The role of diagnostic laparoscopy in the evaluation of female infertility
DOI:
https://doi.org/10.18597/rcog.613Keywords:
Infertility, tubal pathology, laparoscopyAbstract
The controversy about the role of routine diagnostic laparoscopy originates from the incomplete comprehension of several medical topics in discussion. Nevertheless, there is agreement in several points. First, several reliable not invasive means exist to confirm the existing tubal patency. Therefore, the cost and the risks of the laparoscopy exclude the use of the laparoscopy to confirm the tubal patency, documented by radiological images or sonography. In contraposition, the direct visual examination of the pelvic peritoneum yields a great sensitivity for the diagnosis of endometriosis and adhesions that compromise the reproductive organs. Besides, laparoscopy allows an immediate treatment of the majority of these conditions. The unexplained infertility is a diagnosis that asks from the normal appearance of the pelvic organs to the visual examination.
The prognostic value for diagnostic laparoscopy and laparoscopic treatments remain in the area of the controversy. The real prevalence of the non medical detected, but important adherencial disease is between 20% to 42% and the benefits of the laparoscopic treatment measured as for rates of intrauterine pregnancy are between 58% and 62%.
The rate of pregnancy in laproscopy adhesiolysis of fimbrial adhesions or fimbrioplasty is about 35% with a rate of ectopic pregnancy between 9,7% and 14%. Though the rates of pregnancy seem to increase after repairing the adherencial disease, the rate of adhesions relapse must not be sub estimated. A multicentric study in 1991 showed adhesions reformation in 97% of the patients in 66% of the places where the adhesiolysis was realized. Therefore, in relation to the adhesions reformation, the laparoscopy does not offer a substantial benefit compared with the laparotomy.
In relation to endometriosis, it has been observed that this pathology is in a great percentage of unfertile asymptomatic patients, who are not pregnant after an expectant handling period; the randomized trials have demonstrated that the laparoscopic handling of the minimal and mild endometriosis improves the rates of pregnancy in 30,7% versus the expectant handling with a rate of pregnancy of 17,7%. Though the mechanism of the infertility associated with the minimal and mild endometriosis does not have a clear explanation, the treatment of this pathology with controlled hyperstimulation and intrauterine insemination improves the rates of monthly pregnancy, compared with the expectant treatment.
In conclusion, the role of the diagnostic laparoscopy in patients with normal HSG must be reconsidered, since this one, has changed the decisions of treatment into an unexplained infertility even into 25%. Consequently, these finds suggest that further studies are needed to evaluate the delay or not making the diagnostic laparoscopy, its cost-effectiveness, and if the laparoscopy intervention of intra abdominal abnormalities is effective in terms of improving the rates of pregnancy after a treatment with IUI.
Author Biography
Jaime Saavedra S.
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