{"paper_id":"df613bbd-6f7a-4666-8247-5ab1f951be75","body_text":"DOI: https://doi.org/10.53350/pjmhs2115123871 \nORIGINAL ARTICLE \n \nP J M H S  Vol. 15, No.12, DEC  2021   3871 \nEvaluation of Female Infertility Factors Through Diagnostic \nLaparoscopy: a Cross Sectional Study \n \nMOMNA KHAN1, SHUMAILA JAVAID2, SARWAT KHALID3, RAHILA IMTIAZ4, ASMA JABEEN5, ERUM JAHAN6 \n1Assistant Professor Gynaecology, Bilawal Medical College Kotri Hospital/Liaquat University of Medical and Health Sciences Jamshoro, \nPakistan. \n2Post Graduate Resident Trainee Gynaecology, Sharif Postgraduate Medical Institute/Sharif Medical city Hospital Lahore, Pakistan. \n3Assistant Professor Gynaecology, Karachi Medical and Dental College Abbasi Shaheed Hospital, Pakistan. \n4,6Assistant Professor Gynaecology, Karachi Medical and Dental College Abbasi Shaheed Hospital Karachi, Pakistan. \n5Associate professor Gynaecology, Muhammad Medical Collage Mirpurkhas, Pakistan. \nCorresponding author: Momna Khan, Email: drmomnakhan@yahoo.com \n \nABSTRACT \nAim: To evaluate the factors behind primary and secondary infertility in females through diagnostic laparoscopy. \nStudy design: Cross sectional study \nPlace and duration:  This study was conducted at Bilawal Medical College Kotri Hospital/Liaquat University of \nMedical and Health Sciences Jamshoro, Pakistan from June 2019 to July 2020 \nMethodology: The present study is a cross sectional  study conducted at at Bilawal Medical College Kotri \nHospital/Liaquat University of Medical and Health Sciences Jamshoro, Pakistan from June 2019 to July 2020.  A \ntotal of 115  females were included in the study and they all underwent diagnost ic laparoscopy after setting strict \ninclusion criteria. Data was recorded on proforma and analyzed on IBM SPSS  version 22. Primary and secondary \ninfertility frequency was calculated and analyzed.  \nResult: A total of 115  infertile women were considered in t he study and results were recorded after performing \ndiagnostic laparoscopy on all of the participants. Total 74 (64.35 %) had primary infertility and 41 (35.65 %) \nreported secondary infertility. Total 19 (25.67%) participants of primary infertility and 5 (12.19%) participants with \nsecondary infertility showed no abnormality. The most common abnormality found was tubal bl ockage in 17 \n(22.97%) women of primary infertility and 13 (31.70 %) women of secondary infertility. Total 11 (14.86%) patients \nof primary i nfertility were diagnosed with polycystic ovaries (PCO). PCO was absent in patient s with secondary \ninfertility. Total 9 (12.16%) cases of primary infertility and 5 (12.19 %) cases of secondary infertility were \ndiagnosed with Endometriosis.  Total 2 (2.7 %) ca ses of primary infertility and 7 (17.07 %) participants with \nsecondary infertility presented with Pelvic Inflammatory disease (PID).  A total of 6 (8.10%) cases having primary \ninfertility were observed with periovarian adhesions and Peritubal adhesions, wher eas, 9 (21.95%) cases of \nsecondary infertility were seen with these issues.  \nConclusion: Tubal occlusion, periovarian adhesions, peritubular  adhesions, and endometriosis were the most \ncommon factors behind infertility in both primary and secondary  infertility. Ovarian cyst and polycystic ovarian \ndisease were only present in patients with primary infertility.  \nKeywords: Diagnostic Laparoscopy, Primary infertility tubal occlusion, Secondary infertility  \n \nINTRODUCTION \nInfertility is a common issue and it affects about one in six \ncouples. It can be defined as the inability of a couple to \nconceive even after sexual intercourse for a reasonable \nperiod of time, without using any kind of contraception \nmethod. It is difficult  to establish the exact reason behind \nthis prevalence. However, some common factors are delay \nin childbearing, altered sexual behavior, and bad semen \nquality because of smok ing and alcohol addiction. Female \nfactors of infertility are more common than male factors. \nThe focus during investigating the causes of female \ninfertility is