Experience with Hysterolaparoscopy in a Fertility Center in Southeastern Nigeria: A 5-Year Retrospective Review

We aimed to evaluate the use of laparoscopy and dye test with hysteroscopy in the management of infertile women in a private fertility center in southeast, Nigeria.

This is a retrospective review of 214 infertile women who underwent hysterolaparoscopies over a five year period (January 2016 to December 2020) in a private fertility center in southeast Nigeria. The biodata, duration of infertility, indications, and pathological findings were obtained. Analysis was carried out using IBM SPSS statistics version 20. Frequency tables, simple percentages, and component bar charts were used for data representation.

The prevalence of secondary and primary infertility was 4.4% and 3.9%, respectively, with a mean infertility duration of 5.8 (95% CI 5.2–6.3) years. The commonest abnormal laparoscopic finding was pelvic adhesion (123, 57.3%), followed by tubal occlusion (93, 43.5%); More than one-fourth of tubal occlusion cases were bilateral and occurred more at the proximal portion of the tubes. The prevalence of endometriosis and endometrioma were 5.6% (n = 11) and 1.4% (n = 3), respectively. The commonest uterine pathology was uterine synechiae (47, 22.0%), followed by submucus uterine leiomyomata (27, 12.6%). Endometrial polyp was diagnosed in less than one-tenth (16, 7.5%) of the women. The commonest interventions performed were adhesiolysis (30, 14.3%) and polypectomy (11, 5.1%). There was no complication observed.

Many abnormal findings on hysterolaparoscopy were observed among infertile women in Southeastern Nigeria. These findings indicate a need to incorporate hysterolaparoscopy in the routine evaluation of female infertility in Nigeria.

Infertility is a global problem affecting about 5%–8% of couples, with higher rates in sub-Saharan Africa.[1] It is a cause of a serious psychological problem for an unfortunate couple who is not able to fulfill their fertility wishes.[2] This is especially so in Africa where a great desire for a large family still prevails.[3] In Africa, secondary infertility is the most common cause of female factor infertility, resulting from infective processes such as sexually transmitted infection, a post-abortal complication from unsafe abortion, and puerperal sepsis affecting and damaging the genital tract.[4,5] Different approaches have been adopted by gynecologists for proper evaluation of a woman in whom genital tract pathology is suspected as the cause of. These approaches include hysterosalpingography (HSG), laparoscopy and dye test, hysteroscopy, ultrasonography, and hysterocontrast sonogram. The laparoscopy and dye test is regarded as the gold standard in the primary investigation for tuboperitoneal factor infertility when compared to the traditional HSG because of its high diagnostic accuracy compared to that of HSG.[6,7] Laparoscopy can assist in the diagnosis of tubal pathologies such as occlusion and hydrosalpinx, pelvic adhesions, polycystic ovaries, and endometriosis.[8] HSG can evaluate uterine factor infertility, unlike laparoscopy and dye tests. Because of the inherent limitation of laparoscopy and dye test in the evaluation of the uterine cavity, carrying out hysteroscopy at the time of the laparoscopy and dye test can circumvent this limitation.[8] Hysteroscopy service is increasingly available in Nigeria and is associated with a diagnostic yield of 93.3%.[9] Some of the common pathologies that could be identified during hysteroscopy include the following: submucus myoma, endometrial polyps, intrauterine adhesions, lost intrauterine contraceptive device, Mullerian duct abnormalities, and retained fetal bone.[8,9] In Nigeria, there are few reports on the use of hysterolaparoscopy in the management of infertility from a private fertility center. This study is aimed at presenting our experience with the use of hysterolaparoscopy in the management of infertility.

