Indian Journal of Obstetrics and Gynecology Research

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Online ISSN: 2394-2754

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Indian Journal of Obstetrics and Gynecology Research (IJOGR) open access, peer-reviewed quarterly journal publishing since 2014 and is published under auspices of the Innovative Education and Scientific Research Foundation (IESRF), aim to uplift researchers, scholars, academicians, and professionals in all academic and scientific disciplines. IESRF is dedicated to the transfer of technology and research by publishing scientific journals, research content, providing professional’s membership, more...


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Arora, Bodade, Dhurve, Vaishnao, and Bagga: Correlation of laparoscopic finding with ultrasonography and hysterosalpingography findings in females with infertility


Introduction

Infertility is defined as the inability to conceive after one year of unprotected regular sexual intercourse.1 Total infertility is divided into primary and secondary infertility. Primary infertility is defined as the inability to conceive after one year among women 15 to 49 years old with contact with sexually active partners and no contraceptive use. Secondary infertility refers to the inability to conceive following a previous pregnancy.1, 2

Fertility varies across various regions of the world and is estimated to affect 8 to 12 percent of couples worldwide.2 For many couples, infertility and its treatment cause a serious strain on their interpersonal relationship, and cause disturbed relationships with other people.3 The most common factors responsible for infertility in females are anovulatory disorder, tubal factors, uterine and cervical factors along with endometriosis. One third of the infertility cases are due to anatomical abnormalities of the female reproductive tract such as tubal blockage.4, 5

An accurate diagnosis is the best key to the treatment. The workup of the female partner begins with history and examination. It is more important to perform the relevant investigation in a logical order at the correct time as compared to the routine simple so least invasive and most predictive investigations should be performed first. A number of diagnostic tests are being used in clinical practice to assess tubal patency as part of the work-up for sub-fertility.6

Conventional way to assess the uterine cavity, tubal structure and tubal patency was Hysterosalpingography but now it has been largely superseded by laparoscopy and hysteroscopy. Laparoscopy is considered the clinical reference test for diagnosing tubal pathology.7 Laparoscopy allows visualization of peri-adnexal adhesions and the presence of endometriosis, which cannot be done with HSG.8 It provides information regarding tubal and ovarian status, uterine normality and standard means of diagnosing various pelvic pathology e.g. pelvic inflammatory disease, endometriosis, pelvic congestion and tuberculosis. Untreated pelvic inflammatory disease, post-abortal, postpartum infection and tuberculosis are common factors of infertility in developing countries.8

Diagnostic laparoscopy is generally not a part of initial infertility evaluation, however, number of reports haves hown that it is effective procedure for evaluation of long- term infertility.

Materials and Methods

A total of 207 patients were studied from September 2017 to June 2019 at Government Medical College and Hospital, Gondia, Maharashtra. Out of 207 patients, 202 patients had primary/secondary infertility and 5 patients had primary amenorrhea were selected for study.

Study subjects were screened and evaluated clinically with detailed history. All the investigations of female partner were carried out. Before doing laparoscopy, patients were informed of the diagnostic nature of the test and the potential risks involved and consent obtained. Laparoscopy was done during pre-menstrual phase of the cycle. Patients were admitted a day before laparoscopy and after thorough evaluation, preparation and fitness patient were posted for diagnostic laparoscopy.

Standard basic laparoscopic principles were followed during the procedure. Patient in lithotomy position. Per-vaginal and per-speculum examination done and anterior lip of cervix was caught with vulsellum and manipulator was inserted in cervical canal.Umbilicus was used for camera port and assistant manipulates the uterus per-vaginally with manipulator. Uterus, ovaries, tubes and cul de sac were inspected and findings noted. Next chromopertubation test was done with 10-15 ml of 1% aqueous methylene blue via the leech-Wilkinson cannula was inserted and findings noted.

The patient was discharged next day after counseling about the further plan of treatment depending upon the whole investigative workup. Data was collected and grouped. Standard statistical software (SPSS v17) was used for analysis of data.

Results

In this study total 207 patients were studied. Mean age of the study group was 26.71 years (range 19-39 years). Maximum patients (41.54%) were in age group 26-30 years. 81.16% patients had primary infertility, 16.43% patients had secondary infertility and 2.41% had primary amenorrhea. Maximum patients had 3 to 5 years of infertility (mean 5.21 years for primary infertility, 4.57 years for secondary infertility) at presentation. The incidence of study subjects having one abortion is 2.47%, 2 abortions is 6.43% and those having 3 or more abortions is 0.99%.

