The Role of Laparoscopy in the Management of Infertility Patients: A Cross Sectional Study
Dr. Siri vummaneni*¹, Krithika Muthusamy ², Shabana Babu

1,2, 3. MS, DNB OBGYN, SRM Medical College, Kattankulathur.

*Correspondence to: Dr. Siri vummaneni, Ms, DNB obgyn, SRM Medical College, Kattankulathur.

Copyright     

© 2024 Dr. Siri vummaneni. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 24 January 2024

Published: 12 April 2024

DOI: https://doi.org/10.5281/zenodo.10963438

Abstract

Background and Objectives: Infertility affects 10 – 15 % of couples is an important part of clinical practice for many clinicians. Laparoscopy is an important tool to assess the reproductive pathology including tubal patency in infertile women. In the same setting therapeutic intervention can be done.

Objectives of the study: To determine the definitive reproductive pathology using laparoscopy to provide the basis for treatment of infertility patients. To appraise the evidence on the effectiveness of laparoscopy in the treatment of female infertility.

Methods: This is a crossectional study conducted on 95 women with primary infertility from 1/08/14 to 1/08/15 . Infertility work up included semen analysis, Ultrasonography, TSH, LH,FSH, serum prolactin. Women were subjected to laparoscopy under GA. Laparoscopic findings were noted and therapeutic interventions were done if required . Intra operative and post operative complications were noted.

Result: The mean age of women in the study was 28.6 yrs.The mean duration of infertility was 5.2 yrs. In 87.4% of the women pelvic pathology was noted on laparoscopy. Among these 33.6% of the women had undiagnosed pathology detected on laparoscopy. The pathology detected was polycystic ovaries (35.7%),tubal pathology(17.8%), tubal block(11.5%),pelvic adhesions(22.1%) endometriosis(15.7%). Therapeutic intervention was done in 75.7% of the women. There was difficulty in creating pneumoperitoneum in 2 women. None of the women had intraoperative or post operative complications.20 women conceived during the period of study.

Conclusion: Ovulatory infertility(43%) and tubal infertility and adhesions (22%) are common causes of infertiliy. Laparoscopy is a valuable technique for the complete assessment of female infertilityand has successfully shortened the duration of infertility and increased the conception rate in my study. Hence laparoscopy can be used as a gold standard in the diagnosis and management of infertility particularly among the women whose

1. Age > 30 YRS

2. Duration of infertility > 5 yrs

3. PCODS patients who are Gnrh resistant and high serum LH

4. Unexplained female infertility

and should be used early in the diagnostic work up

Keywords: Infertility, Laparoscopy.

LIST OF ABBREVIATIONS

ART - Assisted Reproductive Technology

BMI - Body Mass Index

COH - Controlled Ovarian Hyper stimulation

CPR - Cumulative Pregnancy Rate

CPT - Chromopertubation

CHC - Chocolate cyst

DAD - Dense adhesions

DC - Dermoid cyst

DES - Diethylstilbestrol

ESHRE - European Society of Human Reproduction and Embryology

END - Endometrial deposites

FUL - Fulguration of endometrial spots

FSH - Follicle Stimulating Hormone

FLAD - Flimsy adhesions

GA - General Anaesthesia

GnRH - Gonadotropin Releasing Hormone

HC - Haemrrhagic cyst

HSG - Hysterosalphingography

ICSI - Intra Cytoplasmic Sperm Injection

IUI - Intrauterine Insemination

IOP - Intra operative complications

LH - Leutenizing Hormone

LOD - Laparoscopic Ovarian Diathermy

LPD - Leutal Phase Defect

ULF - Leutenised Unruptured Follicle

NOTES - Natural Orifice Transluminal Endoscopic Surgery

OB - Obliterated

OC - Ovarian cyst

OCY - Ovarian cystectomy

PCO - Polycystic ovaries

POP - Post operative complications

PCOD - Polycystic Ovarian Disease

PCOS - Polycystic Ovarian Syndrome

PCT - Post Coital Test

PHAD - Peri hepatic adhesions

PTAD - Peri tubal adhesions

SILS - Single Incision Laparoscopic Surgery

TSH - Thyroid Stimulating Hormone

USG - Ultrasonography

WHO - World Health Organization

 

