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Year : 2016 | Volume : 4 | Issue : 3 | Page : 155 - 157  


Original Articles
Laparoscopic evaluation of female factors in infertility

Aruna Reddy G1, Anita H2, Swarupa Rani A3, Anupama H4

1, 2 & 3 Assistant Professor, 4 Professor, Department of Obstetrics &Gynecology, Gandhi Medical College, Secunderabad

Corresponding Author:

Dr. Aruna Reddy G                                                                                                                                             Received: 02-03-2016

Email: arunasreddy@rediffmail.com                                                                                                             Accepted: 01-06-2016

                                                                                               

Abstract:

Background: Diagnostic laparoscopic evaluation for infertility is indicated for women who failed to achieve a successful pregnancy after twelve 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 couples.

Objective: To find out different causes of female infertility with diagnostic laparoscopy and their comparative frequency in primary and secondary infertility.

Methods: All 72 infertile women who underwent diagnostic laparoscopy for primary and secondary infertility during this study period were included in the study, conducted at Department of Obstetrics & Gynecology, Gandhi Medical College/Hospital, Secunderabad from January 2015 to December 2015.

Results: 72 infertile women underwent laparoscopy during the study period. Among this 56 (77.77%) of patients had primary infertility, while 16 (22.22%) had secondary infertility. Among this, 15 (20.82%) patients who underwent laparoscopy have no visual abnormality. Common findings were tubal blocks in 12 (16.66%) and PCO 13 (18.05%) in these patients. Polycystic ovaries were not found in cases of secondary infertility. Endometriosis was found in 4 (5.55%) patients.PID was found in 3 (5.35%) patients peritubal and periovarian adhesion were found in 7 (9.73%). Fibroids were found in 12 (16.66%) cases and ovarian cysts were found in 5 (6.94%) cases and uterine anomalies were found in 2 (2.77%) cases.

Conclusion: Most common cases responsible for infertility were tubal occlusions and polycystic ovaries. Next common finding on Laparoscopy was fibroid and other cases which were found were ovarian cysts, endometriosis, and peritubal and periovarian adhesions. And in 20.82% of cases no visual abnormality was detected.

Keywords: Laparoscopy, Primary Infertility, Secondary Infertility, Tubal Blocks, PCOS.

INTRODUCTION:

 

Infertility leads to considerable personal suffering and disruption of family life. According to United Nations “Reproductive health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity in all matters relating to the reproductive systems and its functions and processes.” [1] Diagnostic evaluation for infertility is indicated for women who failed to achieve a successful pregnancy after twelve months or more of regular unprotected intercourse. [2] 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 couples. Based on this, 60 – 80 million couples all over the world can be labeled as suffering from infertility. [3]

Laparoscopy provides information regarding tubal and ovarian status, uterine normality and standard means of diagnosing various pelvic pathologies e.g. Pelvic Inflammatory Disease, Endometriosis, Pelvic congestion and Tuberculosis. [4 & 5] Besides this laparoscopy is the most useful method of assessment of tubal patency. [6] Untreated pelvic inflammatory disease, post abortal, postpartum infections and tuberculosis are common factors of infertility in developing countries. [7]

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 at the study centre.

MATERIAL AND METHODS

 

This observational prospective study was carried out from January 2015 to December 2015 in Obstetrics & Gynecology department of Gandhi Medical College/Hospital. Earlier evaluation is warranted after six months of unsuccessful efforts to conceive in women over age of 35 years due to the observed age related decline infertility as a women approaches age 40 and also may be justified based on medical history and physical findings, including, but not limited to the following three.

  1. History of oligo-menorrhea or amenorrhea.
  2. Known or suspected uterine/tubal/peritoneal diseases or stage III or IV endometriosis.
  3. Known or suspected male sub fertility.

