Laparoscopy

Diagnosing and managing unexplained infertility still remains an enigma. Infertility affects  1 in 10 cou­ples and unexplained infertility accounts for about 20% of cases. Diagnosis is usually made when the female partner ovulates regularly, has patent Fallopian tubes, and has a partner with normal sperm count and function.

Hysterosalpingography (HSG), Laparoscopy, or both can be used to assess tubal patency.

PROS-When laparoscopy is used as a standard test for tubal function, instead of HSG, the incidence of unexplained infertility may reduce from 10 to 3.5%.

When lap­aroscopy was performed for infertile patients with normal HSG findings, 21%-68% of patients had pathologic abnormalities like endome­triosis, tubal disease, and peritubular adhesions (Corson et al. 2000). Laparoscopy helps in detecting infertility causes in the pelvic cavity, which could then be treated, allowing postoperative pregnancies. Therefore, laparoscopy has both diagnostic and therapeutic importance.

CONSOther school of thought, Fatum et al. (2002) sug­gests that diagnostic laparoscopy should be omitted in patients with unexplained infertility. These patients should be treated with 3-6 cycles of ovulation Induction and IUI, and if the treatment is unsuc­cessful, they should be switched to Assisted Reproductive Techniques(ART), because of  (1) improved outcome of ART in today’s era, (2) lower pregnancy rate fol­lowing diagnostic laparoscopy for patients with suspected unexplained infertility and normal HSG findings than fol­lowing ART, and (3) lack of a contribution from diagnostic laparoscopy in the management plan for patients with sus­pected unexplained infertility and normal HSG findings.

Clinical history is very important for the selection of the more appropriate diagnostic tool. It's important to classify patients as high-risk and low-risk. High-risk patients with a past history of infection, prolonged infertility, and positive clinical findings usually warrant early laparoscopy whereas HSG is initially indicated as the less invasive procedure in low-risk patients.  Omitting laparoscopy from the infertility work-up when HSG is normal and there is no contributing past history can reduce the cost of fertility treatment without compromising success rates.

Conclusion: Laparoscopy and laparoscopic surgery for adhesiolysis or ablation of endometriotic lesions should be reserved for cases where ART is not

easily available or covered by health care services.