Is laparoscopy necessary before assisted reproductive technology?

An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review

Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.

Proven and unproven methods for diagnosis and treatment of infertility

Infertility and subfertility affect a significant part of the population. Among various definitions of this pathology, the most common one is provided by the World Health Organisation; it says that infertility is 'a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourses'. The global prevalence of infertility is about 50-70 million couples. Since the process of human reproduction involves a large number of factors, a broad spectrum of infertility tests might be applied. Some of the tests focus directly on the pregnancy, some are only partially effective, whereas others should not be recommended for infertile couples. The aim of this review is to present a critical evaluation of the infertility diagnostic process and to discuss the recommendations for its most effective treatment.

The Role of Laparoscopic Investigation in Enabling Natural Conception and Avoiding in vitro Fertilization Overuse for Infertile Patients of Unidentified Aetiology and Recurrent Implantation Failure Following in vitro Fertilization

The present study aims to explore the effectiveness of laparoscopic surgery on women presenting with infertility, of unidentified aetiology according to the standard infertility investigation, and recurrent failed In Vitro Fertilization (IVF) attempts. Identifying and correcting possible underlying pathologies by laparoscopy may subsequently enable natural conception in an effort to address infertility and avoid IVF overuse. One-hundred and seven (107) women with unidentified aetiology of infertility and recurrent failed IVF attempts met the inclusion criteria. Laparoscopic surgery was performed as the endpoint of the patients' diagnostic journey, aiming to identify a possible underlying factor as the cause of infertility. Sixty-two (62) out of 107 patients (57.94%) that underwent laparoscopy were diagnosed with endometriosis, 25 out of the 107 patients (23.3%) were diagnosed with periadnixal and pelvic adhesions, and 20 cases (18.69%) presented with no pathology and remained unexplained. Following identification and correction of endometriosis and pelvic adhesions, patients were invited to conceive naturally. For the patients that laparoscopic investigation failed to reveal any pathology they were categorized as unexplained infertility and were subjected to a single IVF cycle. Natural conception success rate within the first postoperative year was the primary outcome. Within the first postoperative year, 30 out of 62 patients (48.38%) diagnosed with endometriosis following laparoscopic investigation achieved a natural conception, and 28 out of them (93.4%) reported live-births. Additionally, 11 out of 25 patients (44%) diagnosed with periadnixal and pelvic adhesions achieved natural conception within the first operative year. Regarding the group of unexplained infertility patients, only four out of the 20 patients (20%) achieved clinical pregnancy in the first post-operative IVF cycle. In conclusion, laparoscopy appears to be a promising approach, addressing infertility, providing significant diagnostic findings, while avoiding IVF overuse regarding patients of unidentified infertility presenting with recurrent failed IVF attempts.

A feasibility study to evaluate pelvic peritoneal anatomy with a saline intraperitoneal sonogram (SIPS)

OBJECTIVE

To prove the safety and feasibility of evaluating pelvic anatomy with a new imaging technique called saline intraperitoneal sonogram (SIPS).

DESIGN

Prospective clinical case series.

SETTING

Outpatient fertility clinic.

PATIENT(S)

Ten women with unexplained infertility and normal hysterosalpingograms (HSG). Five women with no known risk factors and five women with known risk factors for adhesive disease were enrolled.

INTERVENTION(S)

Step 1 required performing a sonohysterogram. Step 2 involved directing a 17-g oocyte retrieval needle into a pocket of peritoneal fluid under ultrasound guidance and infusing normal saline. The pelvic anatomy was evaluated with the three-dimensional and four-dimensional mode on pelvic ultrasound.

MAIN OUTCOME MEASURE(S)

Technical feasibility, safety, time, fluid infusion, and deficit volumes.

RESULT(S)

All 10 patients successfully completed the protocol. One of the five women with no risk factors for adhesive disease and a normal HSG was discovered to have a unilateral hydrosalpinx and filmy adhesive disease on SIPS. Both findings were confirmed on laparoscopy. Three out of the five women with known risk factors had abnormal SIPS imaging and were confirmed on laparoscopy to have significant adhesive disease. The average procedure time was 45 minutes (±15 minutes).

CONCLUSION(S)

This study demonstrates that SIPS is a safe, quick, and potentially cost-effective method for evaluating pelvic adhesive disease in an outpatient facility in women with unexplained infertility and a normal HSG.

The position of diagnostic laparoscopy in current fertility practice

In everyday clinical practice, it is not always clear if and when exactly in the fertility work-up a diagnostic laparoscopy should be offered. The aim of this review is to analyse the available evidence with respect to alternative diagnostic methods for detecting tuboperitoneal infertility and with respect to the position of diagnostic laparoscopy in women with infertility. A literature search of the National Library of Medicine and the National Institutes of Health (PubMed) was performed using the key words 'diagnostic laparoscopy and infertility'. The study methodology was carefully considered in an effort to present conclusions preferably based on randomized controlled trials (RCTs). The routine use of diagnostic laparoscopy for the evaluation of all cases of female infertility is currently under debate. According to data published in retrospective non-controlled studies, diagnostic laparoscopy after several failed cycles of ovulation induction enables the detection of a significant proportion of pelvic pathology amenable to treatment. A Cochrane review has shown that laparoscopic ovarian diathermy in clomiphene-resistant polycystic ovarian syndrome is at least as effective as gonadotrophin treatment, and results in a lower multiple pregnancy rate. The role of laparoscopy before the start of treatment with intrauterine insemination is controversial, according to one RCT. In women with bilateral ultrasonically visible hydrosalpinges, two RCTs have demonstrated increased implantation and pregnancy rates in IVF cycles after salpingectomy. Although RCTs which have studied the benefit of laparoscopic surgery in moderate or severe endometriosis are still lacking, its value has generally been accepted. In conclusion, some specific clinical settings, solid evidence is available to recommend the use of diagnostic laparoscopy in current fertility practice. There is however a need for more RCTs to answer remaining questions regarding its value in the diagnosis and treatment of some patients with infertility.

Rational diagnosis and treatment in infertility

Subfertility is a statistical concept. When a pregnancy has not been achieved within a year of unprotected intercourse, the odds are that an underlying pathological mechanism is at play. Advanced female age, longer duration and primary infertility, are important prognostic factors, suggestive of low fecundity and indicating a need for further diagnosis and treatment. Many diagnostic tests only have screening value and the only gold standards are hysteroscopy and laparoscopy. Severely impaired semen quality should lead to andrological work-up. Postcoital test and endometrial biopsy are obsolete. Treatment should preferably be aetiological, such as in anovulation, and sometimes also in endometriosis and tubal infertility. Primary treatment of male infertility is not proven to be advantageous. Conception-enhancing techniques such as intrauterine insemination (IUI), in vitro fertilisation (IVF) with or without intracytoplasmic sperm injection (ICSI), have shown to be effective. As a rule, and where possible, IUI is preferred and only if four to six cycles have failed should IVF be offered.