Inclusion criteria: All women who failed to conceive after twelve months of regular intercourse were included. All the cases which were included in the study had a normal serum FSH, LH, Prolactin, Progesterone, Testosterone levels. Four known hypothyroid cases that were on treatment with normal TSH levels were included. Ultrasound findings were normal in all the cases except four cases which showed polycystic ovaries on ultrasound.

Exclusion criteria:  

  1. Couples who had not lived together for at least twelve months and those with male factor infertility.
  2. Patients with absolute or relative contraindication for laparoscopy i.e., any preexisting cardiovascular or respiratory condition, generalized peritonitis, intestinal ileus or obstruction and abdominal hernia.

A complete and relevant history and clinical examination was carried out. A complete hormonal profile including FSH, LH, Prolactin, Progesterone, Testosterone, TSH and Abdominal Ultrasound was done. 72 infertile women underwent laparoscopy for both primary and secondary infertility. Patients were admitted in the pre menstrual period. After taking informed consent diagnostic laparoscopy was carried out. Per speculum and per vaginal examination was done in all the patients. During the procedure, pelvis, uterus, fallopian tubes, round ligaments, uterovesical pouch, utero sacral ligaments and pouch of Douglas were inspected. Pathology anywhere was noted.

In cases of PCO drilling was done. Flimsy adhesions if present were released. Tubal testing was done by injecting methylene blue in all the cases. Dilatation and curettage was carried out and endometrium was sent for histopathology.

Above information is documented in proforma and analyzed. Frequencies were calculated for laparoscopic findings regarding primary and secondary infertility.

RESULTS

 

The following table shows the findings of Diagnostic laparoscopy in the study where among 72 patients 56 (77.77%) patients presented with primary infertility and 16 (22.22%) of patients presented with secondary infertility. Tubal blocks were seen in 12 (16.66%) and PCOS were seen in 13 (18.05%). Fibroids were seen in 11 (15.27%) of patients. Endometriosis were seen in 4 (5.55%) patients, Ovarian cysts were seen in 5 (6.94%) and few findings were pelvic inflammatory disease, peritubal and periovarian adhesions and uterine anomalies.

 

 

Table 1: Laparoscopic findings in primary and secondary infertility

Findings

Primary infertility (N = 56)

Secondary infertility (N = 16)

Total (N = 72)

No visible abnormality

14 (25%)

01 (6.25%)

15 (20.82%)

Tubal blocks

09 (16.07%)

03 (18.75%)

12 (16.66%)

Poly Cystic Ovary

13 (23.21%)

00

13 (18.05%)

Fibroids

07 (12.5%)

04 (25%)

11 (15.27%)

Peritubal and periovarian adhesions

04 (7.14%)

03 (18.75%)

07 (9.73%)

Ovarian cysts

03 (5.35%)

02 (12.5%)

05 (6.94%)

Pelvic inflammatory disease

01 (1.79%)

02 (12.5%)

(12.5%)

Uterine anomalies

02 (3.57%)

00

02 (2.7%)

 

Table 2: Characteristic age wise distribution

Age groups (years)

Primary infertility (N = 56)

Secondary infertility (N = 16)

20-30

45 (80.3%)

10 (62.5%)

30-40

11 (19.6%)

06 (37.5%)

 

According to age wise distribution, among 56 cases of primary infertility 45 (80.35%) were in the age group of 20 – 30 years and 11 (19.6%) of cases were in the age group of 30 – 40 years. Among secondary infertility 16 cases, 10 (62.5%) were in the age group of 20 – 30 years and 6 (37.5%) were in the age group of 30 – 40 years.

Table 3: Duration of pregnancy

Age groups (years)

Primary infertility (N = 56)

Secondary infertility (N = 16)

1-5

32 (57.1%)

07 (43.7%)

6-10

20 (35.7%)

07 (43.7%)

11-15

04 (7.1%)

02 (12.5%)

 

According to duration of infertility, in primary infertility 56 cases 32 (57.1%) cases were between 1 – 5 years of duration, 20 (35.7%) between 6 – 10 years and 4(7.1%) between 11 – 15 years. In secondary infertility 16 cases 7 (43.7%) cases were between 1 – 5 years duration, 7 (43.7%) between 6 – 10 years and 2 (12.5%) between 11 – 15 years.

