Rationale for Procedure
Laparoscopy is typically the final step of a workup for infertility and is used to avoid open surgery. Diagnostic laparoscopy can be used as an adjunct to salpingography to help diagnose causes of infertility. Lesions that may not be seen with salpingography and are viewed better with laparoscopy include endometriosis and adhesions.
Technique
The lithotomy position is employed so that cervical manipulation can be used. When cervical manipulation is not needed, standard supine positioning is used. A primary trocar site is placed in the periumbilical region, and additional trocars are placed in the right and or left lower quadrants as needed [1]. Methylene blue or other dye can be injected into the fallopian tube to check for patency. Peritoneal fluid can be obtained to check for endometriosis. Endometriosis observed should be biopsied and classified with tools such as the American Society for Reproductive Medicine Guidelines. Adhesions can be identified and classified as mild, moderate, or severe. Pathology affecting the fallopian tube can be classified as mild (a superficial vascular pattern suggesting congestion or inflammation and/or minimal kinking, and/or minimal fibrosis), moderate (salpingitis, isthmica, nodosum, distal phimosis, high degrees of vascular change, fibrosis, ampullary dilation after visualization with chromotubation), or severe (obstruction of the tube proximally or distally). Treatment of identified pathology can be initiated at this time.
Indications
• Infertility particularly after normal hysterosalpingography
Contraindications
• Inability to tolerate general anesthesia or significant pelvic adhesions that may preclude safe access or visualization
Risks
• Procedure- and anesthesia-related complications
Benefits
• Identification of the reason for infertility
• Possible therapeutic intervention
• Confirmation of lack of pathology may also be important for further treatment options
Diagnostic Accuracy of the Procedure
The diagnostic yield of the procedure for infertile women after negative hysterosalpingography has been described to range between 21 and 68% (level III) [1,2,4]. Identified pathology includes intrinsic tubal disease (3-24%), peritubal adhesions (18-43%), and endometriosis (up to 43%) [1,3-5]. The procedure has been described to have a higher yield in secondary infertility (54%) compared with primary infertility (22%) (level III) [1]. Furthermore, DL has been shown to alter treatment decisions in at least 8% of patients (level III) [2] and may lead to earlier intervention with assisted reproductive technology [4].
Procedure-related Complications and Patient Outcomes
Procedure-related complications include bowel injuries, bleeding, urologic injuries, vaginal cuff wounds, peritonitis, and pelvic pain. In a large multicenter French study (n=30,000), diagnostic and therapeutic laparoscopy were found to be associated with a 3.3 per 100.000 mortality and a 4.6 per 1,000 morbidity risk (level II) [7]. Complications requiring conversion to laparotomy occurred in 3.2 per 1,000 patients. The risk of complications was related to the complexity of surgery and the experience of the laparoscopist. One in four intraoperative complications was missed during the procedure.
After laparoscopy up to 45% of patients may become pregnant within 1 year, many without in vitro fertilization (level III) [3,4]. While bilateral tubal occlusion on laparoscopic inspection usually signifies the need for in vitro fertilization, pregnancies in patients with this pathology have been described [5].
Cost Effectiveness
There are no available data on the cost effectiveness of DL for infertility.
Limitations of the Available Literature
The quality of the available literature is limited, as all of the available studies are retrospective studies from single institutions. Furthermore, there is a paucity of data on long-term outcomes and pregnancy rates and no data on cost-effectiveness and quality of life. In addition, there is no consistency in the reporting of pregnancy success after laparoscopy, as some studies consider the use of in vitro fertilization a success and others a failure. These shortcomings limit our ability to provide firm recommendations.
Recommendations
Diagnostic laparoscopy can be used safely in female patients with infertility (grade B). Diagnostic laparoscopy may be considered in appropriately selected infertile patients even after normal hysterosalpingograms, as important pelvic pathology may be identified in a significant number of patients (grade C). The paucity of available data and the low level of evidence do not substantiate a firm recommendation for the procedure.
Bibliography
1. Hovav Y, Hornstein E, Almagor M, Yaffe C. Diagnostic laparoscopy in primary and secondary infertility. J Assist Reprod Genet. 1998;Oct;15(9):535-7.
2. Tanahatoe S, Hompes PG, Lambalk CB. Accuracy of diagnostic laparoscopy in the infertility work-up before intrauterine insemination. Fertil Steril. 2003
Feb;79(2):361-6
3. Komori S, Fukuda Y, Horiuchi I, Tanaka H, Kasumi H, Shigeta M, Tuji Y, Koyama K. Diagnostic laparoscopy in infertility: a retrospective study. J Laparoendosc Adv Surg Tech A. 2003; June;13(3):147-51.
4. Corson SL, Cheng A, Gutmann JN. Laparoscopy in the “normal” infertile patient: a question revisited. J Am Assoc Gynecol Laparosc. 2000 Aug;7(3):317-24.
5. Mol BW, Swart P, Bossuyt PM, van der Veen F. Prognostic Significance of Diagnostic Laparoscopy for Spontaneous Fertility. J Reprod Med. 1999 Feb;44(2):81-6.
6. Chapron C, Querleu D, Bruhat M, Madelenat P, Fernandez H, Pierre F, Dubuisson J. Surgical Complications of Diagnostic and Operative Gynaecological Laparoscopy. Human Reproduction. 1998 13(4):867-872.