Role of Hysterolaparoscopy in Female Infertility

Infertility is a prevalent condition affecting an estimated 186 million women worldwide.[1] It is defined clinically as the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse. Primary infertility refers to infertility in a patient who has never conceived, whereas secondary infertility denotes difficulty conceiving despite a prior pregnancy. Studies indicate that primary infertility constitutes about 57.5% of cases globally, and secondary infertility accounts for the remaining ∼42.5%.[1,2] Although the global prevalence of infertility among couples has remained around 10–15%, the evaluation and management approaches have evolved significantly over the last three decades.[3] Historically, hysterosalpingography (HSG) was the primary imaging method to assess the uterine cavity and fallopian tube patency in infertility workups. HSG can detect tubal occlusions and uterine contour abnormalities, but it has important limitations; it provides no information on pelvic peritoneal factors (e.g., endometriosis or adhesions) and may give false impressions of intrauterine lesions or anomalies. For example, a congenital uterine septum can appear similar to a bicornuate uterus on HSG, requiring further evaluation for distinction. Consequently, diagnostic laparoscopy has long been considered the gold standard for assessing pelvic causes of female infertility, as it permits direct visualization of the uterus, ovaries, fallopian tubes, and peritoneal surfaces. Laparoscopy combined with chromopertubation (dye test) accurately evaluates tubal patency and can reveal peritoneal-endometriotic implants or adhesions that are often missed by non-invasive methods. Similarly, hysteroscopy allows direct inspection of the endocervical canal and uterine cavity to identify lesions such as fibroids, polyps, septa, or intrauterine adhesions that may impair fertility. By performing these two endoscopic procedures together in a single session—namely, a combined hysterolaparoscopy—a complete evaluation of the female reproductive tract is achieved, addressing both intraperitoneal and intrauterine factors in one step. In addition to its diagnostic advantages, the combined approach offers the opportunity for immediate therapeutic interventions. Detected abnormalities (e.g., adhesions, endometriosis, septum, polycystic ovaries) can often be treated or corrected during the same procedure, potentially obviating the need for multiple separate surgeries. This “see-and-treat” capability is especially beneficial in resource-limited settings or for patients preparing for assisted reproductive techniques such as in vitro fertilization (IVF), as it saves time, reduces cost, and may improve subsequent fertility by promptly addressing correctable lesions. Despite these advantages, the exact role of combined diagnostic hysterolaparoscopy in routine infertility evaluation, particularly for women with normal preliminary investigations or unexplained infertility, remains a subject of ongoing research and discussion. Some clinicians reserve laparoscopy for cases with specific indications (e.g., suspected tubal disease or endometriosis), whereas others advocate for a more liberal use of hysterolaparoscopy in evaluating infertility of unknown cause, given its high diagnostic yield. Local data on the utility of hysterolaparoscopy, especially in the Middle East and North Africa region, have been limited. Understanding the pattern of findings in our region and the potential improvement in pregnancy outcomes after operative interventions can guide practitioners in integrating hysterolaparoscopy into infertility management algorithms. Research question In women with primary or secondary infertility, what is the diagnostic value of combined laparoscopy and hysteroscopy for identifying pelvic and intrauterine causes of infertility? Furthermore, does performing therapeutic surgical procedures during the same session lead to a higher pregnancy rate within 1 year compared with diagnostic evaluation alone? Hypothesis We hypothesized that diagnostic hysterolaparoscopy would detect additional significant abnormalities not identified by prior HSG or by basic evaluation, thus providing more complete information for infertility etiology. Furthermore, we hypothesized that performing simultaneous corrective interventions—such as adhesiolysis, ovarian drilling, or hysteroscopic septum resection—during hysterolaparoscopy would improve subsequent fertility outcomes, as reflected by a higher 12-month pregnancy rate in patients receiving such interventions compared with those who had no abnormalities treated.

Study design and participants This study was a prospective, observational analysis of infertile women undergoing combined diagnostic laparoscopy and hysteroscopy (hysterolaparoscopy). We enrolled 43 women with a clinical diagnosis of infertility who presented to the Obstetrics and Gynecology clinics at Aleppo University Hospital of Obstetrics and Gynecology (Aleppo, Syria) over a period of 24 months from August 2022 to July 2024. Inclusion criteria were: females aged 18–42 years with either primary infertility (no prior pregnancies) or secondary infertility (failure to conceive again after a previous pregnancy, irrespective of outcome). All patients had an infertility duration of at least 1 year. We included women with unexplained infertility (normal ovulatory function, patent tubes on prior tests, and normal semen parameters) who had not conceived despite ovulation induction, as well as women with abnormal HSG findings (e.g., tubal blockage or uterine filling defects) requiring further evaluation. Couples with any major male factor infertility (e.g., severe oligozoospermia or azoospermia) were excluded from this study to focus on female-factor assessment. We also excluded women with uncorrected endocrinopathies that could impair fertility (such as uncontrolled thyroid dysfunction or hyperprolactinemia) until those conditions were treated. Each participant provided informed consent for the surgical procedures, and the institutional ethics committee approved the study protocol. Baseline demographic and clinical information was obtained from all patients, including age, body mass index (BMI), medical comorbidities, and relevant reproductive history. A detailed gynecologic history captured prior pelvic surgeries (such as cesarean deliveries or ovarian surgeries), as well as any prior assisted reproduction attempts or treatments. We also documented the basic infertility work-up results for each couple, including hormonal profiles (follicle-stimulating hormone, luteinizing hormone, thyroid function, prolactin levels) and semen analysis. Notably, 42 of the 43 (97.7%) women had undergone an HSG prior to surgery (one patient with uterine agenesis could not undergo HSG). In addition, the majority of patients (approximately 98%) had