{"paper_id":"0d8a72cd-71df-4931-a834-6cf21b97f90c","body_text":"~ 413 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology  2020; 4(2): 413-417 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com  \n2020; 4(2): 413-417 \nReceived: 14-01-2020 \nAccepted: 16-02-2020 \n \nDr. Manishi Gaur \nIII Year Resident, Dept of Obs & \nGynae, SMS Medical College, \nJaipur, India \n \nDr. Lata Rajoria \nSr Professor& Unit Head, Dept of \nObs & Gyane, SMS Medical \nCollege, Jaipur \n \nDr. Aditi Bansal \nAssociate Professor, Dept of Obs & \nGynae, SMS Medical College, \nJaipur \n \nDr. Jyoti Jain \nIII Year Resident, Dept of Obs & \nGynae, SMS Medical College, \nJaipur, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Manishi Gaur \nIII Year Resident, Dept of Obs & \nGynae, SMS Medical College, \nJaipur, India \n \nRole of combined hysterolaparoscopy for the diagnosis \nof female infertility in tertiary care centre \n \nDr. Manishi Gaur, Dr. Lata Rajoria, Dr. Aditi Bansal and Dr. Jyoti Jain \n \nDOI: https://doi.org/10.33545/gynae.2020.v4.i2g.559  \n \nAbstract \nBackground: Infertility, one of the most common disorders confronting gynaecologist, has multifactorial \netiology and none of the laboratory findings alone is conclusive in diagnosis. Combined diagnostic \nhysterolaparoscopy helps in finding the etiology and planning further management.  \nAims & objective: To Evaluate the role of simultaneous combined diagnostic hysterolaparoscopy in the \nevaluation of female infertility. \nMaterials and methods: This was a descriptive type of interventional study on 80 infertile patients \nattending outpatient Department of Obstetrics and Gynaecology,  SMS Medical college, Jaipur from June \n2018 on words excluding male factor infertility with normal hormonal profile. \nResults: We studied 80 patients comprising of 56 (70%) cases of Primary Infertility and 24 (30%) cases of \nsecondary infertility. The average age of active married life in 80 patients was between 8 and 9 years.  The \nmost common pathologies found on DHL were Tubal factors in 40% cases, PCOD in 11.3% cases,  \nEndometriosis in 8.5% cases, and uterine anomalies in 6.35% cases. \nConclusion: Laparoscopy and hysteroscopy play very important role as diagnostic tools in infertile \nwomen. Combined diagnostic laparoscopy and hysteroscopy should be performed in all infertile patients \nbefore the treatment. \n \nKeywords: Role of combined hysterolaparoscopy diagnosis of female infertility multifactorial etiology \n \nIntroduction  \nAccording to WHO Infertility is defined as  inability to conceive after 1 year of regular \nunprotected sexual intercourse. It affects 10 -15% of couples in reproductive age group  [1]. \nNational survey of Family Growth estimates an increase in the number of infertile women from \n5-6.3 million to 6.4-7.7 million by 2025 [2]. Infertility can be divided into primary and secondary \ninfertility. Primary Infertility denotes those patientswho have never conceived. Globally most \ninfertile couple suffers from primary infertility [3]. The WHO estimates the overall prevalence of \nprimary infertility in India to be between 3.9 an d 16.8% [4]. Secondary Infertility indicates the \ncouple has experienced a pregnancy before although not necessarily alive birth has occurred but \nfailure to conceive subsequently. Resolve -national fertility association states that  3 million \ncouples are unable to conceive for the second time [5]. \nThough Basic laboratory investigations, routine pelvic examinations, sonography and \nhysterosalpingosonography (HSG) are good enough to exclude gross intrauterine pathology, but \nsubtle changes in the form of small polyp,  adhesions and seedling fibroid are better picked up \nwith magnification by hysteroscopy. Laparoscopy is the gold standard for diagnosing tubal and \nperitoneal disease, endometriosis and adhes ions because no other imaging technique provides \nsame degree of se nsitivity and specificity. Laparoscopy with direct visual examination of the \npelvic reproductive anatomy is the only method available for specific diagnosis of peritoneal \nfactors that may im pair