Laparoscopic evaluation of tubal factors in infertility patients a cross sectional study

Introduction: Infertility affects a significant proportion of reproductive -age women , with tubal factors contributing to 25 -35% of cases globally. Laparoscopy remains the gold standard for evaluation of tubal patency, pelvic adhesions, and associated pathology , offering both diagnostic and therapeutic advantages. Early laparoscopic assessment is particularly valuable in settings with high rates of pelvic inflammatory disease, endometriosis, and previous pelvic surgery. Aims and Objectives: This study aimed to evaluate tubal factors contributing to infertility using diagnostic laparoscopy and to assess the prevalence and pattern of tubal and associated pelvic pathology in women presenting with primary and secondary infertility.

This was a cross -sectional observational study conducted in the Department of Obstetrics and Gynaecology , KPC Medical College & Hospital , Kolkata, West Bengal. The study was carried out over a period of one year (July 2019 to June 2021) and included a total of 88 infertile women undergoing evaluation for tubal and ovarian factors as part of infertility work-up.

Among 88 infertility patients , most were aged 25 -30 years (41%) with infert ility <5 years (46%) and normal BMI (87%). Menstrual irregularity was seen in 53% , hirsutism in 11% , and hormonal abnormalities were uncommon. Ultrasound showed polycystic ovaries in 42% , ovarian cysts in 5% , and hydrosalpinx in 2%. Laparoscopy revealed no rmal tubes in 72%, blocked tubes in 17%, adhesions in 22%, and endometriosis in 4%. Ovarian drilling (43%) and cystectomy (30%) were the most frequent interventions.

Laparoscopic evaluation plays a critical role in identifying tubal and associa ted pelvic pathologies contributing to infertility. A significant proportion of patients demonstrated tubal factor involvement, highlighting the importance of early laparoscopy in guiding appropriate management. Incorporating laparoscopy into infertility w ork-ups enhances diagnostic accuracy , aids therapeutic planning, and may improve reproductive outcomes.

Infertility, laparoscopy, tubal factor , chromopertubation, pelvic adhesions , hydrosalpinx, endometriosis

Infertility is a glob al public health concern affecting millions of couples and carries significant medical, psychological, social, and economic consequences. The World Health Organization (WHO) defines infertility as the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse , and recent estimates indicate that nearly one in six individuals worldwide will experience infertility at some point in their lives [1]. Female infertility contributes to almost half of all infertility cases, with tubal factor infertility remaining one of the most important etiological categories, especially in low-and middle-income countries [2]. The fallopian tubes play a fundamental role in human reproduction by facilitating oocyte capture, sperm transport, fertilization, and early embryonic development before implantation in the uterus. Any disruption to these processes due to structural or functional tubal pathology can therefore significantly impair fertility. Globally, tubal factors account for approximately 25-35% of female infertility, although the prevalence tends to be higher in regions with increased rates of sexually transmitted infections (STIs) , pelvic inflammatory disease (PID) , and genital tuberculosis [3]. The most common causes of tubal da mage include previous pelvic infections , endometriosis, prior pelvic or abdominal surgery , puerperal sepsis, post-abortal infections, and complications associated with intrauterine devices (IUDs) [4]. These conditions can result in tubal occlusion , hydrosalpinx, fimbrial damage , or peritubal adhesions , ultimately interfering with fertilization and embryo transport. International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 373 ~ Accurate evaluation of tubal patency is therefore a key component of infertility assessment. Various diagnostic methods are available , including hysterosalpingography (HSG) , saline infusion sonography (SIS), hysterosalpingo-contrast sonography (HyCoSy), and laparoscopy. HSG is commonly used as a first - line screening tool; however , it has limitations , such as false - positive findings from tubal sp asm and inability to reliably evaluate peritubal adhesions or subtle pelvic pathology [5]. While SIS and HyCoSy have emerged as valuable noninvasive alternatives offering improved patient comfort and avoidance of radiation exposure, they still cannot repla ce the comprehensive pelvic assessment that laparoscopy provides [6]. Diagnostic laparoscopy is widely regarded as the gold standard for evaluating tubal factor infertility because it allows real -time visualization of pelvic anatomy , direct assessment of t ubal patency through chromopertubation , and identification of associated pelvic abnormalities such as endometriosis , adhesions, and inflammatory sequelae [7]. Additionally , laparoscopy serves as both a diagnostic and therapeutic tool. Procedures such as ad hesiolysis, endometriotic lesion excision , and tubal reconstructive surgery can be performed during the same session, offering improved fertility outcomes in carefully selected patients [8]. Patterns of tubal pathology often vary between women with primary and secondary infertility. While primary infertility may be associated with congenital anomalies or unexplained causes , secondary infertility is more frequently linked to acquired tubal damage from previous pregnancies , obstetric complications , or pelvic infections. Consequently, the prevalence of tubal disease tends to be higher in women with secondary infertility , particularly in settings where reproductive tract infections are common and healthcare access is limited [9]. In many South Asian cultures , infertility is associated with significant stigma , emotional stress , and marital strain , making prompt evaluation and timely management essential for improving both clinical outcomes and psychosocial well-being. In the Indian context , tubal factor infertilit y contributes substantially to the overall infertility burden. High rates of untreated STIs , genital tuberculosis , delayed presentation , and limited awareness of reproductive health amplify the risk of tubal damage. Although noninvasive screening modalitie s such as HSG and HyCoSy play an important initial role , diagnostic laparoscopy remains indispensable in cases with suspected pelvic pathology, inconclusive imaging findings , or failed prior treatments [10]. Furthermore , institution-specific data on the prevalence and pattern of tubal abnormalities are vital for improving infertility services , tailoring therapeutic strategies , and guiding evidence-based clinical decision-making. This study aimed to evaluate tubal factors contributing to infertility using diagnostic laparoscopy and to assess the prevalence and pattern of tubal and associated pelvic pathology in women presenting with primary and secondary infertility.

