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Mark P. Trolice, M.D., FACOG, FACS
Milton McNichol, M.D, FACOG
Board Certified in Reproductive Endocrinology and Infertility
Laparoscopic Evaluation After Failed Pregnancy Attempts
A 1997 study found that 89% of reproductive endocrinologists routinely used laparoscopy in the evaluation of infertile women. Since then, however, many physicians have discarded the procedure as they progress through stages of treatment by ovulation induction, intrauterine insemination (IUI) and, finally, in vitro fertilization (IVF) if the patient has a normal hysterosalpingogram http://www.asrm.org/Patients/FactSheets/hsg.pdf. But hysterosalpingography (HSG) has been shown to have a sensitivity of only 65% for revealing tubal patency and pelvic adhesions.
Capelo et al from the University of Alabama at Birmingham point out that several types of pelvic pathology found during laparoscopy can affect a woman's fertility and consequently her treatment. Diagnostic laparoscopy has been routinely used for anovulatory women who fail to achieve pregnancy after 4 cycles of ovulation induction with clomiphene citrate. To determine if this approach is valid, they retrospectively analyzed records of 721 laparoscopic procedures performed from 1994 to 2002. An aim of the study was to see if they could identify factors that would predict significant pelvic pathology, which could, in turn, lead to identifying specific indications for laparoscopy.
Data were collected for 92 patients who met these criteria:
- failed to conceive with adequate coital exposure for greater than/equal to 2 years
- had a normal pelvic examination
- had a normal hysterosalpingogram
- had a partner with normal semen analysis
- had at least 4 confirmed ovulatory cycles with clomiphene citrate.
Sixty patients had primary infertility; the remaining 32 had secondary infertility. Seventy-nine patients had complained of dysmenorrhea;
29 had reported dyspareunia; 22 had had previous abdominal or pelvic surgery. Laparoscopic examination had shown no pathologic findings in 33 women, endometriosis, mostly stage I, in 37 and pelvic adhesions in 30. Eight patients had greater than/equal to 1 endometrioma and 1 patient had tubal disease.
The laparoscopic findings were correlated with demographic and historical data in the attempt to identify prognostic factors. Statistically significant correlations were found between endometriosis and both dysmenorrhea and the use of natural contraception; both natural contraception and dyspareunia were predictors of endometriomas. Prior use of oral contraceptives and gravidity were inversely correlated with pelvic adhesions, whereas no prior use of oral contraceptives and primary infertility were each associated with a greater incidence of adhesions.
The data were further analyzed to see if there were any predictors of a "positive" laparoscopy, which was defined as surgical findings consisting of stages III or IV endometriosis, an endometrioma, pelvic adhesions or tubal disease.
It was found that 51.7% of the women with dyspareunia had a positive laparoscopy compared with only 27% of the women without this symptom (p equals .033). Women with no prior history of oral contraceptive use had a 64.3% likelihood of having a positive laparoscopy, compared with 29.5% of those who had a history of this use (p equals .016). Similarly, only 29.5% of women who had used any type of contraception had a positive laparoscopy compared with 64.3% of those with no history of any contraceptive use.
Conclusions and Clinical Implications
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The rationale for laparoscopy is to prevent continuing treatment with clomiphene or gonadotropins and IUI if intrapelvic disease is present
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Analysis of the data showed that no history of oral contraceptive use or any contraception and dyspareunia were associated with an increased risk of having significant pelvic pathology on laparoscopy. Eighty-four of the 92 women studied had at least 1 of the potential predictors and 31 of these women had a positive laparoscopy, compared with 1 of 8 women without any predictors. The data support the use of laparoscopy in the routine investigation of oligo-ovulatory women who do not conceive after 4 cycles of ovulation induction with clomiphene citrate, although the procedure might be delayed for those who have no identifiable predictor. The rationale for laparoscopy is to prevent continuing treatment with clomiphene or gonadotropins and IUI if intrapelvic disease is present. With HSG a far from ideal indicator of adhesions and tubal disease, laparoscopy continues to be a useful tool that can save time and money and decrease the stress of repeated cycle failures for infertile couples.
Capelo FO, Kumar A, Steinkampf MP, Azziz R. Laparoscopic evaluation following failure to achieve pregnancy after ovulation induction with clomiphene citrate. Fertil Steril 2003;80:1450-1453.
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