Laparoscopy:as a first line diagnostic tool for infertility evaluation

Comparison of Baseline Characteristics, Sociodemographics, and Gynecological Risk Factors Associated with Secondary Infertility of Females in Pakistan

Introduction

Secondary infertility is characterized by the inability to conceive for a period of 1 year, after having previously conceived at least once.

Objectives

To explore the risk factors of secondary infertility and compare sociodemographics and anthropometric variables of each studied group.

Methods

Study was conducted at University Institute of Public Health, Faculty of Allied Health Sciences, The University of Lahore, collecting data from Gilani Ultrasound Center in 18 months after approval of synopsis. Total 690 females (345 cases and 345 controls) were enrolled. Participants were included in case group if they were 20-45 years of age, having any parity, and confirmed diagnosis of secondary infertility.

Results

The mean age of cases and controls was 33.08 ± 4.17 years and 31.37 ± 4.36 years, respectively. The mean body mass index (BMI) in cases was 27.61 ± 4.27 kg/m2, and in controls the mean BMI was 25.52 ± 4.30 kg/m2. There was not a significant difference among religion that shows no association (p = 0.73) with secondary infertility as profession has association with it (p = 0.01). History of polycystic ovary syndrome, pelvic inflammatory disease, endometriosis, uterine fibroids, menorrhagia, intermenstrual bleeding, and history of abortion are associated with secondary infertility.

Conclusions

While several sociodemographic features and medical disorders have been associated to secondary infertility, it is vital to stress that not all of these factors are controllable by medical therapy. Factors like age and certain medical issues may be unaffected by intervention. However, for controllable variables like BMI and certain medical diseases, focused therapies and lifestyle changes may reduce the chance of subsequent infertility.

Predicted risk factors associated with secondary infertility in women: univariate and multivariate logistic regression analyses

Introduction

Infertile women are those who regularly engage in unprotected intercourse for a period of at least 1 year and are unable to become clinically pregnant. Primary infertility means the inability of couples to conceive, without any previous successful pregnancies. Secondary Infertility refers to the inability to get pregnant for 12 months, after having a previous pregnancy for one time at least. The objectives of the current study were to analyze risk factors for secondary infertility and compare the predictive accuracy of artificial neural network (ANN) and multiple logistic regression models.

Methods

The study was conducted at The University Institute of Public Health collecting data from Gilani Ultrasound Center 18 months after approval of synopsis. A total of 690 women (345 cases and 345 controls) were selected. The women selected for the case group had to be 20-45 years of age, had any parity, and had a confirmed diagnosis of secondary infertility.

Results

Multiple logistic regression (MLR) and ANN were used. The chance of secondary infertility was 2.91 times higher in women living in a joint family [odds ratio (OR) = 2.91; 95% confidence interval (CI) (1.91, 4.44)] and was also 2.35 times higher for those women who had relationship difficulties with their husband [OR = 2.35; 95% CI (1.18, 4.70)]. Marriage at an earlier age was associated with secondary infertility with β being negative and OR being < 1 [OR = 0.94; 95% CI (0.88, 0.99)]. For the logistic regression model, the area under the receiver operative characteristic curve (ROC) was 0.852 and the artificial neural network was 0.87, which was better than logistic regression.

Discussion

Identified risk factors of secondary infertility are mostly modifiable and can be prevented by managing these risk factors.

Assessment of Tubal Patency with Selective Chromopertubation at Office Hysteroscopy versus Modified Minilaparoscopy in Infertile Women

OBJECTIVES

Tubal factor is the leading cause of female infertility. Diagnostic hysterolaparoscopy with chromopertubation plays a pivotal role in its evaluation. Office hysteroscopy (OH) has gained popularity as the outpatient procedure for diagnostic purposes. OH being a less invasive approach, the current study was undertaken to compare the accuracy of assessment of tubal patency with chromopertubation at OH with modified minilaparoscopy in infertile patients.

MATERIALS AND METHODS

The present study was a pilot study conducted from March 2017 to August 2018. Eighty patients were recruited. OH was done without anesthesia. Diluted methylene blue dye was injected. The eddy current of blue dye, "Visualizable flow" at ostium, and disappearance of blue dye from the uterine cavity through ostium was documented as evidence of patent tubal ostium. In case of tubal occlusion, uterine cavity became blue due to backflow of dye. After OH, minilaparoscopy with chromopertubation was performed under general anesthesia. Both tubes were assessed separately for tubal patency.

RESULTS

All patients underwent OH followed by minilaparoscopy in the same sitting. OH was 87.5% sensitive with positive predictive value of 95.2%. Compared to minilaparoscopy, OH is 85.6% accurate in predicting tubal patency. The area under receiver operating curve was 0.96 (SE is 0.15 with 95% confidence interval of 0.93-0.99, P < 0.001). It implies that, OH should correctly identify all laparoscopic cases with probability of 0.96.

CONCLUSION

OH chromopertubation can be used as an alternative to laparoscopy for assessing tubal patency with added advantages of lack of requirement of anesthesia, minimal cost, and better patient acceptance. Moreover, the procedure is less time-consuming and less invasive with high sensitivity and moderate specificity.