Study design: It was a cross-sectional observational study. Place of study: Department of Obstetrics and Gynaecology , KPC Medical College & Hospital , Kolkata, West Bengal 700032. Period of study: 1 Year. (July 2019 to June 2021) Study Variables Age, Duration of Infertility (years) , Menstrual Cycle , Symptomatic Status, BMI, Hirsutism, Serum Prolactin, Thyroid Status, Intervention etc. Sample size: 88 Infertile women undergoing evaluation for tubal and ovarian factors. Inclusion Criteria  Women aged 20 -40 years presenting with primary or secondary infertility.  Patients under going diagnostic laparoscopy as part of infertility evaluation.  Patients with at least 12 months of inability to conceive despite regular unprotected intercourse.  Women willing to provide informed consent for participation. Exclusion Criteria  Women with known uterine or ovarian malignancy.  Patients with contraindications to laparoscopy or general anesthesia.  Women with acute pelvic infection at the time of evaluation.  Patients previously treated with tubal sterilization or tubal ligation.  Pregnant women or those with confirmed early pregnancy. Statistical Analysis: Data were entered into Microsoft Excel and analyzed using SPSS software version 25.0. Descriptive statistics such as mean , standard deviation , frequencies, and percentages were used to summari ze demographic variables and laparoscopic findings. Categorical variables were compared using the chi -square test or Fisher’s exact test as appropriate , and a p-value <0.05 was considered statistically significant.