Study design This was a retrospective study of women who underwent hysteroscopy and laparoscopy at Vaden Specialist Clinics and Fertility Center, Owerri, Imo State, Southeast, Nigeria, from 2016 to 2020. Ethics approval: The ethical approval for this study was obtained from the Health Research and Ethics Committee Vaden of Hospital. (VH/1/2019/02). The study was conducted in accordance with the ethical principles of Helsinki Declaration. Informed consent was not required as the study was retrospective in design and did not contain any data directly obtained by the authors. Sample size calculation The sample size was calculated using the formula for cross-sectional prevalence designs at 95% confidence interval and 5% error margin. Considering a 10% attrition rate, a minimum sample size of 214 was adequate for the study. Study setting The study was carried out at Vaden Specialist Clinics and Fertility Center in Owerri, Imo State, Southeast Nigeria, managed by a team of consultants and medical officers with the help of laboratory scientists, nurses/midwives, and embryologists. It receives referrals from within Imo state and nearby states of Abia, Enugu, Anambra, and Rivers. Study population The case notes of all the women who underwent hysteroscopy and laparoscopy in the center were reviewed. A structured proforma was used to collate data of study patients which included age, parity, level of education, residence, tribe; religion, past gynecological history, indication, hysteroscopy and laparoscopy findings, successful completion rate, and adverse effects. Laparoscopy and dye test with hysteroscopy procedure The procedures were done in the immediate postmenstrual phase commonly on the 10th day of the menstrual cycle. For amenorrheic women, the procedures were done at any convenient time after excluding pregnancy, under general anesthesia. Routine 600 µg of misoprostol was inserted into the posterior vaginal wall for cervical ripening. This was for easy dilatation of the cervix and to avoid cervical injury. The equipment used was ALPHCAMTM HD SUPER (om surgical) Camera unit, 150W Xenon light source, HD monitor, a hysteroscope with a 300-rod lens telescope (om surgical), and automated infusion pump (Richard WOLF). The diagnostic hysteroscopy procedure was performed before the laparoscopy and dye test. It was performed by two gynecologists and two assistant medical officers. Each of the procedures was done by either of the gynecologists assisted by a medical officer. A checklist was used to document intraoperative findings and the treatment given. Following general anesthesia, the patient was placed in a modified lithotomy position, and routine cleansing and draping was done. The cervix was exposed using a Sim’s speculum, and the cervical lip was grabbed with a tenaculum (the cervix was dilated if need be). The diagnostic sheath was used for all the diagnostic procedures, while the operative sheath and resectoscope were used for the corresponding pathologies. The distension medium used was normal saline. It was instilled at a controlled pressure of 100–150 mm Hg. Complete visualization of the endometrial cavity was done before any operative procedure, noting any gross pathology, whether the tubal ostia were visualized or not, and the cervical canal. The fluid collection was done using locally made BRASS V (made using polythene material)m and the fluid deficit was estimated after the procedure. Following hysteroscopy, the gynecologist passed the Sparkman’s cannula from the vagina and retained for the performance of the dye test. About 50 mL of methylene blue was also prepared and kept. For the laparoscopy and dye test, the primary port was created by direct trocar access, and the abdominal cavity was insufflated using carbon dioxide (CO2) to a pressure of 10–20 mm Hg depending on the habitus of the woman after the confirmation of a successful entry. Using the Sparkman’s cannula inserted through the vagina with the elevation of the uterine fundus, with the head down tilt of the operating table (i.e., putting the patient in the Lloyd Davies position), the fallopian tubes were completely visualized after obtaining a panoramic view of the abdominal cavity. The secondary ports were inserted if needed, under direct vision. Demonstration of tubal patency was done following injection of methylene blue via the cervical cannula. The fallopian tube was adjudged to be patent if the methylene blue egressed from the abdominal ostium of the fallopian tubes. Lesions observed during diagnostic laparoscopy were treated. The ports were repaired with a vicryl-0 suture. The patients were discharged the same day following full recovery from anesthesia on the prescription of ofloxacin 200 mg twice daily and metronidazole 400 mg thrice daily for 1 week and 5 days, respectively. Paracetamol 1000 mg and ibuprofen 400 mg were given for analgesia twice daily for 3 days. Ibuprofen was, however, withdrawn for those women with peptic ulcer disease. They were given a 2-week appointment at the clinic. In cases of intrauterine adhesiolysis, a 6Fr catheter (we usually use size 8) was inserted into the uterus at the end of the procedure and then removed on the 7th day post-procedure. Estradiol valerate 2 mg thrice daily for 21 days and medroxyprogesterone acetate 5 mg from the 22nd day were given for 7 days for three cycles. Data analysis The data obtained were analyzed using SPSS version 20 (IBM, Armonk, NY, USA). The results were presented with frequency tables/percentages and bar charts.