Introduction

Infertility affects 10 – 15 % of couples and an important part of clinical practice for many clinicians [1]. Its overall prevalence has been stable during the past 50 years; however, a shift in etiology and patient age has occurred; As the woman's age increases, the incidence of infertility also increases. In our country a stable family structure and the desire for children are the norm and there is also a social stigma associated with infertility. As a result these two, there is an ever increasing demand for diagnostic and therapeutic intervention for the management of infertile couple.

Laparoscopy provides both panoramic view of pelvic reproductive anatomy and a magnified view of uterine, ovarian, tubal and peritoneal surfaces and its pathology. It can confirm a clinical impression, establish a definite diagnosis, follow the course of a disease, and modify the treatment. Certain operative procedures (tubal sterilization, ovarian cyst aspiration, or biopsy of intraperitoneal structures) can be accomplished through the laparoscope. [2]

In the same setting therapeutic interventions like adhesiolysis, PCOD drilling, cystectomy etc. can be performed in these patients. Thus laparoscopy offers both diagnostic and therapeutic advantage to the infertile patients.With bulk of patients belonging to lower socioeconomic status this study offers the advantage of laparoscopy to needy infertile patients. Infertility is a common complaint that warrants evaluation, and often times necessitate scrutiny by laparoscopy.[3]

Since morphological abnormalities of the Fallopian tubes can be visualized directly under laparoscopy, it is generally accepted as the gold standard in diagnosing tubal pathology and other intra abdominal causes of infertility.

DEFINITION OF INFERTIITY

• Infertility is the failure to conceive (regardless of cause) after 1 year of unprotected intercourse.

 

Role of laparoscopy in current fertility practice

Laparoscopy was introduced to clinical practice in the early part of this century and its use in gynecology was described in 1967.

Laparoscopy is a trans-peritoneal endoscopic technique that provides excellent visualization of pelvic structures and often permits the diagnosis of gynecologic disorders and pelvic surgery without laparotomy .[41]

It provides direct visualization of pelvis and complete view of cul-de-sac Laparoscopy allows for the comprehensive evaluation of the pelvis including confirmation of tubal patency and evaluation of tubo-ovarian relationships. Pelvic adhesions, endometriosis, and tubal disease can be assessed and in most circumstances, simultaneously treated in a relatively noninvasive outpatient procedure.[42]

Laparoscopy was the final diagnostic procedure of the female fertility exploration, a sout lined by the American Fertility Society in 1992 and by the World Health Organization guidelines. [7]

Glatstein et al. (1997) reported that 89% of all reproductive endocrinologists in the USA routinely performed a laparoscopy in the diagnostic work-up of infertility.[8]

However, some investigators showed that the diagnostic laparoscopy did not reveal any pathology or only minimal and mild endometriosis in 40–70% of all cases. [9]

Already by the mid-1990's, the test ‘diagnostic laparoscopy’ failed to be an ideal predictor for infertility. [10]

These findings convinced some authors to challenge the need for this procedure in the work-up of infertility. [11]

Disadvantages of diagnostic laparoscopy include the need for general anaesthesia, patient's anxiety and the possibility of adhesion formation.

In a large Finnish follow-up study, the complication rate of diagnostic laparoscopy was 0.6 per 1000 procedures.[12]

However, advantages include the possibility to perform both diagnosis and therapy at the same time, and the opportunity to combine the laparoscopy with the hysteroscopic exploration of the uterine cavity with an endometrial biopsy, all as part of day care surgery.

