{"paper_id":"5b46bbd8-07fe-416a-ac2e-c7f28e762e5a","body_text":"~ 47 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2018; 2(6): 47-49 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2018; 2(6): 47-49 \nReceived: 29-09-2018 \nAccepted: 30-10-2018 \n \nDr. Bachaspati Dash \nProfessor and Head, Department \nof Obstetrics and Gynaecology, \nShri Shankaracharya Institute of \nMedical Sciences, Bhilai, \nChhattisgarh, 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 \n \n \n \n \n \n \n \n \n \n \n \nCorrespondence \nDr. Bachaspati Dash \nProfessor and Head, Department \nof Obstetrics and Gynaecology, \nShri Shankaracharya Institute of \nMedical Sciences, Bhilai, \nChhattisgarh, India \n \nScreening of infertility by laparoscopy in a medical \ncollege and hospital of eastern India: A clinical study \n \nDr. Bachaspati Dash \n \nAbstract \nBackground: Infertility is a major health issue with multifactorial etiology. None of the l aboratory \nfindings alone is conclusive in diagnosing infertility. Laparoscopy has come into play in finding the \netiology and planning the further management of infertility. This study is conducted to screen causes of \ninfertility in a tertiary care teaching hospital of eastern India. \nMethods: 100 cases of primary and secondary infertility were subjected to laparoscopy after taking \ninformed consent. Causes of infertility were found out. The present study was conducted at Hi -Tech \nMedical College and Hospital, Bhubaneshwar, Odisha and initiated after approval from Institutional Ethics \nCommittee of the Institute. \nResults: There were 75 cases (75%) of primary infertility as against 25 cases (25%) of secondary \ninfertility. A maximum of 40 cases (40%) were in the age group of 20 - 25 years. Uterine causes \ncontributed about 14 cases (14%), tubal causes contributed about 34 (34%), ovarian factors accounted for \n27 cases (27%), peritoneal causes contributed for 7 cases (7%), unexplained infertility accounted for 18 \ncases (18%). \nConclusions: Laparoscopy is a gold standard for tubal, ovarian cases, in cases of endometriosis and in \nadhesions till date. Laparoscopy can be used for evaluation of almost all the cases of infertility. Because of \nits potential diagnostic and th erapeutic benefits, all the patients with infertility should undergo laparoscopy \nprior to any advance procedure in infertility management. Diagnostic laparoscopy has become so important \nin the evaluation of infertility that it has now been considered as a basic skill which should be learnt by \nevery gynecologist in the advanced scientific era. \n \nKeywords: Infertility, laparoscopy, eastern India \n \nIntroduction  \nInfertility is a couple oriented diseases; still today 12 -14% [1] of couple are infertile. WHO \nestimates that 60 to 80 million couples worldwide currently suffer from infertility  [2]. Incidence \nof female infertility is 45.67%, male infertility is 54.33%  [3] & may be both can get involved in \nsome of cases, rang e varies from region to region.  Total infertility is divided into primary and \nsecondary infertility. Definitions of primary infertility vary between studies, but the operational \ndefinition, put forth by the WHO, defines primary infertility as “Inability to conceive within two \nyears of exposure to pre gnancy (i.e. - sexually active, non -contraception and non -lactating) \namong women 15 to 49 year old”  [4]. Secondary infertility refers to the inability to conceive \nfollowing a previous pregnancy. Globally, most infertile couples suffer from primary infertility [5].  \nAn infertility evaluation should be performed if a couple has not achieved conception after one \nyear of unprotected intercourse. Evaluation is the starting point for treatment of infertility as it \nmay suggest specific causes and appropriate treat ment modalities. Although the history and \nphysical examination provide important information, specific diagnostic tests are required to \nevaluate infertility. Because the causes of infertility can be multifactorial, a systematic approach \ntypically is used a nd involves testing for male factor, ovulatory factor, uterotubal factor, and \nperitoneal factor. Many of these diagnostic tests are laboratory based, including semen analysis, \nserum progesterone level, and serum basal follicle - stimulating hormone level [6]. \nThe appropriate selection of investigations based on problem areas identified by history and \nphysical examination would guide the physician in the management of the infertile couple  [7]. \nLaparoscopy has been suggested as a mandatory step to preclude th e existence of peritubal \nadhesions and endometriosis as causes of infertility [8]. \nLaparoscopy is now a days a gold standard for evaluating fallopian tube morphology and it can \nalso be used for endometriosis diagnosis as if one centimetre lesion can only b e diagnosed by \nlaparoscopy and in cases of chronic pelvic pain and to rule out adnexal pathology and congenital  \ndefects. This study further focus the role of laparoscopy in finding out the causes of infertility.   \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 48 ~ \nMethods  \nIt was a cross sectional study c arried out in the department of \nobstetrics and gynaecology at Hi -Tech Medical College and \nHospital, Bhubaneshwar, Od isha. Cases with infertility coming \nin the OPD were selected after taking informed consent. 100 \ncases of both primary and secondary inferti lity were considered. \nCases excluded were infertility with male factor and patients \nwith absolute contraindication for laparoscopy i.e. patients with \ncardiopulmonary disease, diaphragmatic hernia, large abdominal \nmasses, paralytic ileus, gross obesity, gen eralized peritonitis, \nbowel obstruction, intraperitoneal haemorrhage. \nFirstly, complete history along with complete systemic \nexamination of all the systems, along with per speculum and per \nvaginal examination were done. After taking informed consent \nlaparoscopy was done under General Anesthesia, during the post \nmenstrual phase in 7th, 8th and 9th day of cycle, pre -operative \nfindings was noted. Chromopertubation with methylene blue dye \nwas carried out to know the patency of the tubes. Tubal, ovarian, \nuterine and peritoneal factors were assessed and further \nmanagement plan was made accordingly. \n \nResults  \nIn our present study we found out that out of 100 cases of \ninfertility, there were 75 cases (75%) of primary infertility, and \n25 cases (25%) of secondary infe rtility (Table 1) We also found \nthat maximum number of cases falls in the age group of 20 -25 \nyears that is 40cases (40%) followed by 33 cases (33%) in 26 -30 \nyears and least number in the age group of more than 40 years \nthat is 03 cases (03%) (Table 2). Max imum number of primary \ninfertility cases were in the age group of 20 -25 years that is 34 \ncases (45.33%) and that of secondary infertility maximum \nnumber of cases were in the 26 -30 years age group that is 09 \ncases (36%) (Table 3). \nUterine causes contributed  about 14 cases (14%) among which \n10 cases (13.33%) were of primary infertility and 04 cases \n(16%) were of secondary infertility. Tubal causes (peritubal \nadhesions, tubal blockage, tubo ovarian masses and \nhydrosalpinx) contributed about 34 (34%) cases, amo ng which \n28 cases (37.33%) were of primary infertility and 06 cases \n(24%) were of secondary infertility. Ovarian factors (PCODS, \nbald ovaries streak ovaries, ovarian cysts) accounted for 27 \ncases (27%) among which 19 cases (25.33%) were of primary \ninfertility and 08 cases (32%) were of secondary infertility. \nPeritoneal causes (endometriosis, genital tuberculosis, \nadhesions) contributed for 07 cases (7%) among which 05 cases \n(6.66%) were of primary infertility and 02 cases (8%) were of \nsecondary infertility.  