Should Diagnostic Laparoscopy be performed in all women as part of infertility work up for all infertile patients?
The routine use of diagnostic laparoscopy in the work-up of infertility has been challenged1.
IVF clinics are omitting diagnostic laparoscopy to reduce cost, anaesthetic and surgical complications. Diagnostic laparoscopy complications are 0.6/10002. However, advantages become obvious with flexibility to treat at the same time and also perform hysteroscopy to assess uterine cavity, perform polypectomy or hysteroscopic myomectomy, division of synaechiae, removal of a septum and endometrial biopsy, as day surgery.
A recent study recommended diagnostic laparoscopy prior to ART for potential diagnostic and therapeutic benefits in patients with unexplained infertility and normal HSG findings3.
According to a meta-analysis, HSG has reasonable specificity (83%) but low sensitivity (65%) to document tubal patency4. Hysterosalpingo-Contrast-Sonography (HyCoSy) is an attractive alternative to HSG because the patient is not exposed to X-rays or iodinated contrast media. The concordance rates on the assessment of tubal patency between HyCoSy and HSG are similar, making this ultrasound diagnostic tool an attractive option for the outpatient screening for tubal patency. Accuracy of HyCoSy was similar to that of HSG5.
The value of HSG performed at an early stage in fertility work-up prior to laparoscopy and dye was questioned as multicentre RCT comparing cumulative pregnancy rates (CPR) in a group where HSG was followed by diagnostic laparoscopy versus a group where diagnostic laparoscopy alone was performed, showed no significant difference in CPR at 18 months6.
A normal laparoscopic examination after two-sided occluded HSG was found in 42% of all patients7; in these cases fertility prospects were only slightly impaired with a three year cumulative ongoing intrauterine pregnancy rate of 9%. On the other hand, fertility prospects were strongly impaired in cases where laparoscopy showed one-sided and two-sided occlusions after a two-sided occluded HSG. The authors suggest that performing a diagnostic laparoscopy after a two-sided occluded HSG is very useful since it enables a division between two groups with significantly different fertility prospects.
Laparoscopy has a recognised role in diagnosis and assessment of mullerian duct abnormality in conjunction with HSG and ultrasound/ MRI.
Laparoscopy is considered the gold standard in the diagnosis of tuboperitoneal infertility. HSG and CAT screening have proven their clinical value and cost-effectiveness for the diagnosis of tubal infertility8. The value of diagnostic laparoscopy in case of abnormal HSG findings has been highlighted6,7. CAT Recent studies concluded that the optimum cut-off titre CAT should be 16 because it gives the best combination of sensitivity and specificity. However, high titres of chlamydial antibodies in infertile women indicate the need for early laparoscopy to assess tubal status9.
Treatment of minimal and mild endometriosis with infertility should not be never-ending discussion. Endometriosis prevalence in infertile population (20–68%) is higher than that in general female population of reproductive age (2.5–3.3%)10,11.
The monthly fecundity rate is around 7% in stages I–II endometriosis and the cumulative live birth rate with expectant management in endometriosis is low12.
It is more likely that relationship between endometriosis and infertility is causal13.
Compared to diagnostic laparoscopy, laparoscopic endometriosis surgery doubled Monthly fecundity rate (6.1%), but was still much lower than the fecundity rate expected in fertile women (20%). In the absence of adhesions, the destruction of the implants also significantly increased the 36-week cumulative probability of ongoing pregnancy with a cumulative incidence ratio of 1.614.
Diagnostic laparoscopy after failed CC ovulation induction did show normal pelvis in 36%, endometriosis and/ or pelvic adhesions in 50 and 33% respectively15. The authors concluded that laparoscopy continues to be a useful tool in the work-up of an infertile couple.
After operative laparoscopic adhesiolysis CPRs was higher at 32 and 45% in 12 and 24 months, respectively, when compared with the 11 and 16% CPRs observed in the non-treated control group16.
Diagnostic laparoscopy to evaluate all cases of anovulatory infertility cannot be advocated due to lack of good-quality studies, but laparoscopy can offer the opportunity to assess and treat endometriosis and adhesions that may limit conception, and to perform laparoscopic ovarian diathermy which is a good option when compared with gonadotrophin treatment in the CC-resistant PCOS patient, but counselling should be offered with regard to the unknown long-term effects of this procedure on the ovarian function17.