mainly on ovulatory factors, utero -tubal \nperitoneal factors , uterine abnormalities, cervical \nabnormalities, damage or blockage of fallopian tubes, \nendometriosis, early menopause, pelvic adhesions, cancer, \nand its treatment . In males, semen migratory factors, \nquality of semen, and quantity of semen are focused [1]. In \n40% of infertility cases, a combination of reasons is seen, \nwhereas, reasons remain undefined in 15% of the cases \n[2]. The prevalence of infertility in Pakistan is 21.9%. About \n4% of them have primary infertility while 18% of them have \nsecondary infertility [3]. Identification of the rea son leads to \nsuccessful treatment. Problem with sperm delivery, \nexposure to environme ntal factors, cancer, and its \ntreatment are some other male factors of infertility.  \n The workup to identify the cause of female infertility \nbegins with acquiring detailed history and performing the \nexamination. History has great significance in such cases. \nPeriod of intercourse, use of contraception, and societal \nfactors are asked. After h istory and examination, some \nnecessary investigations are performed. On the initial level, \ninvasive techniques are avoided. Most predictive laboratory \ninvestigations are carried out first on the basis of the history \nprovided [4]. For instance, if the histo ry is consistent with  \npolycystic ovarian disease  (PCO) then hormone levels are \nassessed and the status of ovaries is evaluated on \nultrasonography. Diagnostic laparoscopy is not generally a \ncomponent of the initial investigation. However, it has been  \nnoticed from multiple research studies that it is an effective \ntechnique for a definitive diagnosis [5]. Status of fallopian \ntubes, ovaries, uterine abnormalities, and pelvic \npathologies such as endometriosis,  pelvic inflammatory \ndisease (PID), tuberculosis, and  pelvic congestion can be \nseen through a diagnostic laparoscopy [6].  It is an effective \ntechnique to find out the patency of tubes. About 21.68% of \ncases have presented definitive diagnosis through \n\nEvaluation of Female Infertility Factors Through Diagnostic Laparoscopy \n \n3872   P J M H S  Vol. 15, No.12, DEC  2021 \nlaparoscopy followed by hysterosalpingography [7]. \nCommon reasons for secondary infertility are PID, retained \nproduct of conception after abortion, tuberculosis, and \npostpartum infection. The present study was carried out for \nthe determination of causes of infertility in females through \ndiagnostic laparoscopy.  \n \nMETHODOLOGY \nThe present study is cross  sectional study . It was carried \nout at  Bilawal Medical College Kotri Hospital/Liaquat \nUniversity of Medical and Health Sciences Jamshoro, \nPakistan from June 2019 to July 2020. A total of 115 \nparticipants were selected for the study. Permission was \ntaken from the ethical review committee of the institute. \nWomen who could not conceive in more than 12 months \nafter repetitive efforts were considered in the study. Total \n74 (64.35%) women had primary infertility a nd 41 (35.65%) \nwomen had secondary infertility. A strict exclusion criterion \nwas set according to which couples who had not been \nliving together for 1 2 months, women  who had \ncontraindication regarding laparoscopy, and couples who \nwere positive for male infertility were not included in the \nstudy. Moreover, the patients who had a pre -existing \nrespiratory condition, cardiovascular condition, intestinal \nileus, obstruction, generalized peritonitis, and any kind of \nhernia were also not included in the study.  \n The history of all the patients was taken in detail and \nrecorded on proforma. A clinical examination was done. \nSome la boratory investigations were considered  \ncompulsory for all the participants to rule out the cause of \ninfertility. These investigations included hormone profiles \nsuch as Luteinizing hormone, follicle -stimulating hormone, \nthyroid-stimulating hormone, progesterone, prolactin, and \ntestosterone. In addition to that, an abdominal ultrasound of \nall the participants was also done to confirm if the diagnosis \ncan be made on imaging or the patient is a potential \ncandidate for the invasive technique.  \n A total of 115 infertile women were selected for \nlaparoscopy. Patients were guided that they would have to \ncome to the hospita l in the premenstrual stage of their \nmonthly cycle for laparoscopy. They were guided and \ncounseled about the study and informed written consent \nwas taken for both the laparoscopy and participation in the \nstudy. Laparoscopy was carried out in such a way tha t the \npelvis of the patients was tho roughly inspected, the uterus  \nchecked along with fallopian tubes, pouch of Douglas, \nround ligament, uterosacral ligament, and ureterovesical \npouch. Patency of fallopian tubes was inspected by \ninjecting Gention violet or methylene blue dye in the uterine \nand the fimbrial end was then c hecked for spillage of the \ndye. The shape and length of the tubes were examined. \nShape, size, the thickness of follicles, affirmation of \novulation with respect to fimbrial tubes was examined in \nboth ovaries. Any presence of pathology in the pelvis, fluid \npresent in the pouch of Douglas, fibroids, endometriosis, \ntubo-ovarian masses, Peritubal adhesions, periovarian \nadhesions, and omental adhesions were also ruled out.  In \naddition to making a diagnosis, dilatation and curettage \nwere also performed in patients  who had menstrual \nabnormalities, endometriosis, and endometrial tuberculosis. \nThe curetted tissue was then sent for histopathology. All \nthe data was recorded and analy zed in the IBM SPSS \nversion 22. \n \nRESULT \nThe present study included a total of 115 partic ipants. The \nratio of patients who had primary infertility was almost two \ntimes the patients who had secondary infertility. There were \n74 (64.35%) patients with primary infertility and 41 \n(35.65%) patients with secondary infertility. The mean \nduration of in fertility in the case of primary infertility was \n3.4±0.6 years and in the case of secondary infertility, it was \n6.9±1.2 years. The mean age of patients who had \npresented with primary infertility was 27.4±3.1 years. The \nmean age of participants who had seco ndary infertility was \n33.4±7.5 years.  \n Out of 74 patients with primary infertility, 19 (25.67%) \nparticipants had no visible abnormality. A total of 55 \n(74.32%) had multiple symptoms such as pain in the pelvis, \ndysmenorrhea, dyspareunia, irregular menstrua l cycle, \nexcessive weight gain, hirsutism, menorrhagia , and \nsecondary amenorrhea. Total  74.32% were identified with \ndifferent issues on diagnostic laparoscopy as mentioned in \ntable 1.  \n In the case of secondary infertility, 5 (12.19%) of the \npatients had no visible abnormality on laparoscopic \nexamination. These participants had similar symptoms as \nthose of primary infertility patients. The findings of \nlaparoscopy are shown in table 2. It can be noted from the \ndata that the most common abnormality seen in both \nprimary and secondary infertility was a tubal blockage. The \nsecond most common reason for primary infertility was \nPCO. Ovulatory causes were not detected in participants \nwith secondar y infertility. However, periovarian adhesions \nand peritubal adhesions were the second most common \nreason for infertility in these participants.  \n \nTable 1 : Reasons of infertility identified on laparoscopy in \nparticipants with primary infertility \nFindings Primary infertility \nn=74 \nFrequency  Percentage \nNo abnormality  19 25.67 \nTubal blockage  17 22.97 \nPolycystic ovaries 11 14.86 \nEndometriosis  9 12.16 \nPID 2 2.7 \nPeriovarian adhesions and \nPeritubal adhesions \n6 8.10 \nFibroids 5 6.75 \nOvarian cyst 5 6.75 \n \nTable 2 : Reasons of infertility identified on laparoscopy in \nparticipants with secondary infertility \nFindings Secondary infertility \nn=41 \nFrequency  Percentage \nNo abnormality 5 12.19 \nTubal blockage  13 31.70 \nPolycystic ovaries 0 0 \nEndometriosis  5 12.19 \nPID 7 17.07 \nPeriovarian adhesions and \nPeritubal adhesions \n9 21.95 \nFibroids 