{"paper_id":"6d768068-2704-453b-a2d0-56fb761b85a6","body_text":"~ 81 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2019; 3(4): 81-83 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2019; 3(4): 81-83 \nReceived: 11-05-2019 \nAccepted: 13-06-2019 \n \nLaxmi Rathore \nSenior Resident, Department of \nObstetrics and Gynecology, Umaid \nHospital, Jodhpur, Rajasthan, \nIndia \n \nVibha Rani Pipal \nConsultant Obstetrician & \nGynecologist, Rajasthan Hospital \nJodhpur, Rajasthan, India \n \nDharmendra Kumar Pipal \nAssistant Professor,  \nDepartment of General Surgery, \nDr. Sampurnanand Medical \nCollege, Jodhpur, Rajasthan, India \n \nMahtab Singh Rajawat \nResident Doctor, Department of \nUrology, BMC, Bangalore, 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 \nCorrespondence \nVibha Rani Pipal \nConsultant Obstetrician & \nGynaecologist, Rajasthan Hospital \nJodhpur, Rajasthan, India \n \nRole of diagnostic hystero-laparoscopy (DHL) in the \nevaluation of infertility \n \nLaxmi Rathore, Vibha Rani Pipal, Dharmendra Kumar Pipal  and Mahtab \nSingh Rajawat \n \nDOI: https://doi.org/10.33545/gynae.2019.v3.i4b.294 \n \nAbstract \nObjective: To determine the role of diagnostic hysteron laparoscopy in the evaluation of infertility  in \ntertiary care centers. \nMaterials and Methods: This retrospective study was conducted at umaid hospital, a tertiary care centers \nin Jodhpur, Rajasthan, India from January 2016 to June 2017. Women aged 20 -40 years with normal \nhormone profile without male factor infertility were included. \nResults: Out of 178 patients, 125 (about 70%) women had primary infertility and the rest  (53) had \nsecondary infertility. The patients in secondary infertility group were slightly elder compared to primary \ngroup.  \nConclusions: Hystero laparoscopy is an effective diagnostic tool for evaluation of certain significant and \ncorrectable tuba-peritoneal and intrauterine pathologies like peritoneal endometriosis, adnexal adhesions, \nand substrate uterus, which are usually missed by other imaging modalities. \n \nKeywords: Hysteroscopy, infertility, laparoscopy \n \nIntroduction  \nInfertility is a growing concern of the society. In India there are approximately 10 -15% couples \nare infertile. Identifying the cause of infertility is complex an d after a standard evaluation 20 -\n30% of couples will have no clearly identifiable cause of their infertility  [1, 2]. It has been \nestimated that using laparoscopy as a standard test have tubal function would reduce the \napparent incidence of unexplained infe rtility from 10% to 3.5%  [3]. Experience has shown that \nmajority of pelvic pathology in infertile women is frequently not well appreciated by routine \npelvic examinations and the usual diagnostic procedures.  The ability to see and manipulate the \nuterus, fallopian tubes, and ovaries during laparoscopy has made it an essential part of infertility \nevaluation. Similarly, visualising the uterine cavity and identifying the possible pathology has \nmade hysteroscopy an equally important tool in infertility evaluatio n. [3] The question of tubal \nmorphology and patency, ovarian morphology, any unsuspected pelvic pathology, and uterine \ncavity abnormalities can all be resolved with accuracy at one session. Additionally, \nhysteroscopic guided biopsy and therapeutic procedures like polyp ectomy, myomectomy, septal \nresection, and adhesiolysis can be done in the same sitting.  [3] This study was undertaken to \nevaluate the role of diagnostic hystero -laparoscopy (DHL) in the comprehensive work up of \ninfertility, which would help in planning appropriate management.  \n \nMaterial & Methods \nPresent study was a retrospective  one which was conducted From January 2016 to June 2017 at \nTertiary centre Umaid Hospital JODHPUR, Rajasthan. Infertile women with age group 20 -\n40years with normal hor mone profile and without male factor infertility were selected and \nwritten informed consent was taken.  DHL with chromo pertubation test was performed in early \nfollicular phase in all the patients.  \n \nResults \nOut of 178 patients, 125 (about 70%) women had primary infertility and the rest  (53) had \nsecondary infertility. The patients in secondary infertility group were slightly elder compared to \nprimary group. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 82 ~ \nIn primary infertility group, laparoscopic abnormalites were \nmore common [Table 1] than hystero scopy. Endometriosis and \nadnexal adhesions were the most common abnormalities \ndetected in laparoscopy in primary and secondary infertility \ngroups respectively [Table 2]. The most common intrauterine \npathology in both the groups was uterine polyp  [Table 3]. The \nprevalence of unilateral and bilateral tubal block was equal in \nboth the groups [Table 4]. \n \nTable 1: Prevalance of hysterscopy and laparoscopy abnormalities \n \nProcedure Primary(125) Secondary(53) \n Normal Abnormal Normal Abnormal \nLaparoscopy 75(60%) 50(40%) 35(66%) 18(34%) \nHysteroscopy 160(83%) 21(17%) 41(78%) 12(22%) \n \nTable 2: Laparoscopy Findings \n \nFindings Primary(125) Secondary(53) Total \nEndometriosis 20(16%) 04(8%) 24 \nAdenaxal adhesions 09(7%) 08(15%) 17 \nTubal pathology 07(6%) 06(11%) 13 \nOvarian pathology 09(7%) 01()2% 10 \nMyoma 02(1.6%) 01(2%) 03 \nUterine anomaly 03(2.4%) - - \n \nTable 3: Hysterscopy Findings \n \nFindings Primary Secondary Total \nMyoma 4 3 7 \nPolyp 7 6 13 \nSeptum 8 11 19 \nSynechiae 0 1 1 \n \nTable 4: Presence of complete tubal block \n \nFindings Primary Secondary \nUnilateral 11 9 \nBilateral 8 14 \n \nDiscussion \nInfertility affects about 10-15% of reproductive age couples. The \nprevalence of infertile individuals is increasing globally. \nTuboperitoneal pathology i s responsible for 40 -50% c ases of \ninfertility [5]. The ability to observe and treatment the uterus, \nfallopian tubes, and ovaries during laparoscopy has made it a \ngold standa rd to evaluate pelvic pathology [6] Similarly, \nvisualizing the uterine cavity and identifying the possible \npathology has made hysteroscopy an essential part of infertility \nevaluation. The abnormalities of pelvic and uterus can resolved \nin combined hysteron laparoscopy, such as the lesion of tubal \nmorphology and patency, ovarian morphology, and uterine \ncavity abnormalities at the same time [7]. Although a diagnosis of \nseptate uterus per se is not an indication for septoplasty, the \nreproductive performance of women with an uncorrected septum \nis rather poor (80% pregnancy loss, 10% preterm delivery, 10% \nterm delivery ) with most losses occurring in the first trimester \n(approximately 65%). Pregnancy outcomes dramatically \nimproved after surgical correction (80% term delivery, 5% \npreterm delivery, 15% pregnancy loss)  [8]. Dysfunctional uterine \ncontractility interfering with ovum or sperm transport or embryo \nimplantation, and poor regional blood flow resulting in focal \nendometrial attenuation or ulceration  [9]. The incidence of \nasymptomatic endometrial polyps in women with infertility has \nbeen reported to range from 10% to 32% [10]. A prospective \nstudy of 224 infertile women who underwent hysteroscopy \nobserved a 50%pregnancy rate after polypectomy [11]. \nDiagnostic hysteron-laparoscopy is a very safe procedure. Other \nthan mild abdominal pain, there were no major surgical or \nanesthetic complications in any of our patients.   \nGoldman et al. found that in the absence of findings during an \nunexplained infertility evaluation, routine laparoscopy was not \nnecessary. The majority of patients who proceed to treatment \nwill become pregnant. However, this study compared pregnancy \noutcomes in women with unexplained infertility rather than \nfindings at laparoscopy [12].  \nShimizu et al. concluded that diagnostic laparoscopy should be \noffered as an option for younger patients who desire \nspontaneous pregnancy because no significant difference was \nfound in the cumulative pregnancy rate between patients \nproceeding to direct IVF and those doing so after laparoscopy. \nIn the latter, however, the chance of spontaneous conceptions \nwas higher [13].    \n \nConclusion \nDiagnostic hysteron laparoscopy is an effective and safe tool in \ncomprehensive evaluation of infertility, particularly for detecting \nperitoneal endometriosis, adnexal adhesions, and septum in the \nuterus. These are correctable abnormalities that a re \nunfortunately missed by routine pelvic examination and usual \nimaging procedures.  \n \nReferences  \n1. Smith S, Pfeifer SM, Collins JA. Diagnosis and \nmanagement of female infertility. JAMA . 2003; \n290:176770.   \n2. Practice Committee of the American Society of \nReproductive Medicine. Eff ectiveness and treatment for \nunexplained infertility. Fertil Steril. 2006; 86(1):114.  \n3. Drake T, Tredway D, Buchanan G, Takaki N, Daane T. \nUnexplained infertility. A reappraisal. Obstet Gynecol . \n1977; 50:644-6.   \n4. Bosteels J, Van Herend ael B, Weyers S, ’Hooghe DT. Th e \nposition of diagnostic laparoscopy in current fertility \npractice. Hum Reprod Update. 2007; 13:477-85. \n5. Dyer SJ. International estimates on infertility prevalence \nand treatment seeking: potential need and demand for \nmedical care. Hum Reprod. 2009; 24(9):2379-2380.   \n6.  Yucebilgin MS, Aktan E, Bozkurt K et al. Comparison of \nhydrosonography and diagnostic hysteroscopy in the \nevaluation of infertile patients. Clin E xp Obstet Gynecol. \n2004; 31(1):56-58.    \n7. Nayak PK, Mahapatra PC, M allick J, et al . Role of \ndiagnostic hystero -laparoscopy in the evaluation of \ninfertility: A retrospective study of 300 patients. J Hum \nReprod Sci. 2013; 6(1):32-34.  \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 83 ~ \n8. Homer HA, Li TC, Cooke ID. The septate uterus: A review \nof management and reproductive out come. Fertil Steril . \n2000; 73:1-14.  \n9. Vollenhoven BJ, Lawrence AS, Healy DL. Uterine fibroids: \nA clinical review. Br J Obstet Gynaecol 1990; 97:285-98.    \n10. Hinckley MD, Milki AA. 1000 office -based hysteron \nscopies prior to in vitro fertilization: Feasibility  and \nfindings. JSLS. 2004; 8:103-7.    \n11. Shokeir TA, Shalan HM, EI -Shafei MM. Significance of \nendometrial polyps detected hysteron scopically in \neumenorrheic infertile women. J Obstet Gynaecol Res . \n2004; 30:84-9. \n12. Goldman MB, MacKenzie TA, Regan MM, Alper MM,  Th \nornton KL, Reindollar RH. Th e role of diagnostic \nlaparoscopy in couples treated for unexplained infertility in \nthe fast track and standard treatment (FASTT) trial. Fertil \nSteril. 2009; 92:S32-3.   \n13. Shimizu Y, Yamaguchi W, Takashima A, Kaku S, Kita N, \nMurakami T. Long -term cumulative pregnancy rate in \nwomen with unexplained infertility aft er laparoscopic \nsurgery followed by in vitro fertilization or in vitro  \nfertilization alone. J Obstet Gynaecol Res. 2011; 37:412-5.","source_license":"CC0","license_restricted":false}