fertility. It is also helpful in diagnosing uterine and ovari an factors [6]. \nThe practice committee of American society of Reproductive Medicine suggests that \nlaparoscopy should be seriously considered before applying aggressive empirical treatments \ninvolving significant costs and potential risks [7]. \nIn addition, hysterolaparoscopy guided biopsy and therapeutic procedures such as polypectomy, \nmyomectomy, septal resection and adhesiolysis can be done in same sitting. Thus, the entire \nprocedure becomes, “diagnostic and therapeutic oriented rather than only diagnostic.” [6] \nKeeping this in view, the present study was designed to assess the utility of combined  \nhysterolaparoscopy in 80 infertile women, as a single step procedure, which would help in \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology  http://www.gynaecologyjournal.com \n~ 414 ~ \nplanning appropriate management in an Indian setting. \n \nAims & objectives: To Evaluate the role of simultaneous \ncombined diagnostic hysterolaparoscopy in the evaluation of \nfemale infertility. \n \nMaterials and methods : Our study was a descriptive type of \ninterventional study on 80 infertile women attending \nGynaecology OP D in the  Department of Obstetrics and \nGynaecology, SMS Medical College, Jaipur from June 2018 to \nJune 2019. \n \nInclusion criteria \nAll infertile women between age 20 to 40 years. \n \nExclusion criteria \n1. Patients having relative contraindications for \nhysterolaparoscopy eg. Anatomic obstacles (difficult access \nto the abdomen, intestinal distention etc.), Physiologic \nobstacles ( cardiovascular, respiratory and chronic liver \ndiseases), and contraindications  related to hysteroscopy \n(bowel obstruction, hernia, generalised peritonitis). \n2. Male factor infertility \n3. Abnormal hormonal profile \n4. Active pelvic Inflammatory disease \n5. Active tuberculosis \n6. Couples who had not lived together for atleast 12 months. \n \nAfter taking detailed history, baseline investigations and clinical \nexamination, hysterolaparoscopy was performed during the \npostmenstrual phase on 7th, 8th or 9th day of cycle under general \nanaesthesia with written and informed consent. \nAt the end of the study , data was com piled, and categorized as \npatients with primary and secondary infertility and benefits and \ndrawbacks of combined hysterolaparoscopy for the  diagnosis \nand treatment in infertile patients analysed. \n \nObservation and discussion \nIn our study, out of the total 8 0 patients, 56 (70.00%) had \nprimary infertility and 24 (30.00%) had secondary infertility.  \nThe mean age was 26.57 ± 3.39 yrs . in women of primary \ninfertility and 27.58 ± 5.31 years in patients of secondary \ninfertility. \n \nTable 1: Distribution of Cases According to Duration of Infertility \n \nDuration of Infertility (in yrs.) Group-A (PI) Group-B (SI) Total \nNo. % No. % No. % \n1 – 5 39 69.64 9 37.50 48 60.00 \n6 – 10 14 25.00 11 45.84 25 31.25 \n11 – 15 3 5.36 2 8.33 5 6.25 \n>15 0 0.00 2 8.33 2 2.50 \nTotal 56 100.00 24 100.00 80 100.00 \n2 = 10.131, d.f. = 3 p = 0.022 Sig \n \nIn present study, the range was 1 - 15 yrs. in primary infertility \npatients and 2 - 20 yrs. in secondary infertility group. Majority \nof patients of primary infertility (69.64%) and that of sec ondary \ninfertility (37.50%) had duration of infertility of 1-5 years. Mean \nduration of infertility in Group -A was 4.71 ± 3 and in Group -B \nwas 7.8 ± 4.8 yrs. The difference in the mean duration of \ninfertility between the 2 groups was statistically significa nt (p= \n0.002). It may be due to the following reasons: - \nWomen who have children whe n young may be less inclined to \nconceive again in later life, \nCoital frequency often declines as age increases,  \nThe incidence of subclinical abortion is unknown [8]. \n \nTable 2: Distribution of Cases According to the Findings on Diagnostic Hysterolaparoscopy \n \nProcedures Group-A (PI) Group-B (SI) Total abnormal findings \nNormal (%) Abnormal (%) Normal (%) Abnormal (%) No. % \nLaparoscopy 13 (23.21) 43 (76.78) 5 (20.82) 19 (33.93) 62 77.50 \nHysteroscopy 26 (46.43) 30 (53.57) 12 (50.00) 12 (50.00) 42 52.50 \nTotal 39 73 17 31 104  \nGroup Aχ2 =5.665 d. f.