International Journal of Medical and Health Sciences

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1 International Journal of Medical and Health Sciences Journal Home Page: ISSN: Original article Laparoscopic Evaluation of Female Infertility Bhabani Pegu 1*, Bhanu Pratap Singh Gaur 2,Nalini Sharma³, Ahanthem Santa Singh 4 1 Senior Resident Doctor, 3 Assistant Professor, 4 Professor & HOD, Department of Obstetrics & Gynecology, NEIGRIHMS, Shillong, Meghalaya, India, 2 Senior Resident Doctor, Department of Community Medicine, NEIGRIHMS, Shillong, Meghalaya, India. ABSTRACT Objectives: To evaluate the causes of female factors both in primary and secondary infertility with diagnostic laparoscopy. Materials and Methods: One hundred women with both primary and secondary infertility were selected for laparoscopic evaluation. This observational study was conducted from March 2013 to February Apart from complete history and detailed examination, all baseline investigations were performed as per our institutional protocol for pre-anaesthetic checkup. Laparoscopy was done in proliferative phase of menstrual cycle and by doing chromopertubation with methylene blue dye, tubal patency was tested. With predesigned proforma, all data were collected. Results: Out of 100 women, 78 had primary infertility and 22 had secondary infertility. During laparoscopy no pelvic pathology was detected in 15.38% of primary infertility and 18.18% in secondary infertility. Single pelvic abnormality detected among total infertility was 78.57% and it was mostly seen in primary infertility than secondary infertility. The commonest finding by laparoscopy was tubal occlusion in both the groups followed by polycystic ovaries, endometriotic deposits, peritubal and periovarian adhesion, pelvic inflammatory disease (PID), genital tuberculosis, ovarian cyst and fibroid. Ovarian findings were significantly high in primary infertility while tubal occlusion followed by peritubal and periovarian adhesion was mostly seen in secondary infertility women. Conclusion: Laparoscopy is a very effective tool for evaluation of female infertility and it should be consider in infertility workup for early treatment decision. KEYWORDS: Laparoscopy, primary infertility, secondary infertility. INTRODUCTION Infertility is defined as the inability to conceive after one year of unprotected regular intercourse [1, 2]. Infertility affects both men and women as it causes psychological distress, depression and low self esteem [3, 4]. According to United Nations reproductive health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity in all matters related to reproductive system and to its functions and processes [5]. Worldwide, more than 70 million couple suffers from infertility [6]. According to WHO the overall prevalence of primary infertility in India to be between 3.9% and 16.8% [7]. The female factors contribute 40-55% in etiologies of infertility followed by male factor 30-40%, both partners 10% and unexplained 10% [8]. The common factor responsible for infertility in female are tubal factor, anovulatory disorder, endrometriosis, uterine and cervical factors [9]. Appropriate selection of investigation based on problem areas identified by history and physical examination would guide the physician in the management of infertile couple [10]. Laparoscopic is a standard means of diagnosing the tubal pathology, ovarian pathology, pelvic inflammatory disease, endometriosis, pelvic congestion and tuberculosis [11]. The laparoscopic examination should be done even in a patient with normal hysterosalpingography with unexplained infertility to diagnose peritoneal factor and endrometriosis [12]. So laparoscopy is not only help in identification of unsuspected pelvic pathology but also contribute to decision making of infertility management. Int J Med Health Sci. July 2014,Vol-3;Issue-3 172