received some form of ovulation induction therapy (e.g., clomiphene citrate or letrozole±gonadotropins) in the course of their infertility management before referral for hysterolaparoscopy. Hysterolaparoscopy procedure All hysterolaparoscopy procedures were performed in the early follicular phase of the menstrual cycle (Day 6–11) to avoid disrupting an early pregnancy and to optimize visualization. Surgeries were carried out under general anesthesia in a lithotomy position, with antibiotic prophylaxis given according to hospital protocol. While the same two senior gynecologic surgeons supervised all cases, the procedures were not all performed by a single surgeon; a team of experienced attending gynecologists performed the surgeries, ensuring standardized technique. The laparoscopic portion was performed first. A small infra-umbilical incision was made, and pneumoperitoneum was established with carbon dioxide. A 10-mm diameter rigid laparoscope (Karl Storz, Tuttlingen, Germany) with a 0° angled telescope was introduced. A thorough inspection of the pelvis was conducted, evaluating the uterus, bilateral fallopian tubes, ovaries, uterine ligaments, cul-de-sac, and peritoneal surfaces. Any abnormal findings were recorded. Chromopertubation was then performed by injecting dilute methylene blue dye through a transcervical cannula (using a Leech–Wilkinson cannula) into the uterine cavity, while observing tubal ostia spillage laparoscopically. Tubal patency was thus assessed as follows: free spillage of dye from the fimbrial ends indicated open tubes, whereas no spill or delayed spill indicated tubal occlusion or functional impairment. We defined the laparoscopy as abnormal if any of the following findings were present: tubal obstruction (unilateral, bilateral, or delayed passage of dye); peritubal or peri-ovarian adhesions; pelvic adhesions (e.g., bowel or omental adhesion to uterus or adnexa); endometriosis (visual implants or ovarian endometriotic “chocolate” cysts); uterine surface fibroids; ovarian cysts (≥3cm); polycystic ovarian morphology; or other pelvic pathology. When such abnormalities were encountered, appropriate operative interventions were carried out during the same session whenever feasible. Adhesions were lysed using blunt and sharp dissection or electrocautery as needed to restore normal tubo-ovarian anatomy. Endometriotic implants on peritoneal surfaces were ablated or excised, and endometriomas were fenestrated or cystectomized. If polycystic ovaries were observed (enlarged ovaries with multiple small subcapsular follicles and a thick capsule), an ovarian drilling procedure was performed (typically three to four punctures in each ovary using electrocautery) to induce ovulation. Any visible superficial fibroids or ovarian benign cysts were removed if accessible. Hemostasis was achieved and copious irrigation performed before concluding the laparoscopy. Immediately following laparoscopy and in the same anesthetic session, a hysteroscopy was performed. A 5-mm rigid hysteroscope (Karl Storz) was introduced gently through the cervix (often after slight dilation with a Hegar dilator up to 5–7mm as needed). The uterine cavity was distended with normal saline 0.9% at an appropriate pressure using an irrigation pump or gravity. Systematic inspection of the endocervical canal; uterine cavity (fundus, anterior, posterior and lateral walls); endometrium; and tubal ostia was undertaken. Any intracavitary lesions were noted. Hysteroscopy was considered abnormal if any of the following were present: uterine septum or significant arcuate deformity, intrauterine synechiae (adhesions), submucosal fibroids, endometrial polyps, anomalous uterine shape (e.g., bicornuate or unicornuate uterus), endometrial hyperplasia or suspected neoplasm, or features of chronic endometritis (e.g., diffusely inflamed or ragged endometrium). Operative hysteroscopic interventions were performed concurrently for identified lesions when possible. For instance, small endometrial polyps were resected using hysteroscopic scissors or graspers. In cases of uterine septum, a hysteroscopic septum resection was done using microscissors, under laparoscopic guidance if needed to avoid perforation. Submucosal fibroids (Type 0 or I Myomas) were resected hysteroscopically if technically feasible (none of the fibroids in our series exceeded 2–3cm intracavitary component). After completing both endoscopic evaluations and necessary interventions, patients were monitored in recovery and discharged, typically the next day, with advice on routine analgesics. They were counseled to attempt spontaneous conception in subsequent cycles (or resume fertility treatment as appropriate) and to follow up in the infertility clinic. Outcome definitions and data collection Data were recorded for each patient on a structured form, including demographic variables and all findings from HSG, laparoscopy, and hysteroscopy. The specific operative interventions performed during hysterolaparoscopy were documented. We paid special attention to correlating the findings of preoperative HSG with the intraoperative findings. For instance, if HSG suggested a uterine anomaly or tubal block, we noted whether this was confirmed or refuted by hysteroscopic/laparoscopic observation (e.g., HSG diagnosis of bicornuate uterus vs. hysteroscopic finding of septate uterus). After the surgery, all patients were followed for at least 12 months to track fertility outcomes. Follow-up was conducted via outpatient visits or telephone contacts every 3 months to inquire about pregnancy status. The primary outcome of interest was the occurrence of a clinical pregnancy within 1 year of the hysterolaparoscopy. Pregnancy was defined as a positive serum β-hCG test with subsequent sonographic confirmation of an intrauterine gestational sac. We also noted whether any patients required assisted reproductive techniques (e.g., in vitro fertilization) during the follow-up period or if pregnancies were spontaneous. Patients who did not conceive within 1 year were offered further fertility treatment as indicated. Those lost to follow-up or who had not completed 12 months of follow-up by the time of analysis were accounted for in the outcomes. Statistical analysis All collected data were entered and analyzed using SPSS Statistics (version 18.0). Continuous variables such as age and duration of infertility were summarized as mean±standard deviation (SD) and range. Categorical variables (e.g., types of findings, intervention performed, pregnancy occurrence) were summarized as frequencies and percentages. The primary analysis was descriptive, given the observational nature and sample size. For comparisons of pregnancy rates between groups (intervention vs. no intervention), we used the chi-square test. A P-value <0.05 was considered the threshold for statistical significance in comparative analyses.