DISCUSSION:

 

Laparoscopy is a mandatory procedure for full assessment of the infertile couple. Female age is the single most important determinant of spontaneous as well as treatment related conception. While there is no universally accepted definition of advanced reproductive age, 35 years is considered as the limit in infertility terms (American Society of Reproductive Medicine 2006). [8]

Among ovulatory disorders polycystic ovarian disease was the commonest endocrine disorder associated with anovulation. The prevalence of PCO in asymptomatic women is thought to be between 16% and 33%. [9] In the present study incidence of PCO is 18.05%. Endometriosis may lead to female infertility, although it is not confirmed whether it is sole cause of infertility or it is only contributory factor that leads to it. For diagnosing and treating a patient of endometriosis visual or microscopic confirmation through laparoscopy is necessary. [10]

Study conducted by Mahmood showed incidence of endometriosis in 13.6% of patients. In the present study 5.3% of patients of primary infertility and 6.25% of patients with secondary infertility showed endometriosis. Frequency of fibroids is 11 (15.27%) of cases which is high as compared to 6% cases reported by Khaula from Lahore. [11]

Studies conducted by Preeti Kanal, at Jhansi (UP) in 2006 showed tubal abnormalities were noted in half of the infertile patients brought to the hospital for treatment. [12] Laparoscopy with dye injection was the best method in evaluating the causes of primary and secondary infertility especially tubal blockage. [12] In my study 12 (16.66%) of cases showed tubal blocks which were common in secondary infertility cases.

In the present study no visible abnormality was noted in 14 (25%) in primary infertility and 1 (6.25%) of cases in secondary infertility, in primary infertility common finding were tubal blocks and PCO, whereas in secondary infertility common findings were tubal blocks, fibroids and peri tubal adhesions.

CONCLUSION:

Laparoscopy is effective and should be considered earlier in infertile workup, for early treatment decisions. Tubal blocks and ovulatory disorders (PCO) are the common causes for female infertility in the present study. Laparoscopy is most useful in diagnosing cases with endometriosis, tubal factor infertility and uterine anomalies. Most of the cases in primary infertility were tubal blocks and PCO, whereas in secondary infertility cases most of the cases were tubal blocks, peritubal adhesions, PIDs and Fibroids. In my study most of the cases were in the age group of 20 – 30 years and duration was 1 – 5 years of infertility in case of primary infertility. In case of secondary infertility the most of the cases were in the age group of 20 – 30 years and duration of infertility was between the age group of 1 – 5 years and 6 – 10 years of duration.

REFERENCES:

 

  1. The initial investigation and management of the infertile couple. LONDON RCOG Press:1998.
  2. Pertilsteril, Definitions of infertility and recurrent pregnancy loss, a committee opinion, Practice committee of American Society for Reproductive medicine, 2013; 99:63.
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  8. Maheshwari A. Hamilton M. Bhattacharya S. Effect of female age on the diagnostic categories of infertility. Hum Reprod 2008;23:538–42.
  9. Enda Mcveigh. Polycystic ovarian Syndrome. In: Baker PN. Lensley DM, editors, Obstetrics and Gynecology: Oxford University Press; 2004 P.588–93.
  10. Farook SM. Laparoscopic evaluation of chronic pelvic pain. Am KE Med Coll 1998; 4:21–4.
  11. Khaula K, Rehana MM. Various factors for infertility in infertility clinic, Gynae Unit-I, Services Hospital, Lahore. Ann King Edward Med Uni 2005;11(4):427-31.
  12. Askpublication.com (Internet) Study of primary infertility in females by diagnostic laparoscopy, Paper 02 July cited 2006 Dec. Available from http://www.askpublication.com/paper 02_july – Dec 2006.htm 

 





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