MEDICINSKI GLASNIK

14
Medicinski Glasnik, Volumen 9, Number 1, February 2012
LAPAROSCOPY BEFORE IVF?
Many authors still support alternative diagnostic
methods in the diagnostics of tubal pathology in
everyday practice, such as HSG and Chlamydial
antibodies, although laparoscopy represents the
golden standard in the diagnostics of tubal and
peritoneal pathology (41). Diagnostic laparoscopy
can be avoided in cases of clearly confirmed
diagnosis where IVF is considered as only successful
treatment (5).
However, many agree that in cases of adnexal
pathology such as hydrosalpinx or endometriotic
cysts, laparoscopic surgery is needed before IVF
procedure (8).
LAPAROSCOPY IN IDIOPATHIC INFERTILITY
Nakagawa et al have studied the use of laparoscopic
surgery in patients who were diagnosed
with unexplained (idiopathic) infertility, comparing
two groups: first those who underwent ART
treatment without prior laparoscopy and the second
group that underwent laparoscopy before
any other ART techniques. They discovered that
in 87.2% of the women, laparoscopy revealed abnormal
findings; endometriosis lesions, peritubal
adhesions and tubal obstructions. After laparoscopy
48.9% of the patients achieved pregnancy,
with the pregnancy rates ranging between 27.2
and 100 % according to age groups. Authors recommend
that laparoscopy should be strongly
considered for examining women with unexplained
infertility (42). Another Japanese group of
authors has performed laparoscopies in patients
with unexplained infertility. In their conclusion,
they found no significance in pregnancy rates
between patients who underwent IVF or spontaneously
achieved pregnancy (43).
AGE OF THE PATIENT AND LAPAROSCOPY
There is general tendency of avoiding laparoscopic
treatment in patients older than 35 due to
the fact that their reproductive capacity is weakening
with age (44). From our clinical experience,
we have seen that many women are sent directly
to the IVF centers, often with insufficient pretreatment
diagnostics (11). The aforementioned
studies indicate that there is a significant benefit
for patients, if laparoscopy is performed, even in
cases of unexplained infertility (42,43).
The issue of ovarian reserve and functional fertile
capacity of women can be easily resolved by
determination of serum Anti Müllerian Hormone
(AMH) level.
Anti-Mullerian hormone is produced by the granulosa
cells of the antral and preantral follicles and
serum AMH levels reflect the ovarian pool of primordial
follicles (44). Anti-Mullerian hormone
levels remain stable during adulthood decreasing
towards menopause (45)¸. Inter and intracycle
variability of AMH is low enough to allow measurement
at any time of the cycle. More importantly,
AMH levels are not affected by contraceptive
pills or GnRH agonists (46).
Moreover, AMH is a good predictor of ovarian
response in younger patients (45) and can also be
a predictor of live birth as a result of IVF (47).
Furthermore, AMH can be used as a marker of
extensiveness of the endometrioma resection by
its postoperative decline (48).
The number of centers in our region in which
AMH level can be determined is increasing.
In conclusion, the routine use of diagnostic laparoscopy
in evaluation of female infertility is
still a matter of discussions. Current evidence
shows that surgical treatment of minimal and
mild endometriosis improves pregnancy rate.
The European Society for Human Reproduction
and Endocrinology (ESHRE) has recommended
in its guidelines IVF as a suitable method of reproduction
especially in cases of tubal pathology,
severely reduced male fertility and more unsuccessful
attempts of assisted reproduction (26),
but laparoscopic salpingectomy is indicated before
IVF procedure, if a hydrosalpinx is verified
by ultrasound (15,17).
The use of laparoscopy in diagnostics and treatment
of tubal pathology is known and undisputed.
Diagnostic laparoscopy is indicated in cases of
bilateral anomaly seen on HSG.
Role of laparoscopy in cases of unexplained infertility
is still a matter of discussions, but some
reported studies are in favour of diagnostic laparoscopies
(42,43) Laparoscopic ovarian drilling
does not have better influence on ovulation in
comparison with gonadotropin use, but LOD significantly
reduces the risk of multiple pregnancies
when compared to gonadotropins, and reduces
number of miscarriages and complications