1 Birmingham Women's Hospital, Metchley Park Road, Birmingham B15 2TG, UK
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Introduction |
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We read with interest the debate article (Fatum et al., 2002) about the usefulness of a diagnostic laparoscopy in infertile women with normal hysterosalpingogram. The authors address a clinical issue of importance in everday practice. However we feel that the following points should be clarified.
One of the references the authors use to support their views is that given by Gleicher in which the probability of clinically significant tubal disease in women with a normal gynaecoradiological procedure is noted to be small (Gleicher, 2000). What needs to be clarified is that the gynaecoradiological procedure, championed by Gleicher and colleagues, should not be considered equivalent to a routine hysterosalpingography (Gleicher et al., 1992a
). Gynaecoradiology, as defined by Gleicher et al., is a new approach in tubal assessment (Gleicher et al., 1992b
). In fact the same group have expressed their reservations about the weaknesses of hysterosalpingography in assessing tubal status (Karande et al., 1995
). Therefore whatever applies to the results of laparoscopy and dye after a normal gynaecoradiological procedure, should not be seen as transferable to the results of a laparoscopy and dye after a routine normal hysterosalpingogram.
The authors also refer to the randomized controlled trial by Marcoux et al.(1997) and its conclusion that laparoscopic resection or ablation of minimal and mild endometriosis enhances fecundity in infertile women (Marcoux et al., 1997
). They comment that the monthly fecundity rate amongst the infertile women treated laparoscopically in this study is much lower than the rate expected in fertile women. It is questionable whether fertility rates in fertile women should be seen as benchmarks against which pregnancy results of treatments for infertility should be judged. The fact that pregnancy rates after laparoscopic treatment of mild or minimal endometriosis in infertile women are not as good as rates for fertile women does not necessarily imply that a laparoscopy should not follow a normal hysterosalpingogram.
In discussing the merits of a laparoscopy after a normal hysterosalpingogram, the authors seem to argue that the increasing success rates of assisted reproduction technologies (ART) is another reason why a diagnostic laparoscopy in this context is not essential. It is not until the last paragraph of their article that they acknowledge that ART is not always easily available or covered by health care services, and a reality in which patients in many countries have to make treatment choices. We would add that it is not always desired by patients who might regard ART as an unwanted intervention. Such issues probably deserve a more prominent place in our debates.
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Notes |
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References |
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Gleicher, N. (2000) Cost-effective infertility care. Hum. Reprod. Update, 6, 190199.
Gleicher, N., Parrilli, M., Redding, L., Pratt, D. and Darande, V. (1992a) Standardization of hysterosalpingography and selective salpingography: a valuable adjunct to simple opacification studies. Fertil. Steril., 58, 11361141.[ISI][Medline]
Gleicher, N., Thurmond, A. Burry, K.A. and Coulam, C.B. (1992b) Gynecoradiology: a new approach to diagnosis and treatment of tubal disease. Fertil. Steril., 58, 885887.[ISI][Medline]
Karande, V.C., Pratt, D.E., Rabin, D.S. et al. (1995) The limited value of hysterosalpingography in assessing tubal status and fertility potential. Fertil. Steril., 63, 11671171.[ISI][Medline]
Marcoux, S., Maheux, R. and Berube, S. (1997) Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on endometriosis. N. Engl. J. Med., 337, 217222.