Department of Obstetrics, Gynaecology and Reproductive Medicine, Vrije universiteit Medical Centre PO Box 7057, 1007 MB Amsterdam, The Netherlands 1 To whom correspondence should be addressed. e-mail: cb.lambalk@vumc.nl
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Abstract |
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Key words: diagnostic laparoscopy/endometriosis/hysterosalpingogram/infertility work up/intrauterine insemination
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Introduction |
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In infertile couples laparoscopy reveals abnormal findings in 2168 % of the cases after normal hysterosalpingogram (HSG) ( Wood, 1983; Henig et al., 1991
; Opsahl et al., 1993
; Cundiff et al., 1995
; Belisle et al., 1996
; al Badawi et al., 1999
; Corson et al., 2000
). This high prevalence of abnormal findings gives the impression that diagnostic laparoscopy might be of considerable value. However, the additional value of laparoscopy over a normal HSG does not only depend on the prevalence of disclosed pathology, but also on the contribution of diagnostic laparoscopy with regard to the decision of which treatment should be applied. Depending on the severity of the laparoscopic findings, the initial treatment decision, IUI, can be changed into direct laparoscopic correction of the abnormality followed by IUI, fertility-improving surgery by laparotomy or referral to IVF.
Recently, there has been a growing tendency for bypassing diagnostic laparoscopy in couples suspected of having unexplained infertility including a normal HSG as suggested in recent debates in this journal by Balasch and by Fatum et al. (Balasch, 2000; Fatum et al., 2002
). Fatum et al. stated that couples with unexplained infertility should be treated by 36 cycles of combined gonadotrophins and IUI without preceding diagnostic laparoscopy, and if unsuccessful they should be switched directly to IVF. In their opinion, this approach would probably prove to be the most cost effective and efficient treatment protocol. If this was the case, then such treatment protocols should not only be applied in couples suspected of having unexplained infertility, but also in couples with other infertility factors requiring IUI such as mild male subfertility and cervical hostility.
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Laparascopic findings and consequences to treatment |
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Most findings concerned tubal adhesions and minimal or mild endometriosis. In these cases, laparoscopy was not only diagnostic but also therapeutic, because of laparoscopic removal of tubal adhesions and coagulation or laser evaporation of endometriosis. Therefore, the clinical value of diagnostic laparoscopy in infertility work up is probably primarily determined by the effect of these laparoscopic interventions to pregnancy rates.
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Adhesions |
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In our clinic, chlamydia antibody testing (CAT) is not used as a diagnostic test for the assessment of tubal pathology. Therefore we could not identify its additional value with respect to the identification of patients with relevant tubal pathology after normal HSG. The use of CAT is based on the assumption that a Chlamydia trachomatis infection in the past is the cause of tubal pathology. If CAT identifies a large enough proportion of patients with tubal pathology who would benefit from laparoscopy, then the selection process is enhanced and routine laparoscopy could be unnecessary. However, CAT fails to provide information about the extent of tubal pathology which is of significance to further treatment decisions. Furthermore, CAT is unable to detect other causes of tubal pathology nor the presence of endometriosis. Since in our clinic endometriosis is more frequently found at laparoscopy than tubal pathology, 96 (19%) cases of endometriosis and 28 (6%) cases of tubal pathology, the use of CAT would be of limited additional value after normal HSG.
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Endometriosis |
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The reported prevalence of endometriosis found at laparoscopy in infertile women is 2535%, whereas the prevalence in the general population is probably 310% (Strathy et al., 1982; Candiani et al., 1991
; Olive and Schwartz, 1993
; Guzick et al., 1994
; Gruppo Italiano per lo Studio dellEndometriosi, 1994
). This high prevalence of endometriosis in infertile women has led to the assumption that there might be a causal relationship between infertility and the presence of endometriosis. In severe stages of endometriosis, the negative influence on fertility can be understood by the impaired tubal motility and ovum pick up function, but in less severe stages the pathophysiology cannot fully be explained by this mechanism and some hypothesize that immunological factors may play a role in endometriosis-associated infertility (Harada et al., 2001
). Although the mechanism of infertility associated with minimal and mild endometriosis remains unclear, treatment with controlled ovarian stimulation and IUI enhances monthly pregnancy rates compared with that of expectant management in infertile patients with minimal to mild endometriosis (Deaton et al., 1990
; Tummon et al., 1997
). Future studies should determine if prior surgical treatment in these cases will increase pregnancy rates after IUI or whether directly proceeding to IUI would be equally or more beneficial.
It is likely that the laparoscopic surgical treatment will significantly enhance pregnancy rates of IUI, since surgical treatment increases natural pregnancy rates. Furthermore, pre-treatment with GnRH agonist of minimal and mild endometriosis before IUI enhances pregnancy rates as shown by a randomized study of Kim et al. (Kim et al., 1996). This study showed that long term pre-treatment with GnRH agonist prior to controlled ovarian stimulation and IUI resulted in a higher pregnancy rate per cycle in infertile patients with endometriosis compared with controlled ovarian stimulation without pre-treatment.
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Laparoscopy and IUI |
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In the previous debates, Balasch and Fatum et al. advocate proceeding directly to three to six cycles of IUI and if unsuccessful immediately switched to IVF instead of finalizing the infertility work up by diagnostic laparoscopy (Balasch, 2000; Fatum et al., 2002
). In our opinion randomized studies assessing the cost effectiveness and timing of diagnostic laparoscopy prior to IUI should be performed before drawing these conclusions. Further studies should assess whether diagnostic laparoscopy is effective prior to IUI in terms of pregnancy rates and additional costs, and whether delayed performance of diagnostic laparoscopy after a few unsuccessful cycles of IUI instead of prior to IUI treatment is more effective.
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Conclusion |
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References |
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