Article Information

Dr. Benozir Haque Panna¹, Prof. Dr. Sehereen F. Siddiqua², Prof. Dr. Ferdousi Islam Lipi³, Dr. Sharmin Abbasi⁴, Dr. Prianka Poddar⁵

¹Assistant Professor, Department of Gynecology & Obstetrics, Popular Medical College, Dhaka, Bangladesh.

²Professor & Head, Department of Gynecology & Obstetrics, Anwer Khan Modern Medical College, Dhaka, Bangladesh.

³Professor, Department of Gynecology & Obstetrics, Popular Medical College, Dhaka, Bangladesh.

⁴Associate Professor, Department of Gynecology & Obstetrics, Anwer Khan Modern Medical College, Dhaka, Bangladesh.

⁵Residence Surgeon, Department of Gynecology & Obstetrics, Popular Medical College, Dhaka, Bangladesh.

*Corresponding author: Dr. Benozir Haque Panna, Assistant Professor, Department of Gynecology & Obstetrics, Popular Medical College, Dhaka, Bangladesh.

Received: 19 September 2024; Accepted: 23 September 2024; Published: 30 September 2024

Citation: Dr. Benozir Haque Panna, Prof. Dr. Sehereen F. Siddiqua, Prof. Dr. Ferdousi Islam Lipi, Dr. Sharmin Abbasi, Dr. Prianka Poddar. Laparoscopic and Hysteroscopic Evaluation of Female Infertility: A Tertiary Level Hospital Study in Bangladesh. Obstetrics and Gynecology Research. 7 (2024): 86-90.

Abstract

Keywords

Laparoscopic; Female infertility; Uterine abnormality; Tubal disease; Ovarian adhesions

Article Details

Introduction:

Infertility is defined as the inability to conceive after 1 year of regular unprotected sexual intercourse [1]. Infertility is a problem of global proportion. The World Health Organization (WHO) estimates 60-80 million couples worldwide suffer from infertility [2]. Infertility varies across regions of the world and is estimated to affect 8-12% of couples’ universal [3]. At present times, infertility is affecting approximately 9-16% of married couples [4]. Some patients conceive with more diagnostic procedures while others never do so despite running through a gamut of investigations. Medical science is constantly striving to achieve such techniques which would bring perfection in diagnosis. Laparoscopy, one of such achievements, offers a simple rapid, and safe way to assess and diagnose intra-abdominal diseases. The main causes of infertility are tubal disease like tubal obstruction, peri-tubal adhesions, periovarian adhesions, ovulatory disorders like cystic ovaries, uterine factors like fibroid uterus, endometriosis, tuberculosis, and male factor infertility [5]. Infertility can be divided into primary and secondary infertility. In primary infertility, no previous pregnancies have occurred, and in secondary infertility, a prior pregnancy although not necessarily a live birth has occurred [6]. Globally, most infertile couples suffer from primary infertility [7]. The female factors contribute most (40-55%) in the etiologies of infertility followed by malefactors (30-40%), both partners (10%), and unexplained (10%) [8]. The importance of diagnostic laparoscopy in female subfertility lies in patients with tubal, peritoneal factors, and uterine factors which may be missed on routine clinical examination and imaging modalities. It helps to evaluate uterine, tubal, and ovarian pathology with a single visual inspection in no time. Undetectable peri-tubal adhesions which often are not visualized by HSG can also be lysed during a laparoscopic examination. Uterine factors like congenital anomalies or fibromyoma of the uterus compressing the tubal lumen and ovarian factors like Stein Leventhal syndrome causing polycystic ovaries, endometriosis, periovarian adhesions are important in the causation of infertility and are best diagnosed by laparoscopy. Early stages of endometriosis are most difficult to diagnose by pelvic examination, but laparoscopy plays an important role in diagnosis. The laparoscope can be manipulated throughout the pelvic bases for a detailed inspection of the peritoneal surface thus providing an effective method of obtaining an early diagnosis in patients with suspected genital T. Diagnostic laparoscopy has been found safe and cost-effective in the initial management of young women with infertility [9]. Laparoscopy can identify milder degrees of distal tubal occlusive disease, pelvic and adnexal adhesions, and endometriosis that may adversely affect fertility [10]. Diagnostic laparoscopy also provides the clinician an opportunity for a therapeutic procedure at the time of diagnosis. The objective of this current study was to assess the effectiveness of the laparoscopic and hysteroscopic evaluation of female infertility.

Methodology

This prospective observational study was conducted in the department of Gynaecology and Obstetrics, Anwer Khan Modern Medical College, Dhaka, Bangladesh, during the period from 26 March 2021 to 21 July 2022. A total of 56 infertile female patients who underwent diagnostic laparoscopy after basic infertility workup were enrolled in this study as study subjects. Properly written consent was taken from all the participants before data collection. The whole intervention was conducted following the principles of human research specified in the Helsinki Declaration [14] and executed in compliance with currently applicable regulations and the provisions of the General Data Protection Regulation (GDPR) [15]. As per the inclusion criteria of this study, patients with primary or secondary infertility, normal semen analysis of the male partner, and patients with polycystic ovarian syndrome not responding to treatment were included. On the other hand, according to the exclusion criteria of this study, couples with male factor infertility, couples who had not lived together for 12 months, patients with absolute or relative contraindications for laparoscopy, cases with hyperprolactinemia or thyroid function abnormalities and vaginal causes for infertility were excluded. A predesigned questionnaire was used in data collection. Along with data regarding the diagnosis of female infertility, all the demographic and clinical information of the participants were recorded and analyzed. All data were processed, analyzed, and disseminated by using the MS Excel program. 

