{"paper_id":"15cb4206-a3cd-4d20-b5d7-7c4296ddd133","body_text":"~ 85 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(3): 85-89 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com  \n2021; 5(3): 85-89 \nReceived: 13-02-2021 \nAccepted: 16-03-2021 \n \nDr. Aya Kamel Shaker \nM.B.CH. B, Resident Doctor at Al-\nElwiyah Maternity Teaching \nHospital, Baghdad, Iraq \nAffiliation: Iraqi Council of \nMedical Health specialization \n \nDr. Abdul Razak H Al-Nakash \nProfessor, M.B. Ch. B, F.I.C.O.G. \nC.A.B.O.G, Baghdad, Iraq \nAffiliation: Iraqi Council of \nMedical Health specialization \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 \n \n \n \n \n \nCorresponding Author: \nDr. Aya Kamel Shaker \nM.B.CH. B, Resident Doctor at Al-\nElwiyah Maternity Teaching \nHospital, Baghdad, Iraq \nAffiliation: Iraqi Council of \nMedical Health specialization \n \nUnexplained infertility; How far laparoscopy can disclose \nthe causes \n \nDr. Aya Kamel Shaker and Dr. Abdul Razak H Al-Nakash  \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i3b.907 \n \nAbstract \nBackground: Unexplained Infer tility is a complex medical disorder that requires the evaluation and \ntreatment of a couple rather than an individual in which the three standard fertility screening tests looking \nnormal.  \nObjective: To identify the underlying causes of infertility in wome n suffering from unexplained infertility \nvia using laparoscopy.  \nPatients and Method: A prospective clinical observation study conducted at Al -Elwyia Maternity \nTeaching hospital at Obstetrics and Gynecology department during the period from the first of Fe bruary \n2019 to the first of August 2019. \nResults: Fifty women with unexplained infertility were included in the study, their main age group (46.0%) \nwere between (25 -29) years and (70.0%) of them are with primary infertility. Their mean duration of \ninfertility was 55± 29 (months). (98%) were presented with patent tubes and only one (2.0%) patient \nshowed one blocked tube by hysterosalpingography. Evidence of pelvic pathology was seen in (76.0%) of \nthe patients and endometriosis constituted about (68.4%) of pe lvic pathology while simple peri tubal \nadhesion was found in12/38 patients (31.6%).  \nConclusion: The main pathology seen in women with unexplained infertility was pelvic endometriosis in \n26/38 patients, followed by simple peri tubal adhesion. \n \nKeywords: Unexplained infertility, laparoscopy, peri tubal adhesion, pelvic endometriosis \n \nIntroduction  \nUnexplained infertility is a complex medical disorder that requires the evaluation and treatment \nof a couple rather than an individual. Infertility is defined as f ailure to conceive after regular \nunprotected sexual intercourse for one year  [1]. If the female partner is 35 year of age or older, \nevaluation should be initiated after 6 months of unprotected intercourse. Fecundability, or the \nability to achieve pregnancy in one menstrual cycle, is a more accurate measurement to evaluate \nfertility potential. The fecundity rate in a normal couple who has had unprotected intercourse is \napproximately 20% to 25% for the first 3 months, followed by 15% during the next 9 months [2].  \n \nPrevalence  \nThe prevalence of infertility in the general population is approximately 14%, affecting about 1 in \n7 couples. Causes of infertility include ovulatory disorders, tubal damage, male factors, and \nuterine or peritoneal problems. Traditionally, after excluding common causes of infertility using \nstandard fertility tests, which include semen analysis, assessment of ovulation, and tubal patency \ntesting. These tests have been selected as standard fertility tests because they were found to have \ndefinitive correlation with pregnancy [3]. \nThe diagnosis of unexplained infertility is made when a cause is not identified after the \ncompletion of standard fertility investigations. It accounts for nearly 40%of female infertility \nand 8% to 28%of infertility i n couples. The reported incidence of unexplained infertility varies \naccording to the age and selection criteria in the study population  [4]. Many couples with a \nprovisional diagnosis of unexplained infertility will subsequently conceive spontaneously; the \nspontaneous pregnancy rate in couples with unexplained infertility has been reported as 2%to \n4% per menstrual cycle. Women’s age is the most important prognostic factor for successful \nspontaneous conception with lower conception rates after the age of 30 y ears. After 12 months \nof unsuccessful attempts, 50% will conceive in the following 12 months and another 12% after \n24 months. (Box1) [3, 4].  