Predictive value of a modified classification of fallopian tube status on prognosis of tubal factor infertility after laparoscopic surgery

Built on 2 existing classification systems, this study was to develop a new classification system to better predict the pregnancy prognosis after laparoscopic surgery in patients with tubal factor infertility and accordingly propose a management strategy.We followed up 423 patients suffering from tubal factor infertility who had undergone hysteroscopic-laparoscopic surgery for 2 years without in vitro fertilization and embryo transfer (IVF/ET). Based on the operative reports, a new, modified classification of fallopian tube status (hereafter referred to as the modified classification) was developed with reference to the 2 existing classification systems (the r-AFS classification of pelvic adhesions and the scoring system of distal tubal obstruction). A score of 0 to 3 was assigned to each of the 4 factors (tubal wall consistency, hydrosalpinx, pelvic adhesions, and tubal patency) for each of the tubes with a total bilateral score of 0 to 24. The patients were classified for the abnormalities of the fallopian tubes into 3 groups: mild (<8), moderate (8-15) and severe (>15). By utilizing SPSS 20.0 Statistic Analysis Software, the data were analyzed with t test, Chi-Square test, ANOVA or ROC as appropriate.Each of the 4 factors of the modified classification was independently and closely associated with post-surgical prognosis (P < .05). There was a statistically significant difference in postoperative pregnancy prognosis among the 3 groups of patients (P < .05). Patients with a score of <8 (mild) had the highest intrauterine pregnancy rate, reaching 60.1%. In contrast, patients with a score of 8 to 15 (moderate) had a significant increase in ectopic pregnancy (21.5%), while patients with a score of >15 (severe) had a significantly increased infertility rate of 89.5%. When the pregnancy outcomes were divided into intrauterine pregnancy and other outcomes, the modified classification had the largest area under the ROC curve (0.569) (P < .05). With the optimum cutoff of 4.5, the sensitivity was 88.6%, specificity was 74.5% and accuracy was 63.1%.The modified classification of fallopian tube status is a simple and practical scoring system which can comprehensively and effectively evaluate the function of the fallopian tube and thus is more accurate than the other 2 systems in predicting the postoperative pregnancy outcomes.

Does laparoscopy still has a role in modern fertility practice?

BACKGROUND

More than 3 decades after the introduction of in vitro fertilization (IVF) and despite the improved success rates of assisted reproductive technologies, the argument for performing laparoscopy as a part of the infertility workup still stands.

OBJECTIVE

To evaluate the role of laparoscopy±hysteroscopy in diagnosis and management of infertility in our setting in view of modern fertility practice.

MATERIALS AND METHODS

This case control study was carried out on 600 infertile women subjected to laparoscopy or combined laparoscopy and hysteroscopy at endoscopy unit in Minia University Hospital, Egypt during the period from January 2012 to December 2014.

RESULTS

The causes of infertility as identified by laparoscopy±hysteroscopy were polycystic ovary syndrome (25.1%), tubal factor (30%), uterine cause (4%), and endometriosis (2.7%). No cause was identified in 38.2% of cases. Based on operative findings, women were treated with different options. Expectant management was used in 92 cases (15.3%). Ovulation induction with anti-estrogens or gonadotropins was used in 372 cases (62%). Sixty cases (10%) had intrauterine insemination and sixty four cases (10.7%) underwent in vitro fertilization (IVF) / intracytoplasmic sperm injection (ICSI) treatment. Within 1 yr after laparoscopy, 180 cases achieved pregnancy (30%). The most favorable outcome was recorded in women with unexplained infertility (36.7% of cases got pregnant) followed by women with polycystic ovary syndrome (27.8%). Participants with uterine and tubal infertility factor achieved pregnancy in 25% and 22.8% of cases, respectively. The worst outcome was recorded in women with endometriosis.

CONCLUSION

Laparoscopy still has an important role in the diagnosis and treatment of infertility.

Current management of tubal infertility: from hysterosalpingography to ultrasonography and surgery

RATIONALE

The development of IVF techniques has diminished the importance of tubal infertility but recent discoveries shed a new light on reproductive tubal surgery prior to any IVF cycle.

OBJECTIVE

To adapt current state of the art recommendations concerning tubal factor infertility to actual possibilities in Romanian healthcare system and to grow the awareness of fellow fertility specialists and general practitioners to the improved outcomes of novel management and treatment modalities.

METHODS AND RESULTS

67 free full text articles centered on the subject of management in tubal infertility were identified in international databases. Four articles described general diagnosis using data from medical history, 21 works approached the diagnosis through hysterosalpingography, 14 papers introduced the use of different sonographic procedures, 8 files analyzed the importance of exploratory laparoscopy and 20 articles reviewed different treatment modalities.

DISCUSSIONS

Current data show that active implementation of the large scale use of tubal surgery prior to any IVF cycle will reduce up to 30% the costs associated with obtaining a viable pregnancy in cases with tubal factor sterility.