Human Reproduction, Vol. 17, No. 7, 1929,
July 2002
© 2002 European Society of Human Reproduction and Embryology
Investigation of the infertile couple: laparoscopy after normal hysterosalpingography?
2 Department of Obstetrics and Gynaecology, Hebrew University, Hadassah Ein-Kerem Medical Centre, Kiryat Hadassah, PO Box 12000, Jerusalem 91120, Israel
Correspondence: E-mail: fatum{at}md.huji.ac.il
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Dear Sir,
We appreciate the interest of Dr Papaioannou and colleagues in our debate (Fatum et al., 2002
). We definitely agree with the distinction that has to be made between normal gynaecoradiological procedure as defined by Gleicher et al. (Gleicher et al., 1992a,b) and normal hysterosalpingogram and their relevance to diagnostic laparoscopy. We also do not ignore the crucial role of laparoscopy as a diagnostic tool. Our debate, however, aims to stress the idea that from the clinical point of view, when previous clinical history does not indicate for tubal disease and if the hysterosalpingogram is normal, it is more reasonable in daily practice to treat the couple instead of adding another investigation test.
Our debate (Fatum et al., 2002) suggests that laparoscopy should be omitted after a normal HSG in couples suspected of having unexplained infertility. In these couples, the probability of a clinically relevant peritoneal factor—peritubal adhesions or endometriosis—is very low. In the minority of cases who have normal hysterosalpingogram, laparoscopy may reveal minimal or mild endometriosis or peritubal adhesions. In cases of minimal or mild endometriosis, neither surgery nor medical treatment has been proven to be of any benefit. Expectant management is usually rewarded with reasonable pregnancy rates that are comparable with those obtained by either surgical or medical treatment. Only one trial (Marcoux et al., 1997) found an increase in fertility among women with early stage endometriosis who underwent operative laparoscopy with ablation or excision of the endometriotic tissue. However, this effect was small. The monthly fecundity rate among women who underwent laparoscopic surgery was 6.1%. One in eight women should benefit from resection or ablation. These figures are much lower than the rates expected in fertile women or the results of most IVF attempts and may prove unacceptable to many women or physicians. These women should be acquainted with these low figures, so they can make proper decisions. The fact that pregnancy rates after laparoscopic treatment are far less than rates in fertile women or in IVF programmes may influence the couples' or physicians' decision. This point is especially important in couples with longstanding infertility. In these couples diagnostic or low productive laparoscopic surgeries may be perceived as a waste of precious time and energy. Furthermore, in a similar trial (Parazzini, 1999) involving 101 women, the live birth rate was similar in the diagnostic-laparoscopy and the operative-laparoscopy groups after 1 year of follow-up.
Hysterosalpingography is still the most widespread investigatory measure examining tubal patency. Gynaecoradiological procedures have not gained such widespread use. Still, hysterosalpingography is the mainstay procedure for establishing tubal patency. Whatever the procedure utilized, its efficacy in establishing the diagnosis of peritubal adhesions is very limited. In normal infertile women, laparoscopy will ordinarily show a degree of endometriosis not requiring treatment (Speroff et al., 1999). In these cases the probability of clinically relevant tubal disease or endometriosis is so low, especially in low risk infertility groups, that laparoscopy does not seem to be warranted.
We do believe that in these couples the relatively low contribution of diagnostic laparoscopy and the small benefit of laparoscopic resection or ablation of minimal or low endometriosis justify the treatment by combined gonadotrophins and intra-uterine insemination for 3–6 months and switch to assisted reproductive treatment if such a treatment fails. Patients' demands play an important role in changing our attitude towards `treatment orientated medicine' instead of `diagnostic orientated medicine'. The urge to succeed expressed by both the patient and the physician, especially in couples with longstanding infertility, has driven many of our colleagues to agree with the logical policy presented in our debate. We are aware that assisted reproductive treatment may not always be available or covered by health care services. However, these patients should be informed of the low success rates following diagnostic/operative laparoscopy, before taking a decision concerning the next treatment step.
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Fatum, M., Laufer, N. and Simon, A. (2002) Investigation of the infertile couple: Should diagnostic laparoscopy be performed after normal hysterosalpyngography in treating infertility suspected to be of unknown origin? Hum. Reprod., 17, 1–3.
Gleicher, N., Parilli, M., Redding, L., Pratt, D. and Karande, V. (1992a) Standardization of hysterosalpingography and selective salpingography: a valuable adjunct to simple opacification studies. Fertil. Steril., 58, 1136–1141.[Web of Science][Medline]
Gleicher, N., Thurmond, A., Burry, K.A. and Coulam C.B. (1992b) Gynecoradiology: a new approach to diagnosis and treatment of tubal disease. Fertil. Steril., 58, 885–887.[Medline]
Marcoux, S., Maheux, R. and Berube, S. (1997) Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N. Engl. J. Med., 337, 217–222.
Parazzini, F. (1999) Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomized trial. Hum. Reprod., 14, 1332–1334.
Speroff, L., Glass, R.H. and Kase, N.G. (1999) Female infertility. In Speroff, L., Glass, R.H. and Kase, N.G. (eds) Clinical gynecologic endocrinology and infertility. 6th edn. Lippincott Williams & Wilkins, Philadelphia, PA, USA.
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