with a normal HSG, we found it logical to offer these patients a treatment by combined gonadotrophins and IUI for 36 months and switch to ART if such a treatment fails. This is a reasonable and appropriate suggestion, since even if one finds evidence of peritubal disease by laparoscopy, in most hands IVF will be more successful than treating significant tubal disease through the laparoscope (Speroff et al., 1999).
The impatience of treated couples and considerations of healthcare cost are of utmost importance and influence the type of diagnostic tools or treatments selected by couples. 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. Couples with longstanding infertility will often ask their physician to do something to solve their problem. Additional diagnostic or low productive laparoscopic surgeries may be conceived as loss of precious time and energies.
We suggest therefore, that laparoscopy should be omitted after a normal HSG in couples suspected to have unexplained infertility and advocate the use of ovulation induction for several cycles before reverting to ART. Such an approach will prove to be the most cost effective and efficient treatment protocol. The only indication for diagnostic 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.
![]() |
Notes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() |
---|
Balasch, J. (2000) Investigation of the infertile couple in the era of assisted reproductive technology: a time for reappraisal. Hum. Reprod., 15, 22512257.
Collins, J.A. and Rowe, T.C. (1989) Age of the female partner is a prognostic factor in prolonged unexplained infertility: a multicenter study. Fertil. Steril., 52, 1520.[ISI][Medline]
Crosignani, P.G., Collins, J., Cooke, I.D., Diczfalusy, E. and Rubin, B. (1993) Recommendations of the ESHRE workshop on `unexplained infertility'. Hum. Reprod., 8, 977980.[ISI][Medline]
Cundiff, G., Carr, B.R. and Marshburn, P.B. (1995) Infertile couples with a normal hysterosalpingogram. Reproductive outcome and its relationship to clinical and laparoscopic findings. J. Reprod. Med., 40, 1924.[ISI][Medline]
Drake, T., Tredway, D., Buchanan, G., Takaki, N. and Daane, T. (1977) Unexplained infertility. A reappraisal. Obstet. Gynecol., 50, 644646.[Abstract]
Gleicher, N. (2000) Cost-effective infertility care. Hum. Reprod. Update, 6, 190199.
Gutmann, J.N. (1992) Imaging in the evaluation of female infertility. J. Reprod. Med., 37, 5461.[ISI][Medline]
Henig, I., Prough, S.G., Cheatwood, M. and Delong, E. (1991) Hysterosalpingography, laparoscopy and hysteroscopy in infertility. A comparative study. J. Reprod. Med., 36, 573575.[ISI][Medline]
Hull, M.E., Moghissi, K.S., Magyar, D.F. and Hayes, M.F. (1987) Comparison of different treatment modalities of endometriosis in infertile women. Fertil. Steril., 47, 4044.[ISI][Medline]
Johnson, W.K., Ott, D.J., Chen, M.I., Fayez, J.A. and Gelfand, D.W. (1994) Efficacy of hysterosalpingography in evaluating endometriosis. Abdom. Imaging, 19, 278280.[ISI][Medline]
Marcoux, S., Maheux, R. and Berube, S. (1997) Laparoscopic surgery in infertile women with minimal or mild endometriosis. N. Engl. J. Med., 337, 269270.
Olive, D.L., Stohs, G.F., Metzger, D.A. and Franklin, R.R. (1985) Expectant management and hydrotubations in the treatment of endometriosis-associated infertility. Fertil. Steril., 44, 3541.[ISI][Medline]
Opsahl, M.S., Miller, B. and Klein, T.A. (1993) The predictive value of hysterosalpingography for tubal and peritoneal infertility factors. Fertil. Steril., 60, 444448.[ISI][Medline]
Pepperell, R.J. and McBain, J.C. (1985) Unexplained infertility: A review. Br. J. Obstet. Gynaecol., 92, 569580.[ISI][Medline]
Portuondo, J.A., Echanojauregui, A.D., Herran, C. and Alijarte, I. (1983) Early conception with untreated mild endometriosis. Fertil. Steril., 39, 2225.[ISI][Medline]
Portuondo, J.A., Pena Irala, J., Ibanez E. and Echanojauregui, A.D. (1984) Clinical selection of infertile patients for laparoscopy. Int. J. Fertil., 29, 234238.[ISI][Medline]
Rajah, R., McHugo, J.M. and Obhrai, M. (1992) The role of hysterosalpingography in modern gynecological practice. Br. J. Rad., 65, 849851.[ISI]
Rice, J.P., London, S.N. and Olive, D.L. (1986) Reevaluation of hysterosalpingography in infertility investigation. Obstet. Gynecol., 67, 718721.[Abstract]
Rousseau, S., Lord, J., Lepage, Y. and Van Campenhout, J. (1983) The expectancy of pregnancy for `normal ' infertile couples. Fertil. Steril., 40, 768772.[ISI][Medline]
Simon, A. and Laufer, N. (1993) Unexplained infertility: a reappraisal. Ass. Reprod. Rev., 3, 2636.
Speroff, L., Glass, R.H. and Kase, N.G. (1999) Female infertility. In Speroff, L., Glass, R.H., Kase, N.G. (eds) Clinical Gynecologic Endocrinology and Infertility, 6th edn. Lippincott Williams & Wilkins, Philadelphia, PA, USA.
Swart, P., Mol, B.W., van der Veen, F., van Beurden, M., Redekop, W.K. and Bossuyt, P.M. (1995) The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil. Steril., 64, 486491.[ISI][Medline]
Verkauf, B.S. (1983) The incidence and outcome of single-factor and multi-factorial and unexplained infertility. Am. J. Obstet. Gynecol., 147, 175181.[ISI][Medline]