Table 1: Demographic and Clinical Characteristics of Study Participants Number (n) Percentage (%) Age Group (years) ≤ 20 7 8% 20-25 34 39% 25-30 36 41% 31-40 11 12% Total 88 100% Duration of Infertility (years) < 5 40 46% 6-10 38 43% 11-20 10 11% Total 88 100% Menstrual Cycle Regular 41 47% Irregular 47 53% Total 88 100% Symptomatic Status Symptomatic 14 16% Asymptomatic 74 84% Total 88 100% International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 374 ~ Table 2: Clinical Characteristics, Hormonal Profile, and Laparoscopic Interventions of Study Participants Number (n) Percentage (%) BMI (kg/m²) < 18 7 8% 18-25 77 87% 25-30 4 5% Total 88 100% Hirsutism Present 10 11% Absent 78 89% Total 88 100% Serum Prolactin Normal 84 95% Raised 4 5% Total 88 100% Thyroid Status Hypothyroid 2 2% Normal 86 98% Total 88 100% Intervention Ovarian Drilling 38 43% Cystectomy 26 30% Cystectomy & Cyst Aspiration 1 1% Cystectomy & Adhesiolysis 1 1% Cyst Aspiration 4 4% Adhesiolysis 4 5% Bilateral Salpingectomy 1 1% Total 88 100% Table 3: Distribution of BMI Across Age , Duration of Infertility , and Hirsutism Among Study Participants BMI < 18 BMI 18-25 BMI 25-30 Total (n) Age Group (years) ≤ 20 3 5 0 8 20-30 4 61 4 69 31-40 0 10 1 11 Total 7 76 5 88 Duration of Infertility (years) < 5 6 35 2 43 6-10 2 32 0 34 11-20 0 8 3 11 Total 8 75 5 88 Hirsutism Present 0 8 2 10 Absent 8 67 3 78 Total 8 75 5 88 Table 4: Laparoscopic and Ultrasound Findings in Infertility Patients Finding Number (n) Percentage (%) Normal 45 51% Polycystic Ovary 37 42% Ovarian Cyst 4 5% Hydrosalpinx 2 2% Total 88 100% Normal 63 72% Absent tube 1 1% Peritubal adhesions 5 6% Hydrosalpinx 4 4% Blocked tubes (total) 15 17% Unilateral block 5 6% Bilateral block 10 11% Cornual block 1 2% Ampullary block 0 0% Total 88 100% Adhesions 5 6% Obliterated 1 1% Normal 82 93% Total 88 100% No Adhesions 69 78% Pelvic Adhesions 5 6% Peritubal Adhesions 5 6% Perihepatic Adhesions 4 4% Total 88 100% Endometriosis (overall) 4 4% Chocolate Cyst 4 4% Endometriotic Deposits 0 0% Total 88 100% Endometriosis 4 4% Chocolate Cyst 4 4% Endometriotic Deposits 0 0% Total Participants 88 100% Fig 1: Distribution of Gram-Positive Cocci (GPC) Isolates International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 375 ~ Fig 2: Distribution of Gram-Negative Bacteria (GNB) Isolates The study included 88 participants, with the majority aged 25-30 years (41%) , followed by 20 -25 years (39%) , ≤20 years (8%) , and 31 -40 years (12%). Most participants had a duration of infertility of less than 5 years (46%) , followed by 6 -10 years (43%) and 11-20 years (11%). Menstrual cycles were regular in 47% of participants and irregular in 53%. Regarding symptomatic status, only 16% of participants were symptomatic, while the remaining 84% were asymptomatic. Among the 88 participants , the majority had a normal BMI (18 - 25 kg/m² , 87%), while 8% were underweight and 5% overweight. Hirsutism was present in 11% of participants and absent in 89%. Serum prolactin was normal in 95% and raised in 5% of participants. Thyroid dysfunction was uncommon , with only 2% being hypothyroid. Regarding laparoscopic interventions, ovarian drilling was the most frequent procedure (43%), followed by cystectomy (30%) , cyst aspiration (4%) , adhesiolysis (5%), cystectomy combined with cyst aspiration or adhesiolysis (1% each), and bilateral salpingectomy (1%). BMI distribution among participants showed that most had a normal BMI (18 -25 kg/m²), with few underweight (<18 kg/m²) or overweight (25 -30 kg/m²). When stratified by age , participants aged 20 -30 years predominantly had normal BMI (61/69), whereas younger (≤20 years) and older (31 -40 years) participants showed more variation. Regarding duration of infertility, normal BMI was most common across all groups , with underweight and overweight participants being fewer. Among participants with hirsu tism, the majority had normal BMI (8/10) , and none were underweight , while overweight participants comprised 20% (2/10) of those with hirsutism. Ultrasound findings showed that 51% of participants had normal ovaries, while 42% had polycystic ovaries , 5% ha d ovarian cysts, and 2% had hydrosalpinx. Laparoscopic evaluation revealed normal tubes in 72% of participants , with 17% having blocked tubes, including 6% unilateral and 11% bilateral blocks; other abnormalities included absent tubes (1%) , peritubal adhesions (6%), hydrosalpinx (4%), cornual block (2%), and no ampullary block. Adhesion assessment showed 6% had adhesions, 1% were obliterated , and 93% were normal. Further distribution indicated that 78% had no adhesions , while pelvic, peritubal, and perihepa tic adhesions were present in 6% , 6%, and 4% , respectively. Endometriosis was identified in 4% of participants, all of whom had chocolate cysts , while no endometriotic deposits were seen.