During the period under review (2016–2020), 2389 women were managed in the hospital for various indications, with 199 of these women managed primarily for infertility – 104 for secondary infertility and 95 for primary infertility. Fifteen were evaluated for infertility with other clinical findings. This gave a prevalence rate of 8.3%. The point prevalence of secondary and primary infertility was 4.4% and 3.9%, respectively. Table 1 represents the sociodemographic and obstetric characteristics of the study population. The mean age of the women was 35.8 (95% CI 34.8–36.7) years. The majority of the women had tertiary education. Socio-demographics and obstetrics characteristics of the study population Figure 1 represents the various indications for hysterolaparoscopy among women. The majority of the cases were in women ≤35 years of age. In less than half of the cases (48.6%), hysterolaparoscopy was carried out because of secondary infertility, while in 44.4% (95) of cases, it was carried out because of primary infertility. Mullerian abnormality was the indication in 0.5% of the women. Distribution of the indication for pan-hysteroscopy with the age of the women. Figure 1 represents the various indications for pan-endoscopy among women. The majority of the cases were in women ≤35 years of age. Less than half of the cases (48.6%) were found in women with secondary infertility, while 44.4% (95) of cases were in those with primary infertility. Mullerian abnormality was the indication in 0.5% of the women Table 2 represents the clinical and surgical findings of the women before hysterolaparoscopy. The mean duration of infertility was 5.8 (95% CI 5.2–6.3) years. More than half (51.4%) of the women investigated in our clinic had no prior surgical intervention. Cesarean delivery was the most common surgical procedure among women. Secondary dysmenorrhea and abnormal vaginal discharge were the two commonest gynecological problems identified among the women. Less than 10% of the women had a pelvic inflammatory disease that was properly evaluated and treated before undergoing hysterolaparoscopy. Clinical and surgical findings of the study population prior to hysterolaparoscopy Laparoscopy and dye test findings of the women were as shown in Table 3. Insertion of the primary pot was easy in all the cases with an average number of 1 pot and a range of 1–4. The volume of gas used ranged from 10 to 20 cm3 with a mean value of 10.1 ± 0.9 cm3. In more than one-fifth (20.1%) of the procedures, dye injection was difficult, and the average volume of methylene dye used was 50.7 ± 5.2 mL. More than one-third (38.3%) of women had a normal pelvic cavity. The prevalence of abnormal pelvic findings was 62%. Endometriosis was diagnosed in 5.6% of the study population. The prevalence of tubal blockade in our review was 43.5%, and it was bilateral in 61 (28.5%) women. Hydrosalpinx and endometrioma were found in 4.2% and 1.4% of the women, respectively. Laparoscopy and dye test findings among the study population The mean uterine depth was 5.5 (95% CI 5.3–5.7) cm, with a minimum depth of 3 cm and a maximum depth of 8 cm (not shown in the table). As shown in Table 4, the majority of the patients (196, 91.6%) had normal internal cervical os. Uterine adhesion, submucus leiomyomata, and endometrial polyp were seen in 47 (22.0%), 27 (12.6%), and 16 (7.5%) of cases, respectively. Uterine Ostia was either fibrosed (25.7%) or not visualized (31.8%) among the women. Some of the procedures performed include polypectomy (11, 5.1%) and adhesiolysis (30, 14.3%), myomectomy (1, 0.5%), and removal of foreign bodies (1, 0.5%). The average volume of fluid used was 1.6 (95% CI 1.5–1.7) L and lasted 28.8 (95% CI 26.9–30.7) min. The is a 5-year review of the hysterolaparoscopy finding of women evaluated for infertility in a specialist fertility center in southeast Nigeria. The prevalence of infertility during the period under review was 8.9%, with a mean infertility period of 5.8 (95% CI 5.2–6.3) years. The mean duration of infertility in our study is similar to those in previous studies in Nigeria.[4,7,8] Secondary infertility is the commonest indication for a woman to undergo hysterolaparoscopy in our study, which supports the findings of previous studies[8] and related studies.[10-13] Tuboperitoneal pathologies contribute significantly to female factor infertility in Sub-Saharan Africa, including Nigeria, due to an increase in the rate of genital tract infections.[4,7,14-16] This is evident in our study where the prevalence of tubal factor infertility was 41.6%, with pelvic adhesion occurring in 57.5% of the women. The above findings were in keeping with earlier reports by Ikechebelu and Mbamara[7] and Ugboaja et al.