Diagnostic laparoscopy is an essential part of full assessment and treatment of infertility. [13]

It provides information regarding tubal status, any pelvic adhesions, ovarian and uterine pathology. [14]

 

Laparoscopy in PCOS

J.Cohen et al. (1972) reported 21 pregnancies resulting from 51 successive ovarian biopsies with laparotomy they came to the conclusion that this procedure was of therapeutical value for certain types of ovarian infertility. [15]

Gjoannaess (1984) proposed the use of laparoscopic multi electro cauterization in the treatment of PCOS. He achieved an ovulation rate of 92% and a pregnancy rate of 69%.

In a 1989 publication, after a follow-up of 10 years, Gjoannaess reported the outcome of pregnancy of 89 women who conceived after electro cauterization. The abortion rate was15%, which is less than after clomiphene treatment or wedge resection. [16]

In a recent Cochrane review (Farquhar et al., 2005 ), the efficacy of laparoscopic drilling of the ovarian capsule (laparoscopic ovarian diathermy, LOD) by diathermy or laser in clomiphene resistant PCOS has been compared to gonadotrophin treatment based on a total of 15 RCTs. The reviewer's conclusion is that there is no difference in the live birth rate and the miscarriage rate in women with clomiphene resistant PCOS undergoing LOD when compared with gonadotrophin treatment. However, the reduction in multiple pregnancy rate in women undergoing LOD makes this option attractive. [17]

 

Laparoscopic adhesiolysis

Adhesions may form due to prior infection, such as a ruptured appendix or pelvic inflammatory disease (PID), endometriosis, or previous surgery. Peritubal adhesions may impair ovum pick due to decrease in tubal motility. It is said that laparoscopic adhesiolysis might increase the spontaneous pregnancy rates as well as pregnancy rates after IUI. [18]

 

Laparoscopy in endometriosis

Laparoscopy is the gold standard procedure used to diagnose and treat endometriosis.

Endometriotic lesions may be resected or ablated using any of the power instruments. Both of these techniques have shown to improve fertility and decrease pelvic pain in multiple well-designed studies.

Review of literature revealed that, the ablation of endometriotic lesions with adhesiolysis to improve fertility in minimal and mild endometriosis is effective compared to diagnostic laparoscopy alone [19,20]

The ESHRE Special Interest Group for Endometriosis who has recently developed guidelines for the diagnosis and treatment of endometriosis recommends surgical treatment for minimal or mild endometriosis in infertile women, but also mentions that some members of the working group questioned the strength of the evidence of the recommendations in the meta-analysis of Jacobson.[20]

 

Laparoscopy before IVF treatment

With respect to hydrosalpinx, two RCTs have demonstrated increased implantation and pregnancy rates in IVF cycles after salpingectomy for ultrasonically visible hydrosalpinges[21,22], Both these trials have been included in a recent Cochrane review(Johnson et al., 2004) .

According to the meta-analysis by Johnson et al., 2004, eight women would have to undergo salpingectomy prior to IVF to gain one additional live birth[22]

In a retrospective case-controlled study, Garcia-Velasco et al. (2004)demonstrated that laparoscopic removal asymptomatic small endometriotic cysts (<3 cm),immediate proceeding to IVF may reduce the time to pregnancy, treatment costs and the possible detrimental effects of inappropriate surgery on the ovarian function [23]

 However, laparoscopic cystectomy of larger symptomatic endometriotic cysts (>4 cm) improves fertility and reduces recurrence of these cysts when compared to cyst drainage and coagulation[23-25,6]

 

Myomectomy

Studies have shown longer operative times and a higher conversion to laparotomy rate associated with the use of GnRH agonists in laparoscopic myomectomy due to difficult cleavage planes.

An injection of vasopressinin to the uterus may help maintain hemostasis. The defect left by the fibroid must be sutured, which can be difficult laparoscopically for inexperienced practitioners. Barrier techniques may be used to decrease adhesion formation.