=1 P = 0.017(S) \nGroup B χ2= 3.279 1 d. f.=1P = 0.07(NS) \ntotal -χ2 =9.918 d. f.=1; P = 0.002(S) \n \nAccording to table- 2, In prese nt study, laparoscopic \nabnormalities were more common than hysteroscopic (77.50% \nVs 52.50%) in both primary as well as secondary infertility \nwhich is statistically significant (P < 0.002). Pelvic \ninflammatory disease is the most common abn ormality in \nprimary infertility while in secondary infertility incidence of \nendometriosis and adnexal adhesions are equivocal. Thus gold \nstandard technique for diagnosing these disorders is \nlaparoscopy, which is a better predictor of future spontaneous \npregnancy in infertile couples with unexplained infertility. \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology  http://www.gynaecologyjournal.com \n~ 415 ~ \n \n \nFig 1: Distribution of cases according to diagnostic hysterolaparoscopy \n \nMehta AV et al. (2016) [9] found similar results, incidence of laparoscopy abnormalities were higher than hysteroscopy (33.67 Vs \n18.66).  \n \n \nFig 2: Distribution of Cases According to Abnormalities Detected on Hysteroscopy \n \nIn present study, 92.50% of patients had no abnormality in \ncervix. Pin point cervix, fibrosed cervix and a small polyp of 2 x \n1 cm size at the level of internal os was present in 3.57%, 5.36% \nand 1.79% of patients in primary infertility group respectively.  \nIn the study of Koskas M et al.  (2010) [10], cervicoisthmic \nabnormalities were present in 4.3% of patients with 13 cases of \npolyps (2.3%), 9 cases of  stenosis (18% ) and 2 cases of  \nadhesions (0.4%). \nIn present study, 41 (73.21%) patients in Group -A (PI) and 16 \n(66.66%) patients in Group -B had normal findings during \ndiagnostic hysteroscopy. 2 (3.57%) patients in Group -A and 4 \n(16.67%) patients in Group-B had atrophic endometrium. And 5 \n(8.93%) patients in Group -A had polyp oidal endometrium. \nThese changes are due to hypoestrogenic and hyperestogenic \nstate respectively associated with irregular periods due to \novarian dysfunction. while 2 (3.57%) patients in the same grou p \nhad calcified endometrium. 4 (7.14%) patients of Group -A had \nhyperaemic endometrium. These interfere with implantation, \npreventing an embryo from attaching to the uterine wall. \nUterine cavity was tubular & narrow in 1 (4.17%) patients of \nGroup-B. Partial  septum was present in 1 (1.79%) patient of \nGroup-A and 2 (8.33%) patients of Group -B and one patient \n(1.79%) of each group had polyp. Similar findings were reported \nby Puri S et al. (2015) [6], Mehta AV et al. (2016) [9], Nanaware \nSS et al. (2016) [11] \nIn present study, 71.25% of total patients had B/L patent ostia \n(75.00% of patients in Group -A v/s 62.50% of patients in \nGroup-B). 7 (8.75%) patients had periosteal fibrosis in which 4 \n(7.14%) patients belonged to Group -A and 3 (12.50%) patients \nbelonged to Group-B. 1 (1.78%) patient of primary infertility \n(Group-A) had flimsy adhesion around B/L ostia.  \nOn diagnostic hysteroscopy in 4 (7.14%) patients of primary and \n2 (8.33%) patients of secondary infertility had absent fluid \ncurrent through B/L ostia. 7.14%  patients of primary infertility \nand 4.16% patients of secondary inf ertility had absent fluid \ncurrent through U/L ostia.  \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology  http://www.gynaecologyjournal.com \n~ 416 ~ \n \n \nFig 3: Distribution of Cases According to Abnormalities on Diagnostic laproscopy \n \nIn present study, most common laparoscopic uterine abnormality \nin primary in fertility was congestion over the uterine surface in \n7 (12.50%) patients, second was fibroid in 6(10.71%) patients, \nand third was endometriosis and periuterine adhesions in \n5(8.93%) cases. One (1.79%) patient had small hypopla stic \nuterus and another one (1 .79%) had tubercles all over the \nperitoneal cavity involving uterus and bilateral adnexa, \nperitoneum known as Koch abdomen. \nIn secondary infertility on laparoscopy, prevalence of periuterine \nadhesions, fibroid and endometriosis were equivocal. 