[8] of the contribution of tuboperitoneal factor to the cause of female factor infertility in Nigeria. However, unlike in the Ikechebelu and Mbamara[7] study, the prevalence of tubal occlusion of 41.6% in our study is lower than the rate of 60.5% in their study. Our rate is also lower than the rate of 56.5% found in Ugboaja et al.[8] evaluation of women with infertility challenges in Anambra state, Nigeria. On the other hand, a higher rate of pelvic admission (57.5%) was seen in our study population compared to the lower rates of 42.5%[7] and 39.6%[8] in earlier reports.[7] Differences in the study population might be responsible for the above findings. Adequacy of the fallopian tube is paramount for conception to occur. Tubal factor infertility has been estimated to be responsible for 39.17% of causes of subfertility in Africa.[16] Our laparoscopy and dye test evaluation of the study population demonstrated that a significant number of the women have fallopian tube dysfunctions, evidenced by the various pathologies diagnosed. Tubal occlusion, mainly proximal (61, 28.5%), was diagnosed in more than two-fifths of our study population and was bilateral occlusion in more than one-fifth of the cases. Other fallopian tube pathologies diagnosed in our study include hydrosalpinx (29, 18.2%) and plastering of the fallopian tubes (9, 4.2%) to the uterus. This is probably a sequela of genital tract infection. The absence of a fallopian tube was seen in a woman, which thus highlights the value of laparoscopic studies in infertility work-up. A similar pattern of tubal pathologies although with a different rate of occurrence was reported in Nnewi, southeast Nigeria. In the above study, bilaterality of tubal occlusion, proximal tubal occlusion, hydrosalpinx, and plastered tubes were seen in 20%, 56.2%, 41.7%, and 25.7% of the women, respectively.[8] Higher rates of tubal factor infertility have also been reported in other previous studies in Nigeria and Sub-Saharan Africa.[4,6,16,17] Differences in the study population with different point prevalence of sexually transmitted infection might account for the observation. Hysteroscopy is an important procedure to investigate an endometrial cause of female infertility. Our study showed a high yield of uterine abnormality, which is in congruence with similar studies in Nigeria.[10,12] The four most common uterine abnormalities detected in our evaluation include uterine adhesion 47 (22.0%), sub-mucous leiomyomata 27 (12.6%), endometrial polyp 16 (7.5%), and fibrosed uterine ostia 55 (25.7%). Our hysteroscopic finding of uterine adhesion as the commonest uterine abnormality agrees with those of earlier studies in Nigeria,[10,12,17] although it differs from the report of Ray-Offor and Nyengidiki[9] in Port-Harcourt, Nigeria, where uterine fibroid was the most uterine pathology. The degree of uterine ostial fibrosis among women agrees with that of an earlier report in Lagos, Nigeria.[12] Endometritis and uterine adhesion probably following uterine instrumentation might be responsible for the observation. The uterine septum was seen in 2.3%[5] of our study population, which corresponds to the rate reported by Ajayi et al.[12] in Lagos. This highlights its (uterine septum) possible contribution to female factor infertility in Nigeria. Gynecologists working in our environment must consider this pathology in a woman presenting with infertility with a background history of recurrent miscarriage. In our review, the majority of the women has a grossly normal-looking ovary. The pathologic ovarian yield was 52.8%, with ovarian cyst being the commonest pathologic finding, followed by ovarian adhesion. Shrunken ovaries were seen in 10.3% of women. A shrunken ovary might be an early sign of ovarian dysfunction associated with the peri-menopausal state. Endometriosis was seen in 5.6% of the women; ovarian endometrioma occurred only in the left ovaries (1.4%). Our observed rate of endometriosis is similar to the finding of Ikechebelu and Mbamara[7] in Nnewi, Nigeria Endometriosis is an important cause of female infertility, which could arise from the elaboration of cytokines, resulting in endometrial and tubal dysfunction, distortion of pelvic anatomy, ovarian damage/dysfunction, and impaired gamete implantation.[18] A decrease in sexual frequency because of the involvement of the uterosacral ligament resulting in deep dyspareunia could also cause infertility. Deep dyspareunia and chronic pelvic pain observed in our study might have resulted from endometriosis.[18] It is, therefore, important that laparoscopic evaluation should be carried out in women with the abovementioned symptoms since clinical diagnosis of endometriosis is fraught with errors.