There is a new evidence that minimal and mild endometriosis, treated surgically before starting COH using CC or gonadotrophins and IUI may increase cycle pregnancy rate and reduce time to pregnancy; cumulative live birth rate after four cycles was also similar in patients with minimal endometriosis (70%), mild endometriosis (68%) and unexplained infertility (66%)18.
Progress in ART led to its use after a limited and non-invasive infertility work-up in all infertility patients19.
RCTs have demonstrated increased implantation and pregnancy rates in IVF cycles after salpingectomy for ultrasonically visible hydrosalpinges with best results in bilateral hydrosalpinx20,21.
A retrospective case controlled study22demonstrated that removal of asymptomatic small endometriotic cysts <3cm prior to IVF did not improve fertility outcome. However, laparoscopic cystectomy of larger symptomatic endometriotic cysts >4 cm improved fertility23,24,25.
Radical treatment of all endometriotic lesions by experienced laparoscopist, after several failed IVF cycles, produced spontaneous pregnancies and success with repeated IVF cycles26.
Properly conducted RCTs are required to assess many aspects of use of diagnostic laparoscopy in subfertility. A recent review27 of subfertility-RCTs published in reputable journals did show fatal flaws in design, a misunderstanding of the intention-to-treat principle and statistical errors arising from inappropriate unit of analysis. The review concluded many RCTs were not sufficient to allow reliable interpretation of results, or inclusion in meta-analyses.
1 Fatum M, Laufer N, Simon A. Investigation of the infertile couple: should diagnostic laparoscopy be performed after normal hysterosalpingography in treating infertility suspected to be of unknown origin? Hum Reprod 2002:17; 1–3.
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5 Dijkman A, Mol B, Van der Veen F et al. Can hysterosalpingocontrast-sonography replace hysterosalpingography in the assessment of tubal subfertility? Eur J Radiol 2000: 35; 44–48.
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8 Mol B, Collins J, Van der Veen F et al. Cost-effectiveness of hysteron-salpingography, laparoscopy and Chlamydia antibody testing in subfertile couples. Fertil Steril 2001:75;571–580.
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15 Ochoa Capelo F, Kumar A, Steinkampf MP et al. Laparoscopic evaluation following failure to achieve pregnancy after ovulation induction with clomiphene citrate. Fertil Steril 2003: 80; 1450–1453.
16 Tulandi T, Collins J, Burrows E et al. Treatment-dependent and treatment-independent pregnancy among women with periadnexal adhesions. Am J Obstet Gynecol 1990: 162; 354–357.
17 Farquhar C, Lilford RJ, Marjoribanks J et al. Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 2005: 3; CD001122.
18 Werbrouck E, Spiessens C, Meuleman C et al. No difference in cycle pregnancy rate and in cumulative live birth rate between women with surgically treated minimal to mild endometriosis and women with unexplained infertility after controlled ovarian hyperstimulation and intrauterine insemination (IUI). Fertil Steril 2006: 86; 566–571.
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20 Dechaud H, Daures J, Arnal F et al. Does previous salpingectomy improve implantation and pregnancy rates in patients with severe tubal factor infertility who are undergoing in vitro fertilization? A pilot prospective randomized study. Fertil Steril 1998: 69; 1020–1025.
21 Strandell A, Lindhard A, Waldenstrom U et al. Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF. Hum Reprod 1999:14; 2762–2769.
22 Garcia-Velasco J, Mahutte N, Corona J et al. Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched case-control study. Fertil Steril 2004: 81; 1194–1197.
23 Beretta P, Franchi M, Ghezzi F et al. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998: 70; 1176–1180.
24 Chapron C, Vercellini P, Barakat H et al. Management of ovarian endometriomas. Hum Reprod Update 2002: 8; 6–7.
25 Vercellini P, Chapron C, De Giorgi O et al. Coagulation or excision of ovarian endometriomas? Am J Obstet Gynecol 2003b: 188; 606–610.
26 Littman E, Giudice L, Lathi R et al. Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles. Fertil Steril 2005: 84; 1574–1578.
27 Vail, A. and Gardener, E. Common statistical errors in the design and analysis of subfertility trials. Hum. Reprod. 2003: 18; 1000-1004.
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