Baseline characteristics A total of 43 women met the inclusion criteria and underwent hysterolaparoscopy. Of these, 23 (53.5%) patients had primary infertility and 20 (46.5%) had secondary infertility. The ages ranged from 18 to 42 years, with a mean age of 30.8±6.3 years. Just over half (53.4%) of the participants were 30 years of age or younger, and 18.6% were aged 36 or above. The mean duration of infertility was 4.3±2.2 years (range 1–11 years). The mean BMI was 25.2±2.0kg/m2. No patient had any major chronic illness (such as uncontrolled diabetes or cardiac disease) that could affect fertility or anesthesia; all were in generally good health aside from their infertility. Regarding gynecologic and obstetric history, 4 (9.3%) women had a history of at least one previous pelvic surgery. This included three patients who had prior cesarean deliveries (one of whom was found to have a cesarean scar defect during hysteroscopy), and one patient who had undergone a laparoscopic ovarian cystectomy in the past. None of the patients had a history of myomectomy or tubal surgery before enrolling in the study. All couples had undergone a basic infertility evaluation. Hormonal profiles (follicular stimulating hormone (FSH), luteal hormone (LH), thyroid function, and prolactin) were within normal limits in all women, except for two cases of mild hyperprolactinemia which were corrected medically before the procedure. Semen analysis was normal in 35 out of 43 (81.4%) partners; 8 (18.6%) cases showed mild to moderate asthenozoospermia (subnormal sperm motility) but sufficient counts, and these couples were included because female factors were still investigated. Notably, 42 (97.7%) patients had received prior ovulation induction therapy (with clomiphene, letrozole, or gonadotropins) as part of their infertility management, reflecting an empirical treatment approach before proceeding to invasive evaluation. Only one patient (the woman with uterine agenesis discovered on laparoscopy) had never undergone ovulation induction. HSG had been performed in 42 out of 43 women (the remaining one had Müllerian agenesis making HSG impossible). HSG was completely normal (showing patent tubes and normal uterine cavity outline) in 18 (41.7%) cases. The most common abnormal HSG finding was tubal blockage. Unilateral proximal or distal tubal occlusion was reported in 6 (13.9%) women, and bilateral tubal occlusion in 9 (20.9%) women. In 4 (9.3%) patients, HSG suggested the presence of a uterine anomaly described as a bicornuate uterus (often accompanied by normal tube patency in those cases). Three (7.0%) cases showed a filling defect in the uterine cavity on HSG, raising suspicion of an intrauterine mass (such as a polyp or submucous fibroid). One patient’s HSG revealed an isthmocele (a pouch defect) at the site of a prior cesarean scar. Lastly, there was one (2.3%) patient in whom HSG could not be performed due to failure to cannulate the cervix and an incidental finding of uterine absence on exam; this patient was later confirmed to have uterine agenesis at laparoscopy. In summary, HSG was abnormal (indicating some pathology) in 24 out of the 42 patients who underwent the test (57.1%). Tubal occlusion (unilateral or bilateral) accounted for the majority of HSG abnormalities, as shown in Table 1. | HSG finding | Number of cases (n = 42) | Percentage | |---|---|---| | Normal (bilateral patency, normal cavity) | 18 | 41.7% | | Unilateral tubal obstruction | 6 | 13.9% | | Bilateral tubal obstruction | 9 | 20.9% | | Suspected bicornuate uterus (±normal tubes) | 4 | 9.3% | | Uterine cavity filling defect (suspected polyp/fibroid) | 3 | 7.0% | | Isthmocele (defect at prior C-section scar) | 1 | 2.3% | | Cannulation failure (uterine agenesis) | 1 | 2.3% | Laparoscopic findings All 43 women proceeded to diagnostic laparoscopy with chromopertubation as part of the hysterolaparoscopy. Eight (18.6%) patients had a completely normal pelvic examination at laparoscopy (with no visible abnormality and bilateral free spill of dye), as shown in Table 2. In the remaining 35 (81.4%) patients, one or more abnormal findings were identified. The most common laparoscopic finding was pelvic adhesions. Peritoneal adhesions involving pelvic structures were present in 20 (46.5%) women. These included adhesions between the tubes and ovaries (tubo-ovarian adhesions) or between pelvic organs and the peritoneal surfaces. In seven of these cases, adhesions were dense enough to cause bilateral tubal occlusion (the tubes were encased or blocked by adhesions), and in six cases adhesions were associated with unilateral tubal occlusion. Four cases of peri-adnexal adhesions were mild, allowing dye to eventually pass but with delayed tubal filling on chromopertubation (requiring repeated dye injection), indicating functional impairment of tubal patency. Adhesions were sometimes related to endometriosis or prior infection; for example, three cases had adhesions accompanied by visible endometriotic lesions on the ovaries or peritoneum. | Finding at laparoscopy | Number | Percentage | |---|---|---| | Normal pelvis | 8 | 18.6% | | Any abnormal finding | 35 | 81.4% | | Tubal patency defect (any) | 18 | 41.8% | | • Bilateral tubal occlusion | 7 | 16.3% | | • Unilateral tubal occlusion | 6 | 14.0% | | • Delayed/partial tubal spill | 4 | 9.3% | | • Hydrosalpinx (distal tubal dilation) | 3 | 6.9% | | Pelvic adhesions (any) | 20 | 46.5% | | • Dense tubo-ovarian or pelvic adhesions causing bilateral tubal blockage | 4 | 9.3% | | • Adhesions with unilateral tubal blockage | 6 | 14.0% | | • Adhesions with patent tubes (mild adhesions) | 10 | 23.3% | | Polycystic ovaries (PCO morphology) | 14 | 32.5% | | Endometriosis (any stage) | 6 | 13.9% | | • Ovarian endometrioma present | 3 | 7.0% | | Uterine fibroids | 3 | 6.9% | | Adenomyosis (suggested by morphology) | 1 | 2.3% | | Uterine agenesis (absent uterus) | 1 | 2.3% | Polycystic ovaries (PCO) were the second most frequent finding, observed in 14 (32.5%) patients. These ovaries were enlarged with a thick capsule and multiple subcapsular follicles, consistent with polycystic ovary syndrome morphology. Many of these cases had concurrent findings such as adhesions or tube blockage as well (reflecting that multiple factors can coexist in one patient). Tubal patency defects were noted in 18 (41.8%) patients during laparoscopy. This included seven cases of bilateral tubal obstruction (no spill of dye on either side) and six cases of unilateral tubal obstruction (no spill on one side, normal spill on the other). Additionally, hydrosalpinx (distal tubal dilatation with fluid) was