The fibroid may be removed by morcellation or colpotomy. Power morcellators are available to expedite the process.

However, all randomized clinical trials of myomectomy performed by laparoscopy versus laparotomy did not show an increased risk of rupture or poorer reproductive outcomes. These trials were conducted by experts in laparoscopic suturing and in carefully selected patients.

 

INSTRUMENTS

Image 1: Laparoscopy trolley

Image 2 : Light cable and light source

 

Protocol

The women were admitted in their proliferative phase, day prior to the procedure for Pre anaesthetic evaluation as per the hospital protocol. Relevant investigations were carried out. Mechanical bowel preparation was done using polyethelene glycol preparation.

 

Procedure

General anaesthesia was administered.

Patient was placed in dorsal lithotomy position with buttocks extended over the edge of the table for easier manipulation of uterine manipulator.

Laparoscope entry was made using closed technique.

Carbon dioxide was used for insufflation. Halogen light source with fibre optic cable and three chip camera with external video monitor were used for the procedure.

Inspection of the abdominal and pelvic organs was carried out in clock wise direction to visualise the caecum ,appendix, ascending colon, right lobe of the liver ,gall bladder ,falciform ligament, left lobe of the liver, stomach, descending colon and sigmoid colon.

With deep trendelenberg position and uterine manipulation pelvic organs were visualized.

Ancillary instruments were used to aid full examination of fallopian tubes, ovaries and pouch of douglas.

Intially uterus was inspected and proceeded in clockwise direction visualizing anterior culde sac, right adnexa, posterior culdesac, left adnexa, under durface of the ovaries and the fimbrial ends.

Therapeutic intervention was done whenever required like ovarian drilling, adhesiolysis, cystectomy etc.

A uterine cannula was used to inject diluted methylene blue dye to check for tubal patency. Ease of dye injection and number of flushing attempts required to visualize the tubal spill was noted.

The procedure was terminated by evacuating insufflated gas through cannula followed by removal of all instruments and the incision was closed. Aseptic dressing was applied.

Women were shifted to post operative ward and discharged after 24 hrs of observation.

The data was collected on a proforma and analysed

The patients are followed up in the subsequent visits.

 

Image 3 : Laparoscopy being performed

Image 4: Ovarian drilling for polycystic ovaries

 

Aims and Objectives

To determine the definitive reproductive pathology using laparoscopy to provide the basis for treatment of infertility patients

To appraise the evidence on the effectiveness of laparoscopy in the treatment of female infertility.

 

Materials and Methods

This is a cross-sectional study conducted over a period of one year 1/8/14 to 1/8/15.

95 Women attending infertility clinic, at the Department of Obstetrics & Gynaecology, SRM medical college and RC over a period of 1 year from 1/08/14 to 01/08/15 were offered the study entry.

All the participants underwent standard infertility evaluation.

              -> History,

               -> Physical examination,

               -> Ultrasonography,

               -> Hormonal assay involving TSH, FSH, LH and serum prolactin and semen analysis.

A pre informed questionnaire was conducted

Informed voluntary consent obtained.

Women were subjected to laparoscopy under GA.

Laparoscopic findings were noted and therapeutic interventions were done if required.

Intra operative and post operative complications were noted.

Women were shifted to post operative ward and discharged after 24 hrs of observation.

The data was collected on a proforma and analysed.

Inclusion criteria

Women with primary and secondary infertility after informed written consent.

Exclusion criteria

• Patients with cardiac disease.
• Patients with severe anemia.
• Patients with severe obstructive lung disease.

Sample Size: 95

Statistical Analysis:

• The descriptive analysis of the data is done using, Statistical software namely SPSS.
• Graphs and tables were generated using Microsoft word and excel

 

Results

Ninety five patients underwent diagnostic laparoscopy for primary infertility between 1/08/14 to 1/08/15.

Please click here to view complete article