of the study The index study is a hospital-based study, and our findings could not be generalized to the population of women with subfertility issues in the study area. It has an inherent selective bias. Women who were managed were those who presented in our facility and who were able to afford the cost of care. Even though hysterolaparoscopy was performed by a trained gynecologist, clinical/desirability bias are possible confounding factors that could affect the report. To help reduce the above problem, each procedure was carried out by two gynecologists who were blinded to the clinical history of the women, except that they were being investigated for subfertility. Our study might be limited by the sample size. A larger and more comprehensive study involving other fertility clinics in Nigeria will assist in a better report of the applicability of hysterolaparoscopy in infertility management.

Many abnormal findings were found on hysterolaparoscopy among the women evaluated. It comprises intrauterine adhesions, endometrial polyps, submucus fibroids, uterine septum, endometriosis, endometrioma, and tubal occlusion. These findings indicate a need to incorporate hysterolaparoscopy (laparoscopy and dye test with hysteroscopy) in the routine evaluation of female infertility in Nigeria. Acknowledgments We appreciate all the women whose endoscopic findings provided the data for this study; without them, this study would not have been possible. We are also grateful to the staff who assisted us in data collection. Ethics approval The ethical approval for this study was obtained from the Health Research and Ethics Committee of Vaden Hospital. (VH/1/2019/02). Helsinki Declaration The study was conducted in accordance with the ethical principles of Helsinki Declaration. Informed consent This was not required as the study was retrospective in design and did not contain any data directly obtained by the authors. Author contributions BCI: study design, data collection, and interpretation of findings; OSU and CCA: study design, data analysis, interpretation of findings, and drafting of the manuscript. All participated in the review of the final manuscript. All the authors approved the manuscript. Data availability All data generated or analyzed during this study are included in this published article, and any further that may be required will be supplied upon request through the corresponding author. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

1. Mohammed-Durosinlorun A, Adze J, Bature S, Abubakar A, Mohammed C, Taingson M, et al. Use and pattern of previous care received by infertile Nigerian women. Fertil Res Pract 2019;5:1–8. 2. Bakhtiyar K, Beiranvand R, Ardalan A, Changaee F, Almasian M, Badrizadeh A, et al. An investigation of the effects of infertility on Women’s quality of life: A case-control study. BMC Womens Health 2019;19:1–9. 3. Bongaarts J. Trends in fertility and fertility preferences in sub-Saharan Africa: The roles of education and family planning programs. Genus 2020;76:32. 4. Odunvbun WO, Oziga DV, Oyeye LO, Ojeogwu CL. Pattern of infertility among infertile couple in a secondary health facility in Delta State, South-South Nigeria. Trop J Obstet Gynaecol 2019;3:2–6. 5. Akinloye O, Truter EJ. A review of management of infertility in Nigeria: Framing the ethics of a national health policy. Int J Women's Health 2011;3:265–75. 6. Ngowa JDK, Kasia JM, Georges NG-T, Nkongo V, Sone C, Fongang E. Comparison of hysterosalpingograms with laparoscopy in the diagnostic of tubal factor of female infertility at the Yaoundé General Hospital, Cameroon. Pan Afr Med J 2015;22:1–7. 7. Ikechebelu JI, Mbamara SU. Should laparoscopy and dye test be a first line evaluation for infertile women in southeast Nigeria? Niger J Med 2011;20:462–5. 8. Ugboaja J, Oguejiofor C, Ogelle O. Hysterolaparoscopy (hysterolaparoscopy) in the management of female infertility in Nigeria: A report of 230 cases. Niger J Gen Pract 2020;18:53. 9. Ray-Offor E, Nyengidiki TK. Diagnostic yield and therapeutic outcome of hysteroscopy in women with infertility in a referral clinical setting: A port Harcourt, Nigeria experience. Pan Afr Med J 2021;38:155. 10. Ugboaja JO, Oguejiofor CB, Igwegbe AO, Oranu EO. Abnormal hysteroscopy findings among a cross section of infertile Nigerian Women. Niger J Clin Pract 2019;22:9–15. 12. Ajayi A, Biobaku O, Ajayi V, Oyetunji I. Detection of intrauterine lesions by hysteroscopy among women with fertility challenges in an in-vitro fertilization center in Lagos, Nigeria. Crit Care 2015;1:1–8. 13. Fehintola AO, Awotunde OT, Ogunlaja AO, Olujide LO, Akinola SE, Oladeji SA, et al. Preliminary report of experience with gynaecologic laparoscopy in Ogbomoso, Nigeria. Gynecol Surg 2016;13:17–21. 14. Avidime A, Saidu I, Muhammad Z, Aisha A, Adavuruku S. Laparoscopy and hysteroscopy in a tertiary hospital: A 4-year review. Trop J Obstet Gynaecol 2016;33:205. 15. Mboudou E, Morfaw FL, Foumane P, Sama JD, Mbatsogo BAE, Minkande J. Gynaecological laparoscopic surgery: Eight years experience in the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, Cameroon. Trop Doct 2014;44:71–6. 16. Abebe MS, Afework M, Abaynew Y. Primary and secondary infertility in Africa: Systematic review with meta-analysis. Fertility Res Pract 2020;6:1–11. 17. Panti AA, Umar AG, Temitope AO, Adoke AU, Ibrahim R, Bello S. Gynaecological minimal access surgeries performed in a tertiary health institution in north-western Nigeria: A five year review. Sch Int J Obstet Gynecol 2020;03:75–81. 18. Simopoulou M, Rapani A, Grigoriadis S, Pantou A, Tsioulou P, Maziotis E, et al. Getting to know endometriosis-related infertility better: A review on how endometriosis affects oocyte quality and embryo development. Biomedicines 2021;9:273.