observed in three (6.9%) patients—two unilateral and one bilateral—which corresponded to blocked tubes as well. In 4 (9.3%) cases, there was delayed passage of dye through one or both tubes, suggesting mild distal tubal adhesions or partial obstructions that slowed the chromopertubation spillage (these cases were counted as abnormal patency even though some spill eventually occurred). When considering definitive occlusion, our laparoscopy confirmed bilateral tubal occlusion in 16.3% of patients and unilateral occlusion in 14.0%. Notably, these findings did not always match the HSG results. Some patients with HSG-diagnosed tubal blocks were found to have patent tubes on laparoscopy (likely proximal spasm or false positives on HSG), whereas a few with normal HSG showed fimbrial adhesions or subtle block on laparoscopy. Endometriosis was identified in 6 (13.9%) patients. Four of these patients had visible pelvic endometriotic implants with mild to moderate pelvic adhesion formation (Stage I–II endometriosis by revised american fertility society (AFS) classification). Two patients had ovarian endometriomas (chocolate cysts), one bilateral and one unilateral, which were drained during surgery. Uterine fibroids were found in 3 (6.9%) patients on laparoscopy, these were subserosal or intramural fibroids palpable on the uterine surface. In one of these cases, multiple fibroids caused significant distortion of the uterine contour and were associated with a hydrosalpinx on one side and pelvic adhesions on the other side. One patient was noted to have features of adenomyosis (uterus enlarged and boggy with fibrous consistency) on laparoscopy, correlating with a severe dysmenorrhea history. Finally, one exceptional case was the woman whose HSG could not be done; laparoscopy in her revealed an absent uterus with rudimentary fallopian tubes, confirming Mayer–Rokitansky–Küster–Hauser syndrome (uterine agenesis). This explained her primary infertility (and primary amenorrhea). The laparoscopic evaluation demonstrated that a substantial proportion of patients had pelvic pathologies that could contribute to infertility, even in cases where prior evaluations were unremarkable. Notably, peritoneal adhesions and endometriosis—which HSG cannot detect—were found in several patients, underlining the added diagnostic value of laparoscopy. Additionally, in cases with abnormal HSG, laparoscopy provided clarification: for example, differentiating true tubal obstruction from flimsy adhesions or confirming whether a HSG-detected anomaly was indeed present. Overall, only about one in five patients had no pelvic abnormality, implying that the majority of this cohort had a diagnosable female-factor cause identified through hysterolaparoscopy. Hysteroscopic findings Out of the 43 patients, 42 underwent hysteroscopy (the one 18-year-old patient with uterine agenesis lacked a cavity to inspect). In 27 (62.8%) patients, the hysteroscopic examination was completely normal, showing a normal endocervical canal and uterine cavity with no structural abnormalities (in these cases, the endometrium appeared normal and both tubal ostia were seen without any intrauterine lesions), as shown in Table 3. The remaining 16 (37.2%) patients had one or more intrauterine pathologies identified. | Hysteroscopic finding | Number | Percentage | Age (years) | |---|---|---|---| | Normal hysteroscopy | 27 | 62.8% | Mean age 30 | | Any abnormal finding | 15 | 37.2% | – | | -Uterine septum (partial) | 4 | 9.3% | 24, 26, 27, 33 | | - Intrauterine adhesions | 2 | 4.6% | 26, 36 | | - Submucosal fibroid | 2 | 4.6% | 34, 39 | | - Endometrial polyp | 1 | 2.3% | 18 | | - Bicornuate uterus | 1 | 2.3% | 34 | | - (Isthmocele) | 1 | 2.3% | 29 | | - Irregular cavity shape | 1 | 2.3% | 42 | The most common abnormality detected via hysteroscopy was a uterine septum. A septate uterus was diagnosed in 4 (9.3%) cases (3 of the cases had primary infertility vs. 1 case with secondary complaint). These appeared as a fibrous or fibromuscular midline partition extending from the fundus toward the cervix. In our series, all identified septa were partial (none reaching the cervical os); two were large septa nearly dividing the cavity, and two were smaller (subseptate) but deemed clinically significant. Notably, several of these cases had been interpreted as bicornuate uterus on HSG, highlighting how direct visualization helped distinguish a septum (which has a single external fundus) from a true uterine duplication anomaly. Intrauterine adhesions (Synechiae, a.k.a. Asherman’s syndrome) were found in 2 (4.6%) patients (with secondary infertility). One of these had dense adhesions obliterating much of the cavity (likely post-infectious or post-abortion in etiology), which actually prevented the hysteroscope from fully entering the uterine cavity; this case was classified as a severe Asherman syndrome. The other case had moderate adhesions, with filmy bands in the uterine cavity. Two (4.6%) women (one had primary infertility and the other was secondary) were found to have submucosal fibroids on hysteroscopy. These appeared as smooth bulging masses distorting the cavity. One patient had multiple small myomas, one of which was submucosal and compressing the endometrium; the others were intramural. Endometrial polyp was identified in one (2.3%) primary infertile case as a focal soft red lesion arising from the endometrium. This polyp (about 1.5cm) was resected hysteroscopically. In one (2.3%) case, an isthmocele (cesarean scar defect) was visualized at the anterior lower uterine segment. This was seen as a pouch or sacculation at the site of a previous cesarean section scar, with fibrotic edges. It was associated with an abnormal uterine bleeding history in that patient. We performed a minor revision of the edges with the resectoscope to treat it. Finally, in one (2.3%) secondary infertile patient, the hysteroscope findings confirmed a bicornuate uterus—a divided cavity with two distinct ostia far apart and a fundal cleft, consistent with a true bicornuate anatomy. This patient had been suspected of having a congenital anomaly on HSG, and laparoscopy also revealed an external fundal indentation. No surgical correction was done for this anomaly during the procedure (as it would require a Strassman metroplasty, which was not indicated at this time). In summary, hysteroscopy yielded important additional information in about one-third of the patients, particularly identifying lesions (septum, synechiae, polyps) that were missed on prior evaluations. In several cases, hysteroscopic findings complemented laparoscopy by explaining