Shilpa G B

 

Consultant Reproductive Medicine, Shilpa Diagnostics, Davanagere-577004, Karnataka, INDIA.

Email: shilpagb@yahoo.com

 

RESULTS

During study period total 112 patients satisfying study criteria underwent hysterolaparoscopy. 78 % patients had primary infertility while rest 22% had secondary infertility.

 

Table 1: Infertility type

Most patients were from 26-30 years age group (35 %) followed by 21-25 years age group (32 %). In patients with primary infertility, most patients were from 21-25 years age group (40 %) followed by 26-30 years age group (33 %). In secondary infertility patients, 31-35 years age group (48 %) was most common followed by 21-25 years age group (40 %).

 

Table 2: Age distribution

Most patients had duration of infertility less than 5 years (49%), followed by 6-10 years (32 %). Most common duration in primary infertility patients was less than 5 years (53 %) while in secondary infertility patients it was 6-10 years (40 %).

 

Table 3: Duration of infertility

 

In 46% patients no abnormality noted in laparoscopy (primary infertility- 47% and secondary infertility- 44%). In patients with primary infertility PCOS (20%), fallopian tube blockage (14%) and ovarian cyst (9%) were main findings. In secondary infertility patients PCOS (20%), fallopian tube blockage (16%) and peritubular adhesion (8%) were common findings noted.

 

Table 4: Laparoscopic findings*

*- A patient can have one or more clinical finding/s.

Hysteroscopy was normal in 81% patients. (primary infertility- 80% and secondary infertility- 84%). In patients with primary infertility uterine anomaly such as septate uterus/bicornuate uterus/submucous fibroid (10%) was most common finding followed by endometrial polyp (7%). While in secondary infertility patients endometrial polyp (8%) and intrauterine adhesions were common findings.

 

Table 5: Hysteroscopy findings

PCOS drilling (20%), successful tubal cannulation(10%) and ovarian cystectomy (9%) were most common interventions in total and primary infertility patients. In secondary infertility patients hysteroscopic polypectomy and dilatation curettage were also common interventions done. No post-op complication, morbidity or mortality noted in present study.

 

Table 6: Surgical Intervention

*- A patient may underwent one or more surgical intervention/s.

 

DISCUSSION

Routine examination and diagnostic procedures are not enough to evaluate pelvic pathology of infertile women. Uterine and tubal factors can effectively diagnosed by endoscopic approach. Hysterolaparoscopy provides opportunity to understand the levels of infertility among couples which is crucial in order to improve the clinical management of infertility.⁶ Most patients were from 26-30 years age group (35 %) followed by 21-25 years age group (32 %). Increasing lifestyle choices, stress and later age of marriage have made occurrence of Infertility higher than couple of decades ago.⁷ Stressful and exhausting lifestyle is a major cause of infertility in young age as depicted by the study as 26 – 30 years. The prevalence of primary infertility was higher among women aged 20-24 years than among older women.¹ Similar findings noted in present study. In present study 78 % patients had primary infertility while rest 22% had secondary infertility. In a similar study Nayak et³ al observed 69% of cases with primary infertility and secondary infertility in 35% of cases. In 46% patients no abnormality noted in laparoscopy. Kavitha G,⁸ noted normal laparoscopic findings were seen in 42.4% patients while Bhandari S et al.⁹ had 47.9% patients with normal findings. Rai et al.¹⁰ found that the most common abnormality found on Laparoscopy was endometriosis (32%). Among uterine factors, numbers of patients with fibroids were observed in 17 (8.5%) patients followed by congenital anomalies in 6 (3%) patients. In present study PCOS (20%), fallopian tube blockage (14%) and ovarian cyst (9%) were main findings. Similar results were seen in studies done by Puri et al..,¹¹ they detected polycystic ovarian syndrome in 22% of cases while Kabadi and Harsha¹² found ovarian pathology in 20.8% of cases.9 Laparoscopy can improve pregnancy rates and quality of life. It can also reduce costs of further fertility treatments by enhancing response to treatment, guiding further management, circumventing treatments that are of low benefit and avoiding complications like multiple pregnancies.¹³ Laparoscopy can reveal the presence of peritubal adhesions, periadnexal adhesions, tubal pathology, and endometriosis in 35–68% of cases even after normal HSG result.¹⁴ Apart from diagnostic purpose laparoscopy can help in adhesiolysis, ablation of endometriosis, ovarian drilling and ovarian cystectomy in same sitting. Hysteroscopy helps to pick up subtle changes in the form of small polyps, adhesions, and seedling fibroid due to magnification facility. Additionally, hysteroscopy‑guided biopsy and therapeutic procedures like polypectomy, myomectomy, septal resection, and adhesiolysis can be done in the same sitting. In present study 19% females have abnormal findings on hysteroscopy. Patients underwent hysteroscopic adhesiolysis polypectomy, tubal cannulation, septal resection and myomectomy with good results. The high incidence of uterine factors can be attributed to current increased use of hysteroscopy in diagnosis of uterine anomalies and there by their correction as well. Surgical correction of septum improves the pregnancy outcome uterus with 80% term delivery, 5% preterm delivery, and 15% pregnancy loss.¹⁵ Polyps can cause sub-fertility and pregnancy loss by various mechanisms as interference with sperm transport, embryo implantation or through intrauterine inflammation or altered production of endometrial receptivity factors. In infertility patients apart from diagnostic aid many hysteroscopic procedures such as septal resection, polypectomy, submucous myoma resection, adhesiolysis and tubal cannulation can be done at the same time. Thus, hysteroscopy provides both diagnostic and therapeutic advantage in the same sitting with minimal complications. Abnormalities detected on laparoscopy were more common than those in hysteroscopy both in primary infertility group and in secondary infertility group.¹⁶ Similar findings were noted in present study. Certain conditions such as previous abdominal surgery, especially bowel surgery, and a history or presence of bowel/pelvic adhesions, severe endometriosis, pelvic infections, obesity, or excessive thinness. may increase the risk of intra and post-op complications. Proper patient selection and preoperative preparation is essential to reduce risk. Hysterolaparoscopy with chromopertubation is definitely superior in diagnosis of various kinds of tubal pathologies.

 

CONCLUSION

Hysterolaparoscopy is a definitive diagnostic tool for evaluation of female infertility. Hysterolaparoscopy is an effective, safe, reliable and minimal invasive tool in comprehensive evaluation of infertility and also good therapeutic intervention by experienced hands. Abnormalities missed on routine pelvic and radiological examination such as peritoneal endometriosis, adnexal adhesions, septate uterus, tubal blocks are diagnosed and corrected in one setting.

 

Conflict of Interest: None to declare

Source of funding: Nil

 

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