The present study included 88 infertile women, with the majority aged 25 -30 years (41%) , followed by 20 -25 years (39%) , ≤20 years (8%) , and 31 -40 years (12%) , indicating that infertility evaluation predominantly occurs in women of reproductive age , consistent with global and Indian trends [1, 2]. Most participa nts had a duration of infertility of less than 5 years (46%) , followed by 6 -10 years (43%) and 11 -20 years (11%) , highlighting that couples typically seek medical attention within a few years of conception difficulty [3]. Menstrual irregularities were obse rved in 53% of participants , with 47% reporting regular cycles. This aligns with prior studies suggesting that menstrual dysfunction is a common finding in women with tubal or ovarian etiologies of infertility [4]. Symptomatic presentation was low (16%) , with the majority (84%) being asymptomatic , reflecting the silent nature of many tubal and pelvic pathologies [5]. Regarding anthropometric measures , the majority of participants had a normal BMI (18 -25 kg/m² , 87%), with a smaller proportion underweight (8%) or overweight (5%). Hirsutism was observed in 11%, and serum prolactin was raised in only 5% , suggesting that endocrine disorders , while important, were not the primary contributing factor in most cases. Thyroid dysfunction was uncommon (2%) , consistent with previous observations in Indian cohorts where endocrine abnormalities contributed minimally to infertility [6, 7]. Ultrasound findings revealed that 51% of women had normal ovaries , 42% had polycystic ovaries (PCO), 5% had ovarian cysts , and 2% had hy drosalpinx. These findings corroborate earlier Indian studies reporting a high prevalence of PCO among infertile women , reflecting the significant burden of polycystic ovary syndrome (PCOS) in reproductive-aged women [8]. Laparoscopic evaluation demonstrated normal tubes in 72% of participants , whereas 17% had tubal blockages , with unilateral block in 6% and bilateral block in 11%. Other abnormalities included absent tubes (1%) , International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 376 ~ peritubal adhesions (6%), hydrosalpinx (4%), and cornual block (2%). These results are consistent with studies in India reporting tubal factor infertility as a major contributor , accounting for approximately 20 -30% of female infertility cases [9]. Adhesion assessment showed that 6% had adhesions , 1% were obliterated, and 93% were nor mal. Specifically, 78% of participants had no adhesions, while pelvic , peritubal, and perihepatic adhesions were present in 6% , 6%, and 4% , respectively. Endometriosis was identified in 4% of participants , all of whom had chocolate cysts, whereas no endome triotic deposits were seen. This prevalence is comparable to previous studies from India , which report endometriosis in 3-5% of women undergoing laparoscopy for infertility [10]. Tubal pathology, PCO, and pelvic adhesions remain significant contributors to female infertility. Laparoscopy proved crucial for the accurate assessment of tubal patency and pelvic pathology , often identifying asymptomatic conditions that could be missed by noninvasive imaging modalities like hysterosalpingography or ultrasound [5, 6]. Moreover, the distribution of BMI, hirsutism, and endocrine parameters suggests that while metabolic and hormonal factors are relevant, anatomical abnormalities remain a dominant cause in this cohort.

In conclusion , this study highlights t hat tubal factor infertility , polycystic ovarian changes , and pelvic adhesions are the predominant contributors to female infertility in the studied population. Laparoscopic evaluation proved to be a valuable diagnostic and therapeutic tool , enabling accurate assessment of tubal patency, ovarian morphology, and pelvic pathology , even in asymptomatic women. Early identification and appropriate interventions, such as ovarian drilling , cystectomy, or adhesiolysis, can improve fertility outcomes and guide individualized management strategies , emphasizing the continued relevance of laparoscopy in comprehensive infertility care. Conflict of Interest Not available Financial Support Not available

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