HSG discrepancies (e.g., differentiating septate vs. bicornuate uterus). Combining the two modalities, hysterolaparoscopy provided a comprehensive assessment, for example, one patient with unexplained infertility was found to have mild endometriosis with adhesions on laparoscopy and simultaneously a small uterine septum on hysteroscopy—a dual diagnosis that might not have been uncovered without doing both procedures. Therapeutic interventions performed Out of the 43 women, 26 (60.5%) patients had one or more therapeutic interventions performed during the hysterolaparoscopy based on the findings. The remaining 17 (39.5%) patients had purely diagnostic procedures (no surgical intervention other than diagnostic inspection and chromopertubation), as shown in Table 4. Note that some patients underwent multiple interventions in combination. | Intervention category | Number | Percentage | |---|---|---| | No intervention (diagnostic only) | 17 | 39.5% | | Any therapeutic intervention | 26 | 60.5% | | – Ovarian drilling (for PCO) | 13 | 30.2% | | – Adhesiolysis (tubo-ovarian and/or pelvic) | 12 | 27.9% | | • Tubo-ovarian adhesions release | 7 | 16.3% | | • Other pelvic adhesions release | 5 | 11.6% | | – Hysteroscopic septum resection | 4 | 9.3% | | – Ovarian endometrioma cystectomy/coagulation | 2 | 4.6% | | – Myomectomy | 2 | 4.6% | | – Endometrial polypectomy | 1 | 2.3% | | – Isthmocele (C-scar defect) treatment | 1 | 2.3% | The most common intervention was ovarian drilling, which was done in 13 patients (30.2% of the total sample). All these patients had polycystic ovaries visualized at laparoscopy, and drilling was performed to enhance ovulatory potential. In a few of these cases, ovarian drilling was the sole intervention (if no other pathology was present). In others, drilling was combined with treatment of coexistent issues (e.g., adhesiolysis). The second most frequent surgical action was adhesiolysis. We distinguish between adhesions around tubes/ovaries and broader pelvic adhesions: 7 (16.3%) patients had lysis of tubo-ovarian adhesions specifically, and an additional 5 (11.6%) patients had removal of other significant pelvic adhesions (for instance, uterine to abdominal wall adhesions or bowel to pelvic sidewall). For simplicity, a total of 12 (27.9%) patients underwent some form of adhesiolysis (with or without other interventions). Hysteroscopic septum resection was performed in all 4 (9.3%) cases where a uterine septum was diagnosed. A combination of scissors and resectoscope loop was used to cut the septum under direct visualization until the cavity was unified (under laparoscopic confirmation of intact uterine serosa). Removal of endometriotic ovarian cysts (endometrioma excision) was done in 2 (4.6%) patients. These were the ovarian endometriomas identified at laparoscopy; both were fenestrated and the capsule excised or fulgurated. Myomectomy or fibroid removal was performed in 2 (4.6%) cases through abdominal surgery, while hysteroscopic polypectomy (removal of an endometrial polyp) was done in 1 (2.3%) case. Treatment of the isthmocele (cesarean scar defect) was performed in 1 (2.3%) case, by resecting fibrotic tissue around the defect hysteroscopically to promote healing. No intraoperative complications (such as hemorrhage requiring transfusion or visceral injuries) occurred during any of the procedures. All patients tolerated the combined surgery well. It is noteworthy that more than half of the infertile women in our study benefited from an operative procedure during the diagnostic endoscopy, underscoring the therapeutic potential of hysterolaparoscopy. The combination of procedures was tailored to each patient’s findings. For instance, among the 13 ovarian drilling cases, 4 patients also had simultaneous tubal or pelvic adhesions released, and 2 had both drilling and a hysteroscopic septum cut. This integrated approach addressed multiple infertility factors in one setting. Pregnancy outcomes Patients were followed up for a period of 1 year after the hysterolaparoscopy to assess fertility outcomes. Out of 43 women, 12 achieved a clinical pregnancy within 12 months post-surgery, yielding an overall cumulative pregnancy rate of 27.9% for the study cohort. Among the remaining participants, 17 women did not conceive in the 1-year follow-up period. Additionally, 10 women were lost to full follow-up or had not yet completed a year of follow-up at the time of data analysis (these were censored from pregnancy rate calculations). Four patients were entirely lost to follow-up (we were unable to contact them, possibly because they relocated). To evaluate the impact of the surgical interventions on fertility, we compared pregnancy rates between women who had therapeutic interventions during hysterolaparoscopy and those who had a purely diagnostic procedure. Of the 26 women who received one or more interventions, 10 (38.5%) conceived within a year. In contrast, among the 17 women who had no intervention (i.e., their hysterolaparoscopy was purely diagnostic), only 2 (11.8%) became pregnant. This difference suggests a positive association between performing active surgical treatment of identified abnormalities and the subsequent chance of conception (although with our sample size, the difference approached but did not reach statistical significance, P=0.07 by Chi-square). It is worth noting that the two pregnancies in the no-intervention group occurred in patients whose hysterolaparoscopy findings were normal; their infertility remained unexplained, and they eventually conceived spontaneously. Meanwhile, the majority of conceptions occurred in patients whose pathologies had been treated: for example, among those who became pregnant, interventions included ovarian drilling (in six cases), adhesiolysis (in seven cases), polypectomy (one case), endometrioma removal (one case), fibroid removal (one case), and isthmocele repair (one case)—some patients had multiple procedures. On the other hand, none of the four women who underwent only a hysteroscopic septum resection became pregnant during the follow-up, despite successful anatomical correction of the septum. In summary, the fertility outcome data indicate that hysterolaparoscopy was followed by pregnancy in about one-quarter of patients overall within 1 year. The likelihood of pregnancy appeared higher in those where the procedure was not only diagnostic but also corrective (especially for issues like polycystic ovaries and adhesions). This trend supports the concept that addressing peritoneal and intrauterine abnormalities at the time of diagnosis can improve reproductive prognosis.