Result

In this study, in total 56 cases of infertility were taken into consideration. Among those cases, 64% were with primary infertility and the rest 36% were with secondary infertility. In the primary infertility group, out of 36 cases, the majority (58%) were from the age group of 26- 30 years. Similarly, in the secondary infertility group, out of 20 cases, the majority were from the same age group. In laparoscopic diagnosis, out of 36 cases of primary infertility, adhesions were found in 14 (39%) patients, and out of 20 cases of secondary infertility, adhesions were found in 6 patients (30%). Peri tubal/per ovarian adhesions with both tubes blocked were present in 8 cases (23.0%) in the primary infertility group and 3 cases (15%) in the secondary infertility group. Besides these, in the primary infertility group, both tube patent and one tube patent cases were 2.5% (n=1) and 5.1% (n=2) respectively which were 5% (n=1) and another 5% (n=1) in another group respectively. Through laparoscopy, uterine abnormalities like bicornuate uterus (n=2) unicornuate uterus (n=1), and fibroid uterus (n=1) were found in some cases of primary infertility group patients only. According to macroscopic ovarian findings on diagnostic laparoscopy, out of 56 cases of primary infertility, 36 patients (64%) had normal ovaries. But in 3 (5%) cases: cystic ovary, in 4 (7%) cases: unilateral T.O. mass, in 10 (18%) cases: adhesions around the ovary were observed which were noticeable. Tuberculosis was found in 4 cases (11%) in primary infertility patients and 2 cases (9%) in secondary infertility patients. Primary infertility endometriosis was present in 3 cases (8%) and endometriosis was found in 1 case (4.5%) in secondary infertility patients. Fibromyoma was present in one case (3%) of primary infertility. The hysteroscopic findings among participants revealed that 69.6% had normal findings, 32.1% had endometrial polyps, and 30.4% had adhesions. Additionally, chronic endometritis was present in 17.9% of cases, an intrauterine septum in 10.7%, a T-shaped uterus in 7.1%, and submucous myoma in 5.4% of cases. The ratio of abnormal findings was higher in the secondary infertility group than in the primary infertility group.

Figure I: Ring chart showed distribution of study patients according to the type of infertility (N=56)

Table 1: Distribution of study patients according to age groups (N=56)

Figure II: Ring chart showed group wise patients age (N=56)

Table 2: Finding of adhesions on diagnostic laparoscopy (N=56)

Table 3: Uterine abnormality seen on laparoscopy

Table 4: Macroscopic ovarian findings on diagnostic laparoscopy (N=56)

Table 5: Miscellaneous findings of diagnostic laparoscopy

Table 6: Hysteroscopic findings distribution (N=56)

Figure III: Ring chart showed hysteroscopic findings of the patients (N=56)

Discussion

This study aimed to assess the effectiveness of the laparoscopic and hysteroscopic evaluation of female infertility. In this current study, among the total cases, 64% were with primary infertility and the rest 36% were with secondary infertility. Our findings were in correspondence with those of Panchal DL, et al. [13] who found the incidence of primary as well as secondary infertility to be 68% and 32% respectively. Similar findings were also observed by various authors like Gupta S, et al. [12]. This indicates that the incidence of primary infertility is higher because of various social factors, marital disharmony, and rejection by other members of the family. [15] In this study, in the primary infertility group, out of 36 cases, the majority (58%) were from the age group of 26- 30 years. Similarly, in the secondary infertility group, out of 20 cases, the majority were from the same age group. These findings were following a study done by Panchal DN, et al. [13] where maximum infertility cases were from the age group of 21-25 years followed by 26-30 years age groups. A study done by Singh M, et al. [16] also showed similar results. In our study, peri tubal/per ovarian adhesions with both tubes blocked were present in 8 cases (23.0%) in the primary infertility group and 3 cases (15%) in the secondary infertility group. Besides these, in the primary infertility group, both tube patent and one tube patent cases were 2.5% and 5.1% (n=2) respectively which were 5% and another 5% in another group respectively. Through laparoscopy uterine abnormalities like bicornuate uterus (n=2) unicornuate uterus (n=1) and fibroid uterus (n=1) were found in some cases of primary infertility group patients only. In Duigan, et al. [17] bilateral blocks with adhesions were found in 7.9% of cases of primary sterility and 16.1% of cases of secondary sterility which contrasts with our study. On the other hand, Feai, et al. [18] found 5 patients with peri tubal adhesions (18.52%). In this study, according to macroscopic ovarian findings on diagnostic laparoscopy, out of 56 cases of infertility, 36 patients (64%) had normal ovaries. But in 3 (5%) cases: cystic ovary, in 4 (7%) cases: unilateral T.O. mass, in 10 (18%) cases: adhesions around the ovary were observed which were noticeable. Minavi, et al. [19] found polycystic ovaries in 4.76% of cases which was quite close to our finding. The hysteroscopic findings among participants revealed that 69.6% had normal findings, 32.1% had endometrial polyps, 30.4% had adhesions, 17.9% had chronic endometritis, and 10.7% had an intrauterine septum. Nearly similar findings were observed in another study [20]. The findings of another Iranian study [21] were also comparable with that of our study. All the findings of this current study may be helpful in further similar studies.

Limitation of The Study

This was a single-centered study with small-sized samples. Moreover, the study was conducted over a very short period. So, the findings of this study may not reflect the exact scenario of the whole country.

Conclusion

As per the findings of this current study, we can conclude that, among female infertility cases, the majority are found with primary infertility. The majority of female infertility cases may remain free from any type of adhesions. Uterine abnormalities are found more frequently among females with primary infertility. As a safe and cost-effective diagnostic procedure, laparoscopy along with hysteroscopy may be considered a prominent diagnostic tool for the evaluation of the cause of infertility in women.

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