2 4.87 \nOvarian cyst 0 0 \n\nM. Khan, S. Javaid, S. Khalid et al \n \nP J M H S  Vol. 15, No.12, DEC  2021   3873 \nDISCUSSION \nComplete assessment of infertility includes investigating \nthe cause s in both partners. Some laboratory tests are \nsignificant in the identification of the cause. Despite that, \ndiagnostic laparoscopy is considered to be a mandatory \nprocedure to evaluate the definite cause [8]. The age of \nfemale participants has a significant  role in treatment. \nWhereas, yet no such standard age is set . Nonetheless, \nASRM (American Society of Reproductive Medicine) has \nconsidered 35 years as an age limit in terms of fertility [9]. \nIn the present study, a total of 12 participants were above \nthe age of 35 years.  \n The mean duration of primary infertility was 3.4±0.6 \nyears and in the case of secondary infertility, it was 6.9±1.2 \nyears. None of the cases presented with a duration less \nthan 2.5 years. Ashraf et al reported similar results in their \nresearch conducted in Lahore where 58% of participants \nhad primary infertility with a duration ranging from 2 years \nto 5 years and 71% of participants had secondary infertility \nwith a duration above 5 years. None of his participants had \nreported primary infertility for less than 2 years [10].  \n According to the study of Ibrahim et al, diagnostic \nlaparoscopy is not only a significant technique in \ndiagnosing the cause, but it can also help in the treatment \nin certain cases. They found out that the causes of \nunexplained infertility were endometriosis and peritubular \nadhesions. Both of the pathologies can be fixed through \nlaparoscopy. It was also narrated in the conclusion that \nboth these issues are impossible to be detected without \nlaparoscopic intervention [11]. Another similar study was \nconducted by Niaz et al in Peshawar. The study was \nconducted on 196 participants. They observed that 45% of \nthe patients with collectively primary and secondary \ninfertility had genital tuberculosis [12].   \n Another similar study w as conducted by Shinde et al. \nThey had additionally combined hysteroscopy with \nlaparoscopy to make a definitive diagnosis. They \nconcluded that combining both diagnostic techniques is \nvital before starting treatment. According to their results, \npelvic adhes ions were the commonest root cause in both \nprimary and secondary infertility. Pelvic tuberculosis was \nalso predominant in primary infertility. Uterine anomalies, \nsubmucous fibroids, polyps, and Asherman’s syndrome \nwere other minor causes [13]. Talat et al also found that \ntubal blockage was detected more commonly in primary \ninfertility compared to secondary infertility. The same was \nthe case with PID. Similar results were obtained in our \nstudy [14]. \n \nCONCLUSION \nIn our study t he predominant cause of infertili ty in both \ntypes of cases was a tubal blockage. Ovulatory factors \nwere present in abundance in primary infertility while they \nwere absent in secondary infertility. Diagnostic laparoscopy \nis a minimally invasive technique to diagnose the actual \ncause of inf ertility in both primary and secondary infertility. \nIt has a significant role and should be considered earlier in \npatients with PID and pelvic pain. \nFunding source: None \nConflict of interest: None \nPermission: Permission was taken from the ethical review \ncommittee of the institute \n \nREFERENCES \n1. Deshpande PS, Gupta AS. Causes and prevalence of \nfactors causing infertility in a public health facility. Journal of \nhuman reproductive sciences. 2019 Oct; 12(4):287. \n2. Liehr T, Al -Rikabi AB. 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Shinde M, Sable U, Shitole R. Should diagnostic \nhysteroscopy and diagnostic laparoscopy be a combined \nprimary work up in evaluating prima ry & secondary infertile \nwomen? Tuberculosis. 2019; 7:2. \n14. Talat N, Lubna H, Gulmeen, Farrah N, Shahida S. \nLaparoscopic evaluation in infertility. J Coll Physicians Surg \nPak 2009; 19:704-7.","source_license":"CC0","license_restricted":false}