2 (8.33%) \npatients in Group-B had chronic inflammation, one (4.17%) had \nunicornuate uterus and one had rudimentary horn (4.17%). The \ndifference between the 2 groups regarding uterine factors in \ninfertility is not significant (p=0.642). \nIn present study, maximum number  of patients, 10 (17.86%) \npatients in primary and 2 (8.33%) patients in secondary \ninfertility had dilated and tortuous tubes. It may be due to \nsubclinical PID because of lack of sexual education, \nunawareness about the advantag es of contraceptives and poor \nperineal hygiene, particularly during menstrual periods. Thus, \nproper education and counselling of girls are an important \npreventive measure for infertility. \nTuboovarian mass was found in 5 (8.93%) patients of Group -A \nand 1 (4.17%) patient of Group-B. 2 (3.57%) patients of Group-\nA and 1 (4.17%) patient of Group-B had hydrosalpinx. \nPeritubal adhesion was found in 2 (3.57%) patients of Group -A \nand 3 (12.50%) patients of Group -B and 1 (1.79%) patient of \nGroup-A had B/L fibrosed tu be. Lead pipe appearance was \nfound in 1.79% patients of Group -A and 12.50%  patients of \nGroup-B. Only unilateral tube was found in 3 (12.50%) patients \nof Group-B due to h/o salpingectomy for ectopic pregnancy. \nIn present study, 58.92% patients of Group -A ha d normal \novarian morphology compared to 66.66% from Group-B. Ovary \nwas enlarged and pearly white in 5 (8.93%) patients of Group-A \nand 1 (4.17%) patient of Group -B. In 5 (8.93%) patients of \nGroup-A and 3 (12.50%) patients of Group -B ovary not \nvisualized due  to adhesions. Endometrioma w as detected in \novary in 3 (5.36%) patients of Group -A and 2 (8.33%) patients \nof Group-B.  \nOvary was cystic and enlarge in 7.10% patients of Group -A and \n4.17% patients of Group -B. 5.36% patients of Group -A and \n4.17% patients of Group-B had tubo-ovarian mass in ovary.  \nIn present study, POD was involved in 23 (41.07%) patients in \nGroup-A and 7 (29.16%) patients in Group -B. Hyperaemia was \nthe most common finding, 21.42% cases in Group -A and \n12.50% cases in Group-B. \nAdhesion was pre sent in 8.93% of Group -A and 8.33% of \nGroup-B. Gunshot lesions of endometriosis was present in 5 \n(8.93%) patients in Group-A and 2 (8.33%) patients in Group-B. \nOne patient in Group-A had fibrous band obliterating the POD.  \n21.42% patients in Group -A and 17 .50% patients in Group -B \nhad flimsy adhesions which was most common type of \nadhesions in present study. 3.57% patients in Group -A and \n25.00% patients in Group-B had dense adhesion. The difference \nbetween the two groups is statistically significant i.e. adh esions \nwere more common in pr imary infertility in present study. \nSimilar results were found in study of Kabadi YM et al. (2016) \n[12], Rizvi SM et al. (2018) [13], Nisar S et al. (2019) [14] \n \n \n \nFig 4: Distribution of Cases According to Tubal Patency on Diagnostic Laparoscopy \n\nInternational Journal of Clinical Obstetrics and Gynaecology  http://www.gynaecologyjournal.com \n~ 417 ~ \nOn chromopertubation normal patency of the tubes were found \nin 64.29% patients in Group-A and 45.83% patients in Group-B.  \nB/L tubal block was found in 23.21% in Group-A and 25.00% in \nGroup-B. Unilateral tubal block was found in 12.50 % in Group-\nA and 16.67% in Group-B. \nAmong three patients of secondary infertility with history of \nsalpingectomy for ectopic pregnancy, two had normal patency \nand one had agglutinated fimbrial end. \n \nTable 3: Distribution of Cases According to Operative Procedure \n \nProcedure Group-A (PI) Group-B (SI) Total \nNo. % No. % No. % \nCystectomy 4 7.14 0 0.00 4 5.00 \nAdhesiolysis 2 3.57 2 8.33 4 5.00 \nLaparoscopic Ovarian Drilling 3 5.35 0 0.00 3 3.75 \nSeptal Resection 1 1.78 1 4.17 2 2.50 \nLaparoscopic Myomectomy 0 0 1 4.17 1 1.25 \nHysteroscopic Polypectomy 1 1.78 1 4.17 2 2.50 \nCyst Punctured and Suctioned Out 1 1.78 2 8.33 3 3.75 \nCervical Cautery 0 0 1 4.17 1 1.25 \n \nIn 4 (7.14%) patients of Group-A cystectomy was performed for \nendometrioma. Laparoscopic ovarian d rilling was done in 3 \n(5.35%) patients in Group -A. In 3.57% cases of PI and 8.33% \ncases of SI adhesiolysis was performed . Septal resection was \nperformed in 1.78% patients of Group-A (PI) and 4.17% patients \nof Group-B. \nIn 4.17% cases of Group -B laparoscopic  myomectomy was \ndone. Hysteroscopic polypectomy was done in 1.78% patients of \nGroup-A and in 4.17% patients of Group-B. \nIn 1.78% cases of Group -A (PI) and 4.17% cases of Group -B \n(SI) ovarian cyst was punctured and suctioned out. Cervical \ncautery was done i n 1 patient of secondary infertility having \ncervical erosion.  \n \nSummary \nIn our study most common abnormalities on diagnostic  \nhysterolaproscopy was tubal pathology and adhesions in both \nprimary as well as secondary infertility.  By using \nhysterolaproscopy tu bal morphology, tubal patency, ovarian \nmorphology, unsuspected pelvic pathology and uterine cavity \nabnormalities can all be resolved with accuracy at one session. \n \nConclusion \nDiagnostic hysterolaparoscopy plays a valuable role in the \ncomprehensive evaluation of infertility. It helps to find out those \ncauses which are unrevealed by other investigations  and thus \nhelps to guide appropriate therapy. Many diagnostic tests for \nfemale infertility only have screening value but in view of low \ncomplications rate, min imal time requirement and negligible \neffect on the post-operative course, combined  simultaneous \ndiagnostic hysterolaparoscopyis now gold standard test in all \ninfertile patients before treatment.  \n \nReferences \n1. Boivin J, Baunting L, Collins JA, Nygren KG. International \nestimates of infertility prevalence and treatment -seeking: \npotential need and demand for infertility medical care. \nHyman Reproduction. June. 2007; 22(6):1506-1512. \n2. Daily Health Reproductive Report, 2003, 15. \n3. Inborn MC. G lobal infertility and the  globalisation of new \nreproductive technologies. I Clinical Obstetrics and \nGynaecology - Williams and Wilkins, Contemporary \nManagement of Infertility. 1977; 43(4):172. \n4. Rustein SO, Macro OR, Shah IH. Infecundity, infertililty \nand childlessness in developing  countries. DHS \nComparative Reprots No. 9. Calverton, Maryland, USA : \nORC Macro and the World Health Organization, 2004. \n5. Clinical Obstetrics and Gynaecology - Williams and \nWilkins, Contemporary Management of Infertility. 1977;  \n43(4):172. \n6. Puri S, Jain D, Pur i S, Kaushal S , Deol SK. \nLaparohysteroscopy in female infertility : A diagnostic cum \ntherapeutic tool in Indian setting. Int J Appl Basic Med Res. \n2015; 5(1):46-48. \n7. Practice committee of American society of Reprod uctive \nMedicine. Optimal evaluation of the i nfertile female.Fertil \nSteril. 2006; 86:S264-7. \n8. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology \nand Infertility. Wolters Kluwer. 8 th edition. Female \nInfertility. Chapter. 2011; 27:1140. \n9. Mehta AV, Modi AP, Raval BM, Munshi SP, Patel SB, \nDedharotiya SM. Role of diagnostic hysterolaparoscopy in \nthe evaluation of infertility. Int J Reprod Contracept Obstet \nGynecol. 2016; 5(2):437-440. \n10. Koskas M, Mergui JL, Yazbeck C, Uzan S, Nizard J. Office \nhysteroscopy for infertility: a series of 557 consecutive \ncases. Obstet Gynecol Int, 2010, 168096.  \ndoi: 10.1155/2010/168096. Epub 2010 Apr  \n11. Nanaware SS, Saswade M, Shende PN, Gaikwad P, Mahana \nS, Kirane A. Role of Hysterolaparoscopy in the Evaluation \nof Female Infertility in Tertiary Care Centre. International \nJournal of Contemporary Medical Research. October. 2016; \n3(10):3063-3065. \n12. Kabadi YM , Harsha B . Hysterolaparoscopy in the \nEvaluation and Management of Female Infertility. J Obstet \nGynaecol India. 2016; 66(Suppl 1):478-81.  \ndoi: 10.1007/s13224-016-0863-5.  \n13. Rizvi SM, Ajaz S, Ali F, Rashid S, Qayoom T, Rashid L. \nLaparoscopic Evaluation of Female Infertility. International \nJournal of Scientific Study. 2018; 6(2):117-121. \n14. Nisar S , Banday SS. A study of evaluation of various \nfactors of infertility by diagnostic laparosc opy at tertiary \nhospital. Int J Adv Res. 2019; 7(2):1067-1071.","source_license":"CC0","license_restricted":false}