In this prospective study of 43 infertile women, we found that combined diagnostic hysterolaparoscopy had a high diagnostic yield, revealing pelvic and/or intrauterine abnormalities in roughly four out of five patients. Importantly, more than half of the patients received immediate therapeutic interventions during the same procedure, and the cumulative pregnancy rate at 1-year post-surgery was ∼28%. Our findings underscore the value of hysterolaparoscopy as a one-stop diagnostic and therapeutic approach in female infertility, and they align with the growing body of literature advocating its use in comprehensive infertility evaluation. In the following discussion, we compare our results with those from other studies and explore possible reasons for similarities or differences in outcomes.[2–14] Diagnostic findings and comparison with prior studies Infertility type and patient profile The proportion of primary infertility in our cohort was 53.5%, with secondary infertility 46.5%. This mix lies roughly midway in the range reported by other hysterolaparoscopy series. Many studies have observed a predominance of primary infertility cases, for example, Karia et al. and Zeb and Annum reported primary infertility in over 70% of their patients.[7,14] In contrast, some series (particularly from regions with high rates of pelvic infections) found secondary infertility to be more common.[4,8] Our balanced ratio may reflect the general patient population in Syria, where secondary infertility due to factors like post-partum or post-abortal complications (leading to tubal damage) is a significant issue, but primary infertility remains slightly more frequent. The mean age in our study (∼30.8 years) is comparable to that in many other reports, where average ages typically range from the late 20s to early 30s. For instance, Sharma et al. reported a mean age of ∼30 years, and Hemalatha et al. (India) had a mean of around 29 years.[3,9] Some studies, however, included older women—Ugboaja et al. (Nigeria) had a mean age of 35.6 years, reflecting a subset of patients who pursue evaluation later or after prolonged infertility.[4] Age can influence findings; older patients have higher chances of endometriosis or fibroids, whereas younger patients might more often have tubal problems due to infections or congenital anomalies. Laparoscopy versus HSG One of the aims of hysterolaparoscopy is to assess whether laparoscopy plus hysteroscopy provides additional information beyond HSG in infertility workups. In our study, HSG had suggested abnormalities in 57% of cases, primarily tubal occlusions and a few uterine shape anomalies. Laparoscopic examination, however, identified pelvic pathologies in 81% of cases. This indicates that relying on HSG alone would have missed significant issues in many patients, particularly peritoneal factors like adhesions and endometriosis that do not show up on HSG. For example, 46.5% of our patients had pelvic adhesions on laparoscopy, whereas HSG was normal in some of these cases (likely because HSG cannot visualize peritoneal adhesions). Similarly, we found endometriosis in 13.9% of patients, most of whom had normal HSG results (and some had normal ultrasounds as well). These findings echo those of other investigators: a 2021 study by Varlas et al. and a 2025 study by Vinuth et al. concluded that hysterolaparoscopy is a gold standard for infertility evaluation precisely because it can diagnose and treat pelvic and uterine lesions in one session, offering superior accuracy over HSG alone.[1,2] In our series, one striking example was the differentiation of a uterine septum from a bicornuate uterus, HSG indicated a bicornuate anomaly in four cases, but hysteroscopy clarified that three of those were septate uteri (a distinction with important management implications, because septa can be removed hysteroscopically, whereas a true bicornuate uterus might require open surgery or be left alone). This reinforces that hysterolaparoscopy not only finds additional lesions, but can prevent misdiagnosis from HSG. Rate of normal findings We observed a normal laparoscopy in 18.6% of patients (meaning no pelvic pathology and normal dye test). This is broadly consistent with some other reports. For instance, Zeb and Annum. (Pakistan) found 18.5% of patients had normal laparoscopies, and Sharma et al. (India) reported 20% normal laparoscopies, very close to our figure.[3,7] However, other studies have reported both lower and higher rates of normal findings. Puri et al. (India)[8] reported 0% normal laparoscopy in their series (i.e., every patient had some pathology), likely reflecting a highly selected population. On the other hand, some authors have found a much higher proportion of normal laparoscopies: Mehta et al. (India)[5] noted 66% normal laparoscopies, and Karia et al. (India)[14] reported ∼60% with no pelvic findings. Kabadi and Harsha (India)[12] had 42% normal laps. These wide variations may be due to differences in inclusion criteria (unexplained infertility vs. all-comers), sample sizes, or the threshold for calling subtle findings “abnormal.” It might also reflect epidemiologic differences: our region might have a higher prevalence of pelvic infections leading to pathology, whereas in some tertiary centers evaluating IVF candidates, many patients might truly have unexplained infertility with normal pelvis. Surgeon experience and thoroughness in detecting minor abnormalities can also play a role. Our relatively low normal findings rate suggests that our patient selection (unexplained infertility and those with abnormal HSG) was enriched for underlying pathology, which is expected. Pelvic adhesions Nearly half (46.5%) of our patients had pelvic adhesions on laparoscopy, making it the most common finding. This is a high percentage compared to many other studies. For example, Sharma et al. found adhesions in only 6.6%, Mehta et al. reported 6.9%, and Hemalatha et al. ∼20%.[3,5,9] However, some studies in environments with higher rates of pelvic inflammatory disease (PID) have reported adhesion rates closer to ours. Ugboaja et al. observed pelvic adhesions in 39.5% of cases.