Table 1

Gynaecological examination of patient

Per vaginal/ per-rectal findings

No. of subjects

Percent (%)

Uterus

No. uterus felt

4

1.93

Small sized uterus

23

11.21

Normal sized uterus

172

83.09

Enlarged uterus

08

03.87

Total

207

100

Adnexa

Adnexa not palpable

112

54.10

Adnexa palpable

95

45.90

Total

207

100

In 1.93% subjects uterus was not felt, 11.21% had small sized uterus, 83.09% had normal sized uterus and 3.87% had enlarged uterus. In 45.90% adnexa was palpable on gynaecological examination.

Table 2

Distribution of study subjects as per Ultrasonography findings

Ultrasonography Findings

No. of subjects

Percent (%)

Small sized uterus with small sized ovaries

11

5.31

Small sized uterus with normal sized ovaries

07

3.38

Small sized uterus with bigger sized ovaries

04

1.93

Normal sized uterus with small sized ovaries

38

18.36

Normal sized uterus with normal sized ovaries

102

49.29

Normal sized uterus with bigger sized ovaries

37

17.87

Enlarged uterus with normal sized ovaries

07

3.38

Enlarged uterus with bigger sized ovaries

01

0.48

Total

207

100

In the present study, the incidence of normal sized uterus on USG is 49.29%, small sized uterus is 10.62% and enlarged uterus is 3.86%.

Table 3

Distribution of patients according to laparoscopic findings of uterus

Uterus

No. of subjects

Percent (%)

Small sized uterus

25

12.07

Normal sized uterus

165

79.70

Large sized uterus

13

06.27

Mayer – Rokitansky – Kuster - Hauser syndrome

04

1.93

Total

207

100

The incidence of normal sized uterus in laparoscopy is 79.70% and of small sized uterus is 12.07% and enlarged uterus is 6.27%.

Table 4

Distribution of patients according to ovarian findings on laparoscopy

Finding of ovary

No. of subjects

Percent (%)

Streak with e/o ovulation

2

0.97

Streak without e/o ovulation

2

0.97

Normal size with e/o ovulation

98

47.33

Normal size without e/o ovulation

86

41.55

Polycystic ovary with e/o ovulation

1

0.48

Polycystic ovary without e/o ovulation

8

3.86

Ovarian cyst

6

2.9

Only one ovary visualized

2

0.97

Both not visualized

2

0.97

Total

207

100

In this study the incidence of normal sized ovaries on laparoscopy is 47.33%, streak ovaries is 1.94%. The incidence of polycystic ovaries is 4.34% and of ovarian cyst is 2.9%. In 2 (0.97%) subjects both ovaries were not visualized and in 2 (0.97%) only one ovary was visualized.

Table 5

Distribution of patients according to fallopian tube abnormalities on laparoscopy

Findings of fallopian tube

No. of subjects

Percent (%)

Normal

148

71.49

Small hydrosalpinx

26

12.56

Huge hydrosalpinx

9

4.34

Beaded tubes

24

11.59

Total

59

28.49

According to the findings of present study 35 (16.90%) subjects had hydrosalpinx while 24 (11.59%) subjects had beaded tubes and 10 (4.83%) subjects had tubercles over pelvic organs, i.e. uterus, tubes and ovaries.

Table 6

Hysterosalpingography (HSG) findings

Findings of HSG

No of subjects

Percent (%)

Tubes patent

66

52.38

Tubes blocked

37

29.36

Unilateral hydrosalpinx

10

07.94

Bilateral hydrosalpinx

05

03.97

Beaded tubes

03

02.38

Tubes blocked with unilateral hydrosalpinx

02

01.59

Tubes blocked with bilateral hydrosalpinx

02

01.59

Tubes with beaded appearance

01

00.79

Total

126

100

In the present study HSG was done in 62.38% subjects, out of them 52.38% showed patent tubes, while 29.36% showed blocked tubes.

Table 7

Distribution of patients according to chromopertubation findings

Results

No. of subjects

Percent (%)

Patent tube

153

75.75

Blocked tube

Unilateral

Blateral

23.26

Cornual block

4

5

Isthumal block

9

14

Fimbrial block

4

11

Total

17

30

Not possible

2

0.99

Total

202

100

Total 202 patients (97.58%), underwent laparoscopic chromopertubation, In 2 (0.99%) subjects chromopertubation was not possible due to one subject with vaginal atresia and one had pelvic adhesions.