2 MATERIALS AND METHODS This observational study was conducted in Obstetrics and Gynaecology department, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya from March 2013 to February One hundred women including both primary and secondary infertility were selected for laparoscopy. Patients who were unable to conceive after one or more year of regular unprotected sexual intercourse were included in this study. Those who had relative or absolute contraindications for anesthesia or laparoscopy were excluded from the study. Apart from complete history and detailed clinical examination, couple underwent evaluation of ovulation, tubal patency and malefactor by seminal fluid analysis. All infertile women were admitted in the ward one day prior to procedure. Written informed consent was taken. Laparoscopy was done under general anesthesia in early proliferative phase of menstrual cycle. By using CO 2 gas pnemoperitoneum was created. During procedure, inspection was done for any pelvic abnormality like abnormality in the uterus, fallopian tubes, ovaries, uterosacral pouch and pouch of Douglas. Both ovaries were examined regarding shape, size, and their relationship with fimbrial end of the tubes. Peritoneal, periovarian and omental adhesions, tubo-ovarian masses, endrometriotic deposits, fibroids, presence of fluid in pouch of Douglas or any other pathology present was noticed. Fallopian tube patency was tested by injecting methylene blue dye. Dilatation and curettage was done in patient with menstrual abnormalities or suspected endometrial tuberculosis. Specimen was sent for histopathology and TBDNAPCR accordingly. All information was collected on predesigned proforma regarding age of the patient, age at marriage, type and duration of infertility, associated sign and symptoms, provisional diagnosis and laparoscopic findings. RESULTS Table 1: Age distribution of women with infertility at the time of laparoscopy Age (years) In this study total 100 patients were selected for laparoscopy, out of which 78 patients had primary infertility and 22 had secondary infertility % of primary infertility patients were belongs to years of age, while 54.54% of secondary infertility patients were belongs to years of age (Table 1) The mean duration of primary infertility was 3.2 years and 5.4 years in secondary infertility. The duration of infertility ranged from 1-10 years. Maximum number of cases had duration of infertility between 1-5 years both in primary and secondary infertility patients (Table2). Table 2: Duration of infertility among the study subjects Duration (years) No. % No. % In primary infertility 15.38% and in secondary infertility 18.8% were asymptomatic. The common symptoms both in primary and secondary infertility were dysmenorrhea, chronic pelvic pain, menorrhagia, dyspareunia, irregular menstrual cycle and hirshutism (Table3). Out of 100 patients, pelvic abnormality was seen in 84 numbers of patients, out of which 66 (84.61%) were primary and 18 (81.81%) were secondary infertility patients (Table 4). During laparoscopy single pelvic pathology was detected in 78.78% in primary infertility and 77.77% in secondary infertility patients (Table 5). It was observed by laparoscopy that the most common cause of infertility both in primary and secondary was tubal occlusion. Ovarian factors mostly seen in primary infertility patients followed by endometriotic deposits, peritubal and periovarian adhesions, pelvic inflammatory disease (PID), genital tuberculosis, ovarian cyst and fibroids. While peritubal and periovarian adhesion and PID were mostly seen in secondary infertility patients (Table 6). Int J Med Health Sci. July 2014,Vol-3;Issue-3 173

3 Table 3: Presenting symptoms of infertility patients Symptoms Dysmenorrhoea Chronic pelvic pain Menorrhagia Dyspareunia Irregular cycle Hirshutism Asymptomatic Table 4: Distribution of pelvic abnormality in infertility patients Type No pelvic abnormality Pelvic abnormality Table 5: Type of pelvic abnormalities among infertility patients Type Single pelvic abnormality Multiple pelvic abnormality (n=66) (n=18) Table 6: Laparoscopic findings regarding causes of female infertility Findings Tubal occlusion PCOD Peritubal and periovarian adhesion Endometriotic deposits PID Fibroid Ovarian cyst Genital tuberculosis Normal Int J Med Health Sci. July 2014,Vol-3;Issue-3 174