[4] Our high adhesion rate may be attributable to undiagnosed or subclinical pelvic infections in our population (e.g., genitourinary tuberculosis or post-partum infections), as well as the inclusion of post-surgical cases (adhesions from previous surgeries). It is notable that in an Ethiopian study of hysteroscopy (Teka et al.), intrauterine adhesions were extremely common,[13] hinting at widespread infection-related infertility factors in that region. In our study, pelvic adhesions often coexisted with other pathologies (endometriosis in three cases, hydrosalpinx in some, etc.), indicating that multiple insults (infection, endometriosis) can jointly contribute to infertility. The clinical implication is that any history suggestive of PID or previous pelvic surgery should lower the threshold for laparoscopy, as HSG might only show tubal blockage but not reveal the extent of adhesions, which only laparoscopy can confirm and treat. Tubal occlusion Laparoscopic chromopertubation in our series showed tubal occlusion (unilateral or bilateral) in 30.2% of patients. This figure is within the range reported elsewhere, though on the higher side. Studies have reported tubal factor prevalence anywhere from about 7% up to ∼56%. For instance, Kabadi and Harsha noted tubal blocks in only 7.4%, while Ugboaja et al. reported it in 56.5% of cases[4,12] (the latter reflecting a high-PID population in Nigeria). Our result is comparable to Mehta et al. (20% tubal blocks) and Karia et al. (20%), and a bit higher than Sharma et al. (22.6%).[5,14] We found bilateral occlusion more often than unilateral (16.3% vs. 14%), which was similar to some studies like Anusha et al.[15] (India) who also noted bilateral blocks were more common. In contrast, Hemalatha et al. found unilateral block more frequent in their series.[9] The relative predominance of bilateral blockage in our patients might again point to infection-driven damage (e.g., tuberculosis or gonococcal infection often affects both tubes). It also correlates with our high adhesion findings. A concern with bilateral tubal occlusion is the need for advanced fertility treatment (IVF); identifying this definitively via laparoscopy can expedite appropriate referral to IVF if needed, or conversely, identify if an HSG “block” was spurious (as happened in some of our cases where laparoscopy showed patent tubes despite prior HSG reading of blockage). Polycystic ovaries We found PCO morphology in 32.5% of patients, reflecting the subset with anovulatory infertility contributing to their problems. Other studies have reported PCO rates ranging from ∼14% up to nearly 50%. Sharma et al. had 22.6%, Kabadi 13.8%, Zeb ∼19%, whereas Avula et al.[6] (India) reported 48%. Our value is in between. The variability likely depends on how many patients with known PCOS are included; our inclusion of those who failed ovulation induction means we did have a fair share of PCOS cases. The good news is that PCO is treatable (we performed drilling in these cases), which could improve their fertility. Endometriosis Endometriosis was diagnosed in 13.9% of our cohort. This is consistent with a general expectation that 10–20% of infertile women have endometriosis. Our figure is similar to Karia et al. (15%) and Hemalatha et al. (about 20%).[9,14] Some studies have seen higher rates: Sapneswar et al. (India) found endometriosis in 22.5%, Ravikanth and Sullia reported 29.1%,[10,11] whereas others reported lower (Ugboaja 8.2%, Anusha 10%).[4,15] These differences might be due to the criteria for diagnosing minimal endometriosis—some surgeons may only count obvious lesions, leading to underestimation. In our series, endometriosis often co-presented with other factors (adhesions, cysts). We treated what we found, but some minimal endometriosis might have been simply documented and not clinically significant. It is worth noting that in cases of unexplained infertility, even mild endometriosis could affect fertility, and many experts advocate laparoscopy precisely to rule this out or treat it if present. Hysteroscopy findings In our study, hysteroscopy was normal in 62.8% and abnormal in 37.2%. A normal hysteroscopic examination in roughly 50–80% of cases is commonly reported. Our result is in line with most literature, where more than half of infertile women have no intrauterine pathology. For instance, Mehta et al., Anusha et al., and Hemalatha et al. found normal hysteroscopy in more than 80% of cases[5,9,15] indicating relatively few uterine lesions in their population. Interestingly, Ugboaja et al. (with an older cohort)[4] had only ∼38% normal hysteroscopy, meaning 62% abnormal, likely reflecting more fibroids or adhesions in an older population. The most common uterine cavity abnormality we detected was a septate uterus (9.3%). This is a congenital anomaly relevant to infertility and recurrent pregnancy loss. Our septum rate is slightly high but not unusual; Karia et al. reported a 12% incidence of septum (including arcuate). Mehta et al. saw septa in ∼9.6%, very close to ours.[4,5,12] Another study (Kabadi et al.) found uterine malformations (septum, bicornuate, etc.) in 13.8%, which matches our combined rate of septum and bicornuate (∼11.6%). Therefore, our findings confirm that congenital Müllerian anomalies are present in roughly 1 out of 10 infertile women, and diagnosing them is crucial as some (septum) are treatable. Intrauterine adhesions were found in 4.6% of our patients. Elsewhere, reports vary widely: Sharma et al. found 6.6% with adhesions, which is a bit higher. However, studies from Africa have reported alarmingly high rates; for example, in the Ethiopian hysteroscopy study by Teka et al.,[13] intrauterine adhesions were noted in 41–48% of cases, a reflection of the high incidence of untreated infections or pregnancy-related curettage complications in that setting. Our lower rate might indicate comparatively fewer cases of endometrial damage in our group. Nonetheless, intrauterine adhesions, when present, severely impact fertility, and identifying them via hysteroscopy allows prompt treatment. We detected submucosal fibroids in about 4.6% and endometrial polyps in 2.3%. These rates are on the lower side compared to some literature. Ugboaja et al. found polyps in 20% and fibroids in 9%, possibly due to older age and more secondary infertility (fibroids tend to come with age). Our patients’ average age being 30 might explain fewer fibroids. Mehta et al. (with a large sample of 300) reported polyps in ∼5.3% and submucosal fibroids in ∼2.7%, quite comparable to ours. Fibroids that affect the cavity (submucous or large intramurals) can impair implantation, so while our incidence was modest, resecting those found might help those patients. One unique finding in our series was the cesarean scar defect (isthmocele) in 2.3%. This is not commonly reported in older studies, but it is increasingly recognized as a cause of secondary infertility or miscarriage. Repairing it hysteroscopically in our case was an attempt to improve uterine integrity for implantation. Overall, the spectrum of hysteroscopic abnormalities in our study highlights that while the majority of infertile women have a normal uterine cavity, a significant minority have lesions that could affect fertility (septum, adhesions, fibroids, polyps). These