Role of Laparoscopy in Infertility

Infertility is defined as failure to conceive within 1 year of unprotected intercourse, in women less than 35 years of age or within 6 months in women more than 35 years of age. An infertility work up should be offered to any woman who by definition has infertility or is at high risk of infertility. Essential components of an infertility workup include history, physical examination, a panel of laboratory tests and imaging. The tests focus on ovarian reserve, ovulatory function and structural abnormalities. Imaging of the reproductive organs provides valuable information on conditions that affect fertility like, tubal patency and pelvic pathology and assess ovarian reserve.

Introduction

Earlier laparoscopy was a routine approach for the evaluation of infertile couples and was considered as gold standard. However, due to the advancement in assisted reproductive technology (ART), the process of evaluating infertile couples has changed. Currently, the most widely accepted approach to infertility focus on the most efficient and cost-effective tests. The investigation of infertile couples should be rapid and inexpensive, using minimally invasive tests. The focus of treatment has shifted from correcting the pathology to performing ART/IVF. Laparoscopy in women with decreased ovarian reserve or severe male factor infertility offers no benefit and hence the treatment is always IVF.

Laparoscopy as a Diagnostic Procedure

As a diagnostic procedure, laparoscopy is not the first step in treatment of infertility. In cases where tubal pathology such as hydrosalpinx is found on HSG or on Ultrasound, laparoscopy is done which can be diagnostic as well as therapeutic. There is no role of Laparoscopy for tubal recanalization as tubal block can be easily taken care of by IVF and recanalization process increases the chance of Ectopic Pregnancy. Diagnostic Laparoscopy, in cases of unexplained infertility is again controversial as it does not improve the success rate. It can be done in cases of Failed IVF cycle to look for any factor which could not be elicited with the standard tests.

Laparoscopy as a Therapeutic Procedure

The major controversy remains when a patient has certain clinical conditions where the need for surgical intervention is to be decided. Such conditions are-

1. Endometriosis

Endometriosis is significantly associated with infertility. Endometriomas lower pregnancy success rates and surgery adversely affects IVF results. During oocyte collection, endometriomas may rupture and, consequently, cause pelvic infection. Although laparoscopy is not considered must in patients with minimal and mild endometriosis, laparoscopic resection of endometriosis focal points or adhesions may improve the outcome of subsequent IVF/ICSI treatment.

In cases with stage III/IV endometriosis IVF-ET is a better therapeutic option. As favourable IVF results cannot be obtained from the excision of endometriomas and the risk of decreased ovarian reserves is high, a pertinent question is whether endometriomas should be operated to improve fertility treatment results. Recent guidelines suggest that only big endometriomas hindering the way during oocyte retrieval can be drained or removed before OPU. Otherwise laparoscopy for endometriosis in ART is not an option.

2. Pelvic adhesions

Pelvic adhesions that result from pelvic infections, endometriosis and previous surgeries may have a role in subfertility. Pelvic adhesions can contribute to tubal dysfunction. Periadnexal adhesions may encapsulate the fimbriae and prevent the oocyte from being captured. In addition, adhesions may lead to difficult access to the ovary during oocyte pick- up. However, there is insufficient evidence to recommend adhesiolysis.

3. Uterine Fibroids

Myomectomy is recommended in fibroids which distort the uterine cavity as they hamper implantation of the embryos. These myomas include FIGO Type0, Type1, Type2, Type 3 i.e. the submucous myomas and the intramural myomas which touch the uterine cavity. The intramural myomas which are away from the cavity i.e. FIGO Type4, Type5 but bigger in size( more than 4 cm) should be removed. Myomas which are totally serosal, FIGO Type6 may not be removed.

4. Adenomyoma

Laparoscopy in adenomyosis is not advocated as such but focal Type 1 Adenomyoma(>5cm) may be removed laparoscopically.

5. After failed IVF

When laparoscopy is done after a failed IVF cycle, it is likely that pathologies, such as mild endometriosis or adhesions can be detected in about 50% cases. However, no study has confirmed this rate. Sometimes terminal hydrosalpinges detected during diagnostic laparoscopy or proper hydrosalpinx detected on USG need to delink to improve ART outcomes.

Conclusion:
Laparoscopy is not a routine part of the diagnostic approach for infertile couples. In patients with minimal and mild endometriosis, laparoscopic resection – ablation of endometriosis focal points or adhesions may enhance fecundity. In an ovarian endometrioma of 4 cm laparoscopic ovarian cystectomy is recommended if no surgery done previously. 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. A hydrosalpinx negatively affects reproductive outcomes. Laparoscopy is currently not advocated as a routine or first line step in the evaluation of infertile patient.