Laparoscopic Evaluation of Primary and Secondary Subfertility

Background: Prevalence of subfertility in industrialized countries has been quoted as 20%, and seems to be on the rise. Traditional way to assess the uterine cavity, tubal structure and tubal patency was hysterosalphingography but it is now been largely superseded by laparoscopy and hysteroscopy. With the objective of this study was to highlight the role of laparoscopy in establishing the diagnosis of primary and secondary female subfertility and different therapeutic procedure done. Method: This cross sectional study was conducted in the Subfertility and Reproductive Medicine Unit of Gynae and Obstetrics department of Dhaka Medical College Hospital, Dhaka from January 2015 to June 2018. Total 4256 sub fertile patients attended the Infertility OPD. Out of these 215 patients were selected for laparoscopy. Those patients who had contraindication for laparoscopy were excluded from study. Detailed laparoscopic findings were recorded. Results: Out of 125 selected sub fertile patients 136 (63.26%) patients were in primary subfertility group while 79 (36.74%) patients were in secondary subfertility group. In primary subfertility group(n=136), most common laparoscopic finding was PCO in 44 (32.34%) patients followed by peritubal and periovarian adhesions in 24 (17.65%) patients, Bilateral tubal block in 23(16.91%) patients, Endometriosis in 15(11.03%), Unusual tortuous and lengthy tube in 15(11.03%) patients, fibroid in 11(8.09%) patients, Mullerian agenesis and hypoplasia in 3(2.21%) cases. No visible abnormality found in 22(16.18%) cases. The commonest finding by laparoscopy in patients with secondary infertility were PCO in 18 (22.78%) patients and peritubal and periovarian adhesions in 18 (22.78%) patients, followed by Bilateral tubal block in 12(15.19%) patients, fibroid uterus in 12(15.19%) patients, Endometriosis in 10(12.66%), Genital tuberculosis in 3(1.40%) cases. No visible abnormality found in 12(15.19%) cases. Various laparoscopic procedure like Ovarian drilling. Adhesiolysis, ovarian cystectomy, cyst puncture, salphingostomy, Myomectomy. Conclusion: Laparoscopy helped us to detect and treat important clinical condition in bath primary & secondary sub fertility. failed to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse. Since approximately 85% of couples may be expected to achieve pregnancy within that time interval without medical assistance, evaluation may be indicated for as many as 15% of couples3. The causes of infertility are broadly classified as male factors, female factors and unknown or combined 4. About 25-40% of cases of infertility are attributed to male factor2. During the investigations in the female it is mandatory to rule out the pathology of the genital tract. Diagnostic laparoscopy is generally not a part of initial infertility evaluation; however, number of reports have shown that it is effective procedure for evaluation of long term infertility1. Laparoscopy provides information regarding tubal and ovarian status, uterine normality and standard means of diagnosing various pelvic pathologies eg: Pelvic inflammatory Disease, Endometriosis, Pelvic congestion and tuberculosis1 Besides this it is the most useful method of assessment of tubal patency1. An accurate diagnosis is the key to successful treatment1. After normal hysterosalphingography, laparoscopy reveals abnormal findings in 21.68% cases of infertile couples. Untreated pelvic inflammatory disease, postabortal, postpartum infection and tuberculosis are common factors of infertility in developing countries1. Currently, laparoscopy is perceived as a minimally invasive surgical technique that both provides a panaromic and magnified view of the pelvic organs and allows surgery at the time of diagnosis. Laparoscopy has become an integral part of gynecologic surgery for the diagnosis and treatment of abdominal and pelvic disorders of the female reproductive organs5. This study was carried out to determine different causes of female infertility and their comparative frequency in patients with primary and secondary infertility on diagnostic laparoscopy and different therapeutic procedure done at the study centre. Materials and Methods: A cross sectional study was undertaken among married sub fertile women in Female Subfertility and Reproductive Medicine Unit of Gynae and Obstetrics department of Dhaka Medical College Hospital, Dhaka from January 2015 to June 2018. Total 4256 subfertile patients attended the Infertility OPD. Out of these 215 patients were selected for laparoscopy. Those patients who had contraindication for laparoscopy were excluded from study. All the patients were councelled regarding laparoscopy and indication of laparoscopy. Inclusion criteria were primary infertility and secondary infertility Exclusion Criteria were couple who had not lived together for at least 12 months and patient with absolute or relative contraindication for laparoscopy eg: any preexisting cardiovascular or respiratory condition, generalized peritonitis, intestinal ileus or obstruction and abdominal hernia. A complete relevant history and clinical examination was carried out. A complete hormone profile including FSH, LH, prolactin, progesteron, testosteron, TSH, Abdominal ultrasonogram was done. Informed written consent was taken from every patient. Under GA per speculum and pervaginal examination was done in every patient. Detailed laparoscopic findings were recorded. Tubal testing was done by injecting methylene blue in all the cases. D&C was carried out and endometrium was sent for histopathlogy.