Laparoscopy in infertility practice clinical appraisal

Abstract

Laparoscopy is not a routine part of the diagnostic approach for infertile couples. Every patient and clinical condition must be assessed individually. Regarding tubal occlusion, laparoscopy is recommended when HSG reveals a bilateral obstruction. Laparoscopy can be postponed until at least 10 months after a normal patency or unilateral obstruction is revealed by HSG, particularly in females < 36 years of age with normal ovarian reserves. In patients with a history of tuberculosis or severe pelvic infection, laparoscopy should be considered as a first-step approach instead of HSG because in these clinical conditions, tubal morphology and fimbria functional capacity are more important than demonstrating tubal patency. Further randomised controlled trials are warranted to determine whether laparoscopy with IUI should be performed and whether this procedure should be performed before or after IUI. Clinicians should consider the option of diagnostic laparoscopy before IUI in patients with a history of pelvic infection, ectopic pregnancy, tubal surgery or symptoms of endometriosis. In patients with minimal and mild endometriosis, laparoscopic resection–ablation of endometriosis focal points or adhesions may enhance fecundity in the follow up period and may improve the outcome of subsequent IVF/ICSI treatment in infertile women. Laparoscopy and Infertility 61 If an ovarian endometrioma 4 or 5 cm in diameter is present, it is debatable that laparoscopic ovarian cystectomy is recommended to histologically confirm the diagnosis, reduce the risk of infection, improve access to follicles and possibly improve ovarian response, as this may affect the ovarian follicle reserve, considering that an endometrioma often is a pseudocyst with a wall consisting of normal ovarian cortex. For infertile women who have stage III/IV endometriosis and who have previously had one or more operations for infertility, IVF-ET is a better therapeutic option than another operation for infertility. More RCTs have to evaluate the effects of diagnostic laparoscopy after failed ovulation induction, failed ovarian stimulation , IUI or failed ART cycles; however, at least 50% of patient pathologies, such as endometriosis or adhesions, can be detected if laparoscopy is performed. In addition, no evidence suggests that laparoscopy with adhesiolysis before ART increases the pregnancy rate in ART cycles. A hydrosalpinx negatively affects reproductive outcomes. Laparoscopic Clip of the tube is indicated in the case of an ultra-sound-visible hydrosalpinx. The effect of laparoscopic surgery is more predominant in the presence of a bilateral hydrosalpinx. In selected cases with tubal factor infertility, laparoscopic salpingostomy may be indicated, which offers the advantage of natural conception