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 86 ~ \nBox 1: Causes of female unexplained infertility. \n \n Endometriosis \n Undiagnosed tubal factor \n Premature ovarian aging \n Immune infertility \n Oxidative stress \n Poor oocyte quality \n Uterine cavity abnormalities: \n- Endometrial synechiae \n- Endometrial polyps \n- Chronic endometritis \n \nLaparoscopy \nLaparoscopy is a minimally invasive surgical technique that \nprovides a panoramic and magnified  view of the pelvic organs \nand peritoneal surfaces and allows s urgery at the time of \ndiagnosis [5]. Historically, only diagnostic procedures were \nperformed with the laparoscope. In the last decade, use of the \nlaparoscope has expanded. Now various reproduct ive disorders \nare diagnosed and treated primarily with the laparoscope \nincluding pelvic adhesions, endometriosis, and disorders of the \nfallopian tubes. In response to the significant advances in \nendoscopy, today's gynecologic surgeons can integrate operati ve \nlaparoscopy into daily practice and in many situations. Infertility \nis a major health issue with multifactorial etiology. None of the \nlaboratory findings alone is sufficient in diagnosing infertility. \nLaparoscopy provides important and essential informa tion \nhelpful in the investigation and management of infertility [6].  \nLaparoscopy is generally regarded as the most reliable tool in \nthe diagnosis of tubal pathology and other intra -abdominal \ncauses of infertility. Where there is no suggestive clinical sig ns \nand symptoms, laparoscopy offers an excellent means through \ndirect visualization. Diagnostic laparoscopy (DLS) is generally \naccepted as the most accurate procedure to detect tubal \npathology and endometriosis but it is still a matter of debate \nwhether laparoscopy should be routinely done in the infertility \nwork-up. There are several noninvasive and cost -effective tools \nto evaluate or predict tubal pathology. Several studies describe \nthe accuracy of Chlamydia antibody testing (CAT) and \nhysterosalpingography (HSG) with diagnostic laparoscopy as \ngold standard but alone no one tool is conclusive. (6) \nHysterosalpingography has been classically used for decades for \nthe evaluation of tubo -peritoneal infertility. Based on symptoms \nsuggestive of previous pelvic inf lammatory disease (PID), a \nhistory of abnormal vaginal discharge and a previous diagnosis \nof a lower genital tract infection, the positive predictive value of \nthorough history taking, was only 56%, 59%, and 35%, \nrespectively, in predicting tubo -peritoneal infertility in several \nstudies [7].  \nLaparoscopy still reveals tubal pathology or endometriosis in \n35-68% of cases, even after normal HSG and in patients with no \nsuggestive history. Many women with pelvic endometriosis \nhowever are asymptomatic. Lack of sat isfactory non -invasive \ntests for endometriosis has made laparoscopy the gold standard \nfor diagnosis. Laparoscopy also has therapeutic role in \nendometriosis [8].  \n \nThe Role of Laparoscopy in the Infertility Evaluation  \nThe role of laparoscopy in the investi gation of infertility has \nchanged over the past decade. Whereas laparoscopy used to be \npart of the basic infertility workup, it is now reserved for \nselected cases. Given that it allows direct visual examination of \nthe pelvic reproductive anatomy, it is the  test of choice to \nidentify otherwise unrecognized peritoneal factors that influence \nfertility, specifically endometriosis and pelvic adhesions. \nAccording to the guidelines of the ASRM, laparoscopy should \nbe performed in women with unexplained infertility or signs and \nsymptoms of endometriosis or in whom reversible adhesive \ntubal disease is suspected  [9]. However, the role of laparoscopy \nas a standard approach to the management of infertility remains \ncontroversial for several reasons. Although women with \ninfertility have an increased prevalence of endometriosis \n(estimated at greater than 30%), it is difficult to predict which \npatients are likely to benefit from surgery. Furthermore, \nprospective randomized studies exploring the effects of \nsurgically corrected  endometriosis on fecundity have been \nlimited, are sometimes contradictory, and at best have \ndemonstrated a modest effect. Modern fertility treatments, \nespecially in vitro fertilization (IVF), result in marked \nimprovements in fecundity; it is unclear wheth er these \ntreatments are compromised by unrecognized endometriosis. \nConsequently, patients increasingly forego surgery, particularly \nif they are otherwise asymptomatic and their initial diagnostic \nstudies (i.e., hysterosalpingogram) are normal. Theoreticall y, \nthere are potential benefits to routinely performing laparoscopy \nin infertile women [10].  \n \nFirst, it is possible to avoid fertility treatments and their direct \nas well as indirect financial and social costs such as multiple \ngestation pregnancy.  \n \nSecond, intraoperative findings that include Multiple red spots \nof endometriotic lesion, whit scaring inflammation in the Pouch \nof Douglas and uterosacral ligament, brown black lesion on the \novarian surface, ovarian endometriomas, Pelvic and Peritubal \nadhesion can guide postsurgical management, circumventing \ntreatments that are of low benefit and costly.  \n \nThird, surgically correcting endometriosis may enhance \nresponse to fertility treatments or mitigate the effects of \ncomorbidities such as pelvic pain  [10]. The  complexity of \ndeciding if and when laparoscopy should be performed to \ndiagnose and treat endometriosis among infertile women is \nhighlighted by an opinion from the Practice Committee of the \nAmerican Society of Reproductive Medicine: ‘‘the treatment of \nendometriosis. Raises a number of complex clinical questions \nthat do not have simple answers. There are few infertility \nproblems requiring greater clinical acumen.’’  The committee \nsuggests, ‘‘Laparoscopy should be seriously considered before \napplying aggressiv e empirical treatments involving significant \ncost and/or potential risks’’ [11]. \nThe benefits of laparoscopy \n More accurate diagnosis.  \n No stitches.  \n Therapeutic benefit  \n Shorter recovery time  \n Fewer post-op complications less scarring. \n \nAim of the study:  To identify the underlying causes of \ninfertility in women suffering from unexplained infertility via \nusing laparoscopy. \n \nPatients and method \nStudy design and setting: An observation study conducted at \nAl-Elwyia Maternity Teaching hospital at Obstetrics and \nGynecology department during the period from the first of \nFebruary 2019 to the first of August 2019. Patients included in \nthe study were diagnosed to have unexplained infertility (normal \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 87 ~ \novulation, patent tubes, normal seminal fluid analysis) according \nto their medical reports and previous assessment by the \nsupervisor of the current study, who is a consultant gynecologist. \nOn admission, further assessment of the patient was done by full \nhistory taken and examination. The questionnaire paper included \nthe fol lowing data: age, type and duration of infertility, \nmenstrual patterns, presence of dyspareunia, dysmenorrhea, and \nother pelvic pain, and their past medical or past surgical history, \ncurrent medication regime. Examination was concentrated on \nendocrinological evidence of abnormality i.e hirsutism, acne, \nbody weight (obesity), galactorrhea, thyroid gland assessment \nfor presence of any swelling or mass. A verbal and written \nconsents was taken from the participants after explain the idea of \nthe research.  \n \nInclusion criteria: Patients with unexplained infertility Normal \novulation, normal hysterosalpingography or at least one patent \ntube, and normal seminal fluid analysis  \n \nExclusion criteria : Presence of identify cause of infertility \nEvidence of PCOS or other en docrine disease (thyroid disease), \nmale factor infertile, and abnormal hysterosalpingography i.e \n(blocked tubes) The patients then subjected to diagnostic \nlaparoscopy to identify the underlying causes of their problem \nduring follicular phase of cycle. \n \nIntra operative finding: Using laparoscopy (storz) set up under \ngeneral anesthesia, using modified semi lithotomy position, \nunder aseptic technique port entry using umbilical region for \nmain camera and two secondary port at midline suprapubic and \nright mid -clavicular line, inflation of the abdominal cavity by \nusing CO2 up to 15 mmHg, pelvic cavity then visualization for \nany pathology i.e features of endometriosis, pelvic or peri tubal \nadhesion. Some cases normal pelvic were seen. Dye test using \nmethelin blue t o visualized tubes patency and the ovaries were \nassessed for any pathology. The finding was compared with \nhysterosalpingography and then reported on the questionnaire \nformula.  \n \nStatistical analysis : All patients' data entered using \ncomputerized statistical software; Statistical Package for Social \nSciences (SPSS) version 21 was used. Descriptive statistics \npresented as (mean ± standard deviation) and frequencies as \npercentages. Kolmogorov Smirnov analysis verified the \nnormality of the data set. Multiple con tingency tables conducted \nand appropriate statistical tests performed, Chi -square used for \ncategorical variables and t -test was used to compare between \ntwo means. One way ANOVA analysis was used to compare \nbetween more than two means. In all statistical an alysis, level of \nsignificance (p value) set at ≤ 0.05 and the result presented as \ntables and/or graphs. \n \nResults \nTable 1 show that there is a significant difference were found \nbetween age of patients and duration regarding the type of \ninfertility (P<0.05) \n \nTable 1: Duration of age and Infertility according to type. \n \n \nPrimary \n(n=35) \nSecondary \nn=(15) P \nvalue Mean±SD Mean±SD \nAge 27± 4 30±5 0.02 \nDuration (Mean±SD)/ \nYears 5.0±2.7 3.6±1.1 0.05 \nTable 2 show that by using the Hystrosalpingography we found \nthat 97.1%) of the primary infertility were with patent tubes and \nall secondary infertility 15 (100.0%) present with patent tubes \nand only 1 (2,9%) of primary infertility presented with block \ntube.  \n \nTable 2: Hystrosalpingography of the tube according to type of \ninfertility \n \nVariable \nType of infertility \nPrimary Secondary \nNo. % No. % \nHystero-salpingography Patent tubes 34 97.1 15 100 \nBlock tube 1 2.9 0 0 \n \nLaparoscopic finding of the patients shows that, abnormal pelvic \nwere found in 38 (76.0%) of the pa tients and 12 (24.0%) of the \npatients present with normal pelvic. Endometriosis were found \nin 26/38 (68.4%) of patients with abnormal pelvis when minimal \nfound in 9/26 (34.6%) of the patients while 11/26 (42.3%) were \nwith mild endometriosis, moderate endom etriosis in 4/26 \n(15.4%), and sever in 2/26 (7.7%). Adhesion was found in 12/38 \npatients (31.6%), when 8/12 (66.7%) unilateral and 4/12 \n(33.3%) were bilateral adhesion. For tubal patency, it was found \nthat 45 (90.0%) were present with bilateral patency and  only 5 \n(10.0%) were unilateral (table 3). \n \nTable 3: Laparoscopic finding of the studied group \n \nLaparoscopic finding No. % \nPelvic Normal 12 24.0 \nAbnormal 38 76.0 \nTotal 50 100.0 \nEndometriosis (n=26) \nMinimal 9 34.6 \nMild 11 42.3 \nModerate 4 15.4 \nSever 2 7.7 \nTotal 26 100.0 \nPeritubal adhesions (n=12) Unilateral 8 66.7 \nBilateral 4 33.3 \nTotal  12 100.0 \nNo adhesion 38 76.0 \nTubal patency Unilateral 5 10.0 \nBilateral patent 45 90.0 \nTotal 50 100.0 \n \nFor the relation between laparoscopic finding and type of \ninfertility, it was found that there is no significant association \nbetween normal pelvic, endometriosis, peritubal adhesion, and \nTubal patency with type of infertility (table 4).  \n \nTable 4: Association between laparoscopic finding and type of \ninfertility \n \nLaparoscopic finding \nType of infertility P \nvalue Primary (n=35) Secondary (n=15) \nNo. % No. % \nnormal pelvic Normal 9 75.0 3 25.0 0.6 Ns Abnormal 26 68.4 12 31.6 \nPeritubal adhesion (n=12) Unilateral 6 75.0 2 25.0 \n0.1 Ns Bilateral 1 25.0 3 75.0 \nNo adhesion  28 63.0 10 37.0 \nEndometriosis \n(n=26) \nMinimal 6 66.7 3 33.3 \n0.1 Ns Mild 9 81.8 2 18.2 \nModerate 3 75.0 1 25.0 \nSever 0 - 2 100.0 \nTubal patency Unilateral 2 40.0 3 60.0 0.3 Ns Bilateral 33 73.3 12 26.7 \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 88 ~ \nDiscussion \nLaparoscopy is considered as a gold standard in the diagnosis of \nendometriosis and should be offered to couples with UI prior to \nembarking on assisted reproductive techniques. Women \ndiagnosed with mild endometriosis may be offered surgical \nremoval of the endometri osis and this approach has been \nreported to improve postoperative pregnancies. The mean \nduration of the infertility was found to be (55± 29 \nmonths=4.6±2.4 years) which is in agreement with Kanda Y, et \nal study that reported the mean duration of infertility  was (5.0 ± \n2.67) years [12]. Tubal disease is an important cause of infertility \nand should be specifically excluded. The methods for evaluating \ntubal patency are complementary and not mutually exclusive [13]. \nThe current study shows that abnormal patholog y in (76%) were \nfound in