4 DISCUSSION Infertility is a common medical problem. The role of laparoscopy in the diagnosis of primary and secondary infertility is established beyond any doubt. In this study the prevalence of primary infertility was 78% and secondary infertility was 22%. It is nearly similar to the laparoscopy study conducted by Raida M et al where 74.53% had primary infertility and 25.47% had secondary infertility [13]. Another study by Gulfreen et al shows nearly similar results [14]. Many studies in the literature have shown that there is rise in age at which women presented with infertility. It may be due to delayed marriage and child bearing. In our study mean age at presentation was 25 years in primary and 33 years in secondary infertility, while Nausheen et al reported that the mean age at presentation was 28 years in primary infertility and 32 years in secondary infertility [15]. Another study conducted by Talib et al reported earlier mean age in both primary and secondary infertility was 22.1years and 29.4 years [16]. The duration of infertility was 1-5 years in majority patients, 56.41% in primary infertility and 63.63% in secondary infertility while Ashraf V et al reported that 58% of patients had primary infertility of 2-5 years and 71% of patients had secondary infertility of over 5 years and none had primary infertility of less than two years [17]. In our study, symptoms in infertile women were dysmenorrhea, chronic pelvic pain, menorrhagia, dyspareunia, irregular menstrual cycle and hirshutism. These symptoms were frequently found to be associated with pelvic pathology. According to Nausheen et al, major symptoms were dysmenorrhea, dyspareunia and irregular menstrual cycle [15]. Pelvic abnormality was seen in 84.61% of primary infertility and 81.81% of secondary infertility patients. Nearly similar results seen in Raida M et al where 73.51% of primary and 26.49% of secondary infertility patients had pelvic abnormalities but in another study conducted by Bitzer et al shows same percentage of abnormal findings both in primary and secondary infertility[18]. In present study, tubal occlusion was the most common cause of infertility both in primary and secondary groups. The frequency of tubal occlusion in primary infertility was 29.48% and 31.81% in secondary infertility. According to Nausheen et al tubal occlusion in primary and secondary infertility was 21.4% and 33.33% respectively [15]. In developing countries PID is very much common. Tubal occlusion usually represents pelvic infections or past pelvic surgery. A single episode of PID causes upto 10% of future tubal factor for infertility. In our study PID was seen in 3.84% of primary and 13.63% of secondary infertility patients. It is nearly similar with the study conducted by Q Wani et al where PID was present in 2.4% and 11.1% cases of primary and secondary infertility [19]. In another study by Raida M et al, 2.13% in primary and 5.08% in secondary infertility had PID [13]. Tubal blockage and PID were more frequently found in secondary infertility as compared to primary infertility. Tubal occlusion, peritubal and periovarian adhesion are the factors responsible for inhibition for ovum pickup and transport. In our study, the incidence of peritubal and periovarian adhesion was 10.25% and 13.63% in primary and secondary infertility patients. According to Gulfreen et al, peritubal and periovarian adhesion was 5% in primary and 20% in secondary infertility patients [14]. Polycystic ovarian disease (PCOD) is one of the leading cause of female infertility. The prevalence of PCOD in an asymptomatic woman is thought to be between 16% and 33% [20]. In this study, 20.51% of primary and 4.54% of secondary infertility patients had PCOD. According to Q Wani et al 12.1% of primary infertility and no case of PCOD seen in secondary infertility group in their study [19]. In our study, the incidence of endometriosis was 14.10% in primary infertility and 4.54% in secondary infertility patients. Mauzii et al in their study demonstrated that endometriosis occurs three times more often in patients with primary infertility than patient with secondary infertility [21]. Genital tuberculosis is another important cause of infertility. It is not only causes tubal obstruction and dysfunction but also impairs implantation due to endometrial involvement [22]. In our study genital tuberculosis in primary infertility was 2.56% and 4.54% in secondary infertility patients. According to another study by Varma et al, the presence of genital tuberculosis in infertility in different countries ranging between 15% and 25% [23]. CONCLUSION Diagnostic laparoscopy is a valuable and effective investigation for complete assessment of female infertility. It should be consider earlier in woman with history of pelvic inflammatory disease, past pelvic surgery, prolonged primary infertility and chronic pelvic pain for effective treatment decision. ACKNOWLEDGEMENT I am very grateful to all the faculties of the Obstetrics & Gynaecology Department, colleagues and my patients for their help & co-operation in completing this small piece of work. REFERENCES 1.Hammond MG. Evaluation of the infertile couple. Obstet Gynecol Clin North Am. 1987; 14: Taylor A. ABC of sub fertility: Making a diagnosis. BMJ. 2003; 327: Chachamovich JR, Chachamovich E, Ezer H, Fleck MP, Knauth D, Passos EP. Investigating quality of life and health-related quality of life in infertility: a systematic Int J Med Health Sci. July 2014,Vol-3;Issue-3 175

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