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10 REVIEW Role of laparoscopic surgery in treatment of infertility Siniša Šijanović 1, 2 , Domagoj Vidosavljević 3 , Ivanka Šijanović 4 1 Department of Gynaecology and Obstetrics , J.J. Strossmeyer University School of Medicine Osijek, 2 Department for Minimally Inva- sive Gynaecology, Clinic of Gynaecology and Obstetrics, Clinical University Center of Osijek; Osijek, 3 Department of Gynaecology and Obstetrics, Vukovar General Hospital, Vukovar, 4 Department of Ophthalmology, Vukovar General Hospital, Vukovar; Croatia Corresponding author: Siniša Šijanović Department for Minimally Invasive Gynaecology, Clinic for Gynaecology and Obstetrics, Clinical University Centre of Osijek J. Huttlera 4 , 31000 Osijek, Croatia Phone: +385 31 502 344; fax: +385 31 512 307; E-mail: sinisa.sijanovic@os.htnet.hr Original submission: 27 March 2011; Revised submission: 07 June 2011; Accepted: 04 July 2011. ABSTRACT Med Glas Ljek komore Zenicko-doboj kantona 2012; 9(1):10-16 The role of laparoscopy in assisted reproduction is disputed by many. A rising problem of infertility is battled by an increasing number of centres for reproductive medicine in the region. Nevertheless, there is a large number of indications and conditions where laparoscopic surgery should not be avoided as a therapeutic choice or an aid in assisted reproductive techniques (ART). The number of centres where laparoscopic surgery is performed is significantly higher than the number of reproductive centres; a number of gynaecologists educated in laparoscopic gynaecology is growing, making it more available for patients. Key words: assisted reproductive technique, infertility, laparoscopic surgery
INTRODUCTION The role of laparoscopy in diagnostics and treatment of infertility has its place, although there are many disputes among different authors. Diagnostic laparoscopy is used by 87 % of reproductive gynaecologists in the United States as a method of choice in diagnostics of infertility (1). On the other hand, some authors claim that only 40-70% of pelvic pathology , especially minimal and mild endometriosis, is discovered when diagnostic laparoscopy is used (2). The role of diagnostic laparoscopy in diagnostics of infertility is based on two major issues. First of all, is it necessary to perform diagnostic laparoscopy as a final method with possible conversion to therapeutic mode and with the effect that reproductive surgery has to pregnancy rate? Second, is laparoscopy indicated after many unsuccessful inductions of ovulation or artificial reproductive techniques (ART) in order to enhance pregnancy rate? Nowadays, with technological improvements and increasing number of IVF centres diagnostic laparoscopy is avoided as method due to possible surgical complications and risk of general anaesthesia (3). Although minimally invasive, endoscopy is still invasive diagnostic and therapeutic method that carries a risk of possible surgical complications, although minimal, but still possible anaesthesiologic complications, adhesions, and patients fear of surgery as such; and adhesions after laparoscopic procedures are minimal, less than by laparotomy (4). On the other hand it has great advantages - in hands of a skilful surgeon operation that starts as a diagnostic procedure can be easily transformed into therapeutic reproductive surgery. There is also a possibility of hysteroscopic evaluation of uterine cavity resolving any intrauterine pathology (5). Most endoscopic centres in the world do one-day-surgeries, while office hysteroscopy takes more place in reproductive surgery (6). DIAGNOSTIC LAPAROSCOPY VS. HYSTEROS- ALPINGOGRAPHY OR HYSTEROSALPINGO-CON- TRAST-SONOGRAPHY Hysterosalpinography (HSG) enables morphological overview of uterine cavity, salpinx and Šijanović et al Laparoscopy and infertility their conductivity. HSG has reasonable specificity of 83% but bad sensitivity of 65% (7). It gives 50-90% of false negative results and 30-80% of false positive results (8). The method can also have adverse effects such as lower abdominal pain that occurs when contrast is injected, patients’ discomfort, and it is one of the most painful procedures in gynaecology. It can also induce an exacerbation of pelvic inflammatory disease, tuboovarian abscess and pelveoperitonitis (9) Hysterosalpinography plays no role in diagnostics of endometriosis. X-ray can have bad influence on unrecognized pregnancy so it has to be performed in the first half of the menstrual cycle. A comparison of 18th month cumulative pregnancy rate shows no difference between diagnostic laparoscopy (DL) and HSG (8). A Slovenian study describes pathological findings in 79 % of patients that underwent DL: in 46% of patients tuboovarial adhesions were found, in 27 % of cases endometriosis was found. At the same time sensitivity of HSG was 68 %. Slovenian authors concluded that laparoscopy as a diagnostic method in infertile patients has important diagnostic and therapeutic role, while HSG as a method has only limited diagnostic value (10). Retrospective analysis of patients treated at the University Hospital of Osijek has also shown that pathological findings were present in 77 % of patients treated for infertility . Out of that number 28 % of cases were tuboovarial adhesions and 21% of cases were female patients with endometriosis. Findings and conclusions in our study were similar as those represented in the Slovenian study (11). Hysterosalpingo-Contrast-Sonography (Hy-Co- Sy) is an attractive alternative to HSG because patients are not exposed to X ray or iodine contrast. There is a strong similarity in results between HSG and HyCoSy (12). TUBOPERITONEAL PATHOLOGY Prevalence of peritubal adhesions in infertile patients is between 10-23% (13). Positive anamnestic data of previous pelvic inflammatory disease (PID), abnormal vaginal excretion or previous genital and urinal tract infections are indicators of tuboperitoneal pathology (14). Presence of Chlamydial antibodies is an indicator 11
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