women with unexplained infertility that underwent \nlaparoscopy. Laparoscopy is extremely useful in decision \nmaking while dealing with infertility of prolonged duration and \nolder women. In a retrospective study of 495 infertile women  \nwith unexplained infertility, laparoscopy before starting \ntreatment revealed a significant incidence of abnormalities \nresulting a changed in decision. Similarly, when patients with \nunexplained infertility following standard infertility screening \ntests und erwent diagnostic laparoscopy, 21 -68% of these \npatients were found to have pathologic abnormalities which \nincluded endometriosis and tubal disease. [14]. \nMeuleman C et al, reported that endometriosis is found in 4.5%-\n82.0% of women with chronic pelvic pain , and in 2.1% -78.0% \nof infert ile women  [15]. The current study showed that pelvic \npathology by laparoscopy were found in 76% of the studied \ngroup. Which is in agreement with that mentioned by Tsuji I et \nal, which reported the pelvic pathology was present i n (80.7%). \n[16]. \nSebastião F et al, reported that endometriosis was found in 181 \n(76.4) of the infertile patients  [17]. In Begum J, study found that \npelvic pathology by laparoscopy was confirmed in 54.5% of \ncases, moreover he found tubal block was the most  common \npathology (40%), followed by pelvic inflammatory disease \n(18.5%). Ovarian pathology comprised 8.1% whereas pelvic \nendometriosis 4.4% and distorted uterus was also 4.4% of \ninfertile cases diagnosed by laparoscopy [18]. While in our study \nthe most common finding was endometriosis, when 26/38 of the \npatients with unexplained infertility (primary or secondary) then \nsimple peritubal adhesion in 12/38 Tubal and peritoneal \npathology account for the primary diagnosis in approximately 30 \nto 35% of infertile couples [19]. The gold standard technique for \ndiagnosing these disorders is laparoscopy, which is a better \npredictor of future spontaneous pregnancy in infertile coupl es \nwith unexplained infertility  [20]. Jayakrishnan et al ., [19] from \nIndia detected pelvi c pathology in 26.8% cases of infertile \npatients by laparoscopic evaluation. In addition, endometriosis \nand adnexal adhesions were the two major abnormalities found \namong infertile patients in different studies similar to our \nfindings [21]. In contrast to the Study by Godinjak et al., [20] the \nprevalence of adhesions found in the current study is consistent \nwith the prevalence of 5.5% - 41.0% reported by others studie s \n[21, 22]. In previous studies, diagnostic laparoscopy was done for \nunexplained infertility  shown that pathologic abnormalities \nfound in 75% -80% of the infertile patients, in which \nendometriosis was identified in 30% -80% of the cases and \nperitubal adhesions were recognized in 29%-41% of the patients. \n[23] There are no significant differences were found regarding the \nrelation between laparoscopic findings and type of infertility, \nwhich is same that revealed by Begum J, in his study that \nincluded 135 patients using combined hysterolaparoscopy to \nevaluate female infertility [18]. \nOur results at lapa roscopy and hystrosalpingography had shown \nbilateral tubal patency in 49 (98%), and unilateral tubal block in \n1 (2%) of infertile patients. In one study at laparoscopy, carried \nby Godinjak Z, found that bilateral tubal patency was \ndemonstrated in 86.67%, b ilateral tubal block in 5% and \nunilateral block in 8.33% of patients  [20]. Nayak KP et al . got \nnearly equal prevalence of tubal block in primary infertility \npatients (40.9%) and secondary infertility patients (38.2%) [23]. \n \nConclusion \nThe main pathology se en in women with unexplained infertility \nwas pelvic endometriosis followed by simple peritubal adhesion. \n \nNo conflicts of interest \nSource of funding: self \nEthical clearance: was taken from the scientific committee of \nthe Iraqi Ministry of health \n \nReferences \n1. Kamath MS, Bhattacharya S. Demographics of infertility \nand management of unexplained infertility. Best Practice & \nResearch Clinical Obstetrics & Gynaecology. \n2012;26(6):729-38.  \n2. Callahan T, Caughey AB. Blueprints obstetrics and \ngynecology. Lippincott Wil liams & Wilkins 2013 ;20:346-\n55.  \n3.  Gelbaya TA, Potdar N, Jeve YB, Nardo LG. Definition and \nepidemiology of unexplained infertility. Obstetrical & \ngynecological survey 2014;69(2):109.  \n4.  Nandi A, Homburg R. 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