Unexplained infertility accounted for 18 \ncases (18%), among which primary infertility were 13 cases \n(17.33%) and secondary infertility were 05 cases (20%) (Table 4). \n \nTable 1: Number of patients according to the type of Infertility \n \n Number of Cases Percentage of Cases \nPrimary Infertility 75 75% \nSecondary Infertility 25 25% \n \nTable 2: Age distribution in Infertility Cases \n \nAge in Years Number of Cases Percentage of Cases \n20-25 40 40% \n26-30 33 33% \n31-35 14 14% \n36-40 10 10% \n>40 03 3% \nTable 3: Age distribution in Primary and Secondary Infertility \n \nAge in Years Primary Infertility (n=75) Secondary Infertility (n=25) \n20-25 34 (45.33%) 06 (24%) \n26-30 24 (32%) 09 (36%) \n31-35 06 (8%) 08 (32%) \n36-40 04 (5.33%) 06 (24%) \n>40 01 (1.33%) 02 (8%) \n \nTable 4: Causes of Infertility on Laparoscopy \n \nCauses Primary Infertility \n(n=75) \nSecondary Infertility \n(n=25) \nUterine Causes 10 (13.33%) 04 (16%) \nTubal Causes 28 (37.33%) 06 (24%) \nOvarian Causes 19 (25.33%) 08 (32%) \nPeritoneal Causes 05 (6.66%) 02 (8%) \nUnexplained 13 (17.33%) 05 (20%) \n \nDiscussion  \nIn this study 75 cases (75%) were of primary infertility, and 25 \ncases (25%) were of secondary infertility. The prevalence of \nprimary and secondary infertility was similar to the study of \nAvasthi Kumkum et al. (2006) [9] and Sharma N et al. (2012) [10]. \nThere is overall higher incidence of primary infertility in the \npopulation (Table 1)  [11]. This study also showed that maximum \nnumber of cases falls in the age group of 20 -25 years that is 40 \ncases (40%) followed by 3 3 cases (33%) in the age group of 26 -\n30 years and least number in the age group of more than 40 \nyears that is 03 cases (03%). Maximum number of primary \ninfertility cases falls in the age group of 20 -25 years that is 34 \ncases (45.33%) and that of secondary infertility maximum \nnumber of cases falls in the 26 -30 years age group that is 09 \ncases (36%). Similarly according to Paul C. Adamson et al . \n(2011) [12] the prevalence of primary infertility in India was \n12.6% and the mean age was 25.9year range was aged 1 5-30 \nyear. Roupa Z et al . (2009)  [13] studied 110 infertile women, \n64.5% were 20 –29 years, 20.0% were 30 -39 years, 11.8% were \n40-49 years and 3.7% were over 50 years. In the present study, \nuterine causes was found in 14 cases (14%), among which 10 \ncases (1 3.33%) were of primary infertility and 04 cases (16%) \nwere of secondary infertility. Tubal causes (peritubal adhesions, \ntubal blockage, tubo ovarian masses and hydrosalpinx) \ncontributed about 34 (34%) cases, among which 28 cases \n(37.33%) were of primary in fertility and 06 cases (24%) were of \nsecondary infertility. Ovarian factors (PCODS, bald ovaries \nstreak ovaries, ovarian cysts) accounted for 27 cases (27%) \namong which 19 cases (25.33%) were of primary infertility and \n08 cases (32%) were of secondary infe rtility. Peritoneal causes \n(endometriosis, genital tuberculosis, adhesions) contributed for \n07 cases (7%) among which 05 cases (6.66%) were of primary \ninfertility and 02 cases (8%) were of secondary infertility. \nUnexplained infertility accounted for 18 cas es (18%); among \nwhich primary infertility were 13 cases (17.33%) and secondary \ninfertility were 05 cases (20%).  \nAziz N (2010)  [14] studied Fifty infertile women who underwent \nlaparoscopy, 32 (64%) had primary infertility while 18 (36%) \nsecondary infertility. Eight (25.0%) patients with primary and 2 \n(11.1%) patients with secondary infertility had no visible \nabnormality. The common finding was tubal blockage in 7 \n(21.9%) and 6 (33.3%) cases of primary and secondary \ninfertility respectively. Five (15.6%) cas es of primary infertility \nwere detected as polycystic ovaries (PCO) which was not found \nin cases of secondary infertility. Endometriosis was found in 4 \n(12.5%) cases with primary infertility and 2 (11.1%) cases with \nsecondary infertility. Pelvic inflammato ry disease (PID) was \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 49 ~ \nfound in 1 (3.1%) and 2 (16.7%) cases of primary and secondary \ninfertility respectively. Peritubal and periovarian adhesions were \ndetected in 2 (6.3%) cases with primary infertility and 4 (22.2%) \ncases with secondary infertility. Fibro id was found in 2 (6.3%) \nand 1 (5.6%) cases of primary and secondary infertility \nrespectively. Ovarian cyst detected in 2 (6.3%) cases with \nprimary infertility while none was found in cases of secondary \ninfertility. \nAccording to Riffat S et al. [15] in 2010, laparoscopy was done in \n260 patients, ovulatory failure was found out to be 22.09%, tubal \nblockage was found to be 14.41% and tubal blockage with \ntuboovarian mass was found to be 1.31% and endometriosis was \nfound out to be 6.55%. Similar study was done by Cahill et al. \n[16] who found 31% patient had PID, 5% had endometriosis. \nTsuji I et al . [17] in 2009 stated that 57 infertile patients with \nnormal HSG findings underwent diagnostic laparoscopy. In 46 \n(80.7%) of these patients, diagnostic laparoscopy reve aled \npathologic abnormalities. Specifically, endometriosis and \nperitubal and/or perifimbrial adhesions were found in 36 \n(63.2%) and 5 (8.8%) of the patients, respectively. \n \nConclusions  \nInfertility is a global health issue none of the female should be \ndenied of her motherhood, it is a social stigma but efforts could \nbe made for making a couple complete with a family. We are \nable to detect the cause(s) of infertility in the pelvic cavity and \nwere able to design a suitable management plan, which could \nlead to  postoperative pregnancy. Laparoscopy is gold standard \nfor tubal and ovarian causes and in cases of endometriosis and in \nadhesions till date no other technology is present hence \nlaparoscopy can used for evaluation of almost all the cases of \ninfertility. Di agnostic laparoscopy has become so important in \nthe evaluation of infertility that it has now been considered as a \nbasic skill which should be learnt by every gynecologist in the \nadvanced scientific era. Because of the potential diagnostic and \ntherapeutic benefits, patients with infertility should undergo \nlaparoscopy prior to ART. \n \nReferences  \n1. Poppe K, Velkeniers B. Thyroid and infertility. Verh K \nAcad Geneeskd Belg. 2002; 64(6):389-99.  \n2. World Health Organization. Infecundity, infertility, and \nchildlessness in developing countries. DHS Comparative \nReports No 9. Calverton, Maryland, USA: ORC Macro and \nthe World Health Organization , 2004. Available at: \nwww.who.int/.  \n3. Shamila S, Sasikala SL. 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Hum Reprod. 2002;  \n17(1):1-3.  \n9. Avasthi Kumkum, Kaur Jasmine, Gupta Shweta, et al . \nHyperprolactinaemia and its correlation with hypothyroidism \nin infertile women. J Obstet Gynecol. 2006; 56:68-71.  \n10. Sharma N, Baliarsingh S, Kaushik GG. Biochemical \nassociation of hyperprolactinaemia with hypothyroidism in \ninfertile women. Clin Lab. 2012; 58:805-10.  \n11. Inhorn MC. Global infertility and the globalization of new \nreproductive technologies: illustrations from Egypt Soc. Sci. \nMed. 2003; 56:1837-51.  \n12. Paul C Adamson. Prevalence and correlates of primary \ninfertility among young women in Mysore, India. Indian J \nMed Res. 2011; 134:440-6.  \n13. Roupa Z  et al . Causes of infertility in women at \nreproductive age. Health Science Journal. 2009; 3(2):80-7.  \n14. Aziz N. Laparoscopic evaluation of female factors in \ninfertility. J Coll Physicians Surg Pak. 2010; 20(10):649-52.  \n15. Riffat S, et al. Prevalence of infertility in a cross section of \nPakistani population Pakistan. J Zool. 2010; 42(4):389.  \n16. Cahill DJ, Cooke IE, Darling MR. The influence of \nlaparoscopy on infertility management. Ir J Med Sci. 1991;  \n160(2):50-1.  \n17. Tsuji I, Ami K, Miyazaki A, Hujinami N, Hoshiai H. \nBenefit of diagnostic laparoscopy for patients with  \nunexplained infertility and normal hysterosalpingography \nfindings. Tohoku J Exp Med. 2009; 219(1):39-42.","source_license":"CC0","license_restricted":false}