lesions are often missed on routine imaging; for example, ultrasound might not detect a small septum or mild adhesions. HSG can miss polyps or misclassify anomalies. Therefore, hysteroscopy adds definite value, a finding that resonates with other studies where adding hysteroscopy changed management in a portion of patients. Therapeutic impact and outcomes One of the strengths of hysterolaparoscopy is the ability to treat identified abnormalities during the same procedure. In our study, 60.5% of patients benefited from therapeutic interventions. This rate is higher than some prior reports, likely because we proactively treated every finding possible. For comparison, Sharma et al. reported interventions in 26.6% of patients, which is much lower. Kabadi and Harsha reported interventions in about 30% of their cases, including drilling in ∼14%, adhesiolysis 16%, septum resection ∼6%, myomectomy ∼5%, and polypectomy ∼5%. Interestingly, our proportions are higher in each category (drilling 30%, adhesiolysis 28%, etc.), reflecting our higher finding rates as well. Karia et al. also did interventions in a smaller fraction of their patients (e.g., drilling in 8.6%, adhesiolysis 8.6%). The differences likely arise from varying patient profiles (fewer poly cystic ovary syndrome (PCOS) or fewer adhesions in those cohorts) and practice patterns. In settings where IVF is readily available, some clinicians might opt to refer to IVF rather than perform extensive surgeries; in our setting, doing these interventions could potentially spare patients the need for IVF, a consideration given resource constraints. The immediate pregnancy outcome is a critical measure of the effectiveness of interventions. Our overall pregnancy rate of 27.9% within 1-year falls in line with reported post-hysterolaparoscopy pregnancy rates, which generally range from ∼20 to 45%. For instance, Puri et al.[8] observed a 28.2% pregnancy rate after combined endoscopic evaluation, almost identical to ours. Other studies have reported rates like 21% (in some Indian series) up to 45.7% in others.[1] Such variability can result from differences in follow-up duration, use of post-surgery fertility treatments, and patient factors (age, male factors, etc.). Our rate near 28% is encouraging given that many patients had significant pathology; it suggests that addressing those pathologies improved their fertility relative to if we had not intervened. Of course, not all patients conceive even after fixing issues; some remain unexplained or have persistent problems like diminished ovarian reserve that surgery cannot fix. We found that the subset of women who had therapeutic interventions had a notably higher conception rate (38.5%) than those who had no interventions (11.8%). This trend strongly suggests that treating the abnormalities (such as drilling PCO, removing adhesions, etc.) was beneficial. It is important to temper these positive findings with the understanding that some infertility causes cannot be resolved by endoscopy. For example, in cases of ovarian failure or severe male factor, hysterolaparoscopy offers little help. In our cohort, we excluded severe male factor and did not have any obvious ovarian failure cases (most were young). Thus, our patient selection was one that could benefit from surgical intervention, which might partly explain our decent pregnancy rate. Strengths and limitations Strengths This study provides a thorough, combined assessment of both pelvic and intrauterine factors in infertility through hysterolaparoscopy, all within a single procedure. The prospective design ensured systematic data collection on each aspect (HSG, laparoscopy, hysteroscopy, follow-up outcomes). We demonstrated the practical benefit of the “see-and-treat” approach in a real-world setting, showing that many patients had concurrent therapeutic interventions that potentially improved fertility. The study adds to the limited data from the Middle Eastern region on infertility evaluation and management, potentially guiding local practice. By including patients with unexplained infertility and abnormal HSG findings, our results underscore how often standard evaluations can miss significant pathology that hysterolaparoscopy can detect and correct. An additional strength is the completeness of our surgical intervention data—the procedures were performed by experienced surgeons, and we were able to safely address multiple pathologies in one session for most patients, highlighting the efficiency of the approach.

The sample size was modest, involving 43 patients, which may limit generalizability and the statistical strength of comparisons. The study lacked a control group (e.g., infertile women managed without hysterolaparoscopy or with delayed hysterolaparoscopy), so improvements in pregnancy rates are inferred rather than proven by a randomized comparison. Some patients were lost to follow-up or had incomplete follow-up, which could introduce bias in the reported pregnancy rate (we assumed non-followed patients did not conceive, which might under- or over-estimate the true success rate). The follow-up period of 1 year may be insufficient to capture all eventual pregnancies, especially in those who pursued further treatments; a longer follow-up could better assess the long-term benefit of the interventions. Moreover, the study was conducted at a single tertiary referral center, which might receive a higher complexity case mix; thus, our high incidence of abnormalities might not reflect a general primary care population of infertile couples. Finally, while we identified many pathologies, we did not measure certain subtle factors like luteal phase insufficiency, subclinical endometritis (aside from visual inspection), or perform routine endometrial biopsies—these could be topics for future research to complement the hysterolaparoscopy findings.

Our study reinforces that hysterolaparoscopy is a safe and powerful method for comprehensive infertility evaluation. It offers the dual advantage of diagnosing elusive causes of infertility and treating them in the same sitting, thereby improving patients’ chances of achieving the ultimate goal—a successful pregnancy. We recommend that combined laparoscopy and hysteroscopy be considered early in the evaluation of women with unexplained infertility or discrepant test results, especially before embarking on assisted reproductive techniques. Future research with larger samples and randomized designs would be valuable to further quantify the fertility benefit of specific interventions during hysterolaparoscopy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Adhesiolysis; hysteroscopy; hysterolaparoscopy; infertility; laparoscopy; ovarian drilling; pregnancy outcomes