In present study, 29 (14%) had tubal adhesions while 6(2.9%) had ovarian adhesions and 27(13.04%) subjects had both tubal and ovarian adhesions. In 18 (8.7%) subjects there was mild endometriosis and in 7 (3.38%) subjects there was moderate to severe endometriosis. 77 subjects had free fluid in pouch of Douglas / abdomen.

Table 8

Distribution of patients according to various pathologies on laparoscopy

Pathology

No. of subjects

Percent (%)

Structural adhesions

Tubal

29

14

ovarian

6

2.90

Both tubal and ovarian

27

13.04

Total

62

29.94

Endometriosis

Mild

18

8.70

Moderate to severe

7

3.38

Total

25

12.08

Table 9

Correlation of laparoscopy and ultrasonography findings

Organ

Laparoscopy findings (%)

Ultrasonography findings (%)

Mean

‘p’ < 0.05 – significant

Uterus

Small sized uterus

12.07

10.63

.014

.083

Normal sized uterus

79.70

85.51

-.058

< 0.001

Large sized uterus

06.27

3.86

.024

.025

Ovary

Small Ovaries

3.86

23.67

-.198

< 0.001

Normal Ovaries

88.89

56.04

.329

< 0.001

Enlarged ovaries

7.25

20.29

-.130

< 0.001

In the present study, 10.62% subjects had small size uterus, while laparoscopy demonstrated small size uterus in 12.07% subjects, (‘p’ > 0.05 –not significant).85.50% subjects had normal size uterus while laparoscopy revealed it in only 79.70% subjects (‘p’ < 0.05 – significant). 3.86% had enlarged uterus while laparoscopy revealed it in 06.27% subjects (‘p’ > 0.05 –not significant).

Similarly, 3.86% cases had small or non-visualized ovaries on laparoscopy whereas 23.67% cases had sonographically demonstrated small ovaries (‘p’ < 0.05 – significant). 88.89% cases had normal ovaries on laparoscopic whereas 56.04% had normal ovaries on USG (‘p’ < 0.05 – significant). 7.25% cases had enlarged ovaries due to single or multiple cyst whereas 20.29% cases had enlarged ovaries demonstrated on USG (‘p’ < 0.05 – significant).

Table 10

Correlation of Laparoscopy and Hysteroscopy findings

Fallopian Tubes

Laparoscopic findings (%) + chromopertubation

Hysterosalpingography findings (%)

‘p’ < 0.05 -- significant

Mean

Patent tubes

75.75 (n=202)

52.38 (n=126)

< 0.001

0.431

Blocked Tubes

23.26 (n=202)

29.36 (n=126)

0..014

0.030

Hydrosalpinx

16.91 (n=207)

15.08 (n=126)

< 0.001

0.097

Beaded tubes

11.59 (n=207)

3.17 (n=126)

< 0.001

0.097

In the present study, the incidence of patent tubes on laparoscopy is 75.% and that of blocked tubes is 23%. In 30 subjects (14.49%), both the tubes were blocked, out of which 14 had Isthumal block,11 had Fimbrial block, and 5 had Cornual block. In 17 subjects (8.21%), there was unilateral block out of which 9 had Isthumal block, 4 had Fimbrialblock and 4 had Cornual block. In 2 subjects, chromopertubation was not possible due to one subject with vaginal atresia and one had pelvic adhesions.

The incidence of patent tubes on hysterosalpingography is 52.3% andthe incidence of patent tubes on laparoscopy is 75.75%, (‘p’ < 0.05 – significant). The incidence of blocked tubes on laparoscopy is 23.26% and incidence of blocked tubes on hysterosalpingography is 29.36%, (‘p’ > 0.05 – not significant). Incidence of hydrosalpinx on laparoscopy was 16.91% and on HSG was 15.08%, (‘p’ < 0.05 –significant). In the present study the incidence of beaded tubes on laparoscopy was 11.59% and on HSG was 3.17%, (‘p’ < 0.05 –significant).

Discussion

Out of total 207 patients studied. Mean age of the population studied was 26.71 years. Parveen S et al.9 showed the mean age of infertility was 28.4 years. Similarly, a study by Adamson P10 from Mysore, India showed the mean age of infertility was 28.4years.

81.16% subjects had primary infertility whereas 16.43% had secondary infertility. Shetty SK11 showed that there were 68% cases of primary infertility and 32% cases of secondary infertility.

Duration of primary infertility was between 1-13 years with a mean of 5.21 years and secondary infertility was between 2-12 years with a mean of 4.57 years. Study by Babar M et al.12 showed that the maximum number (45.7%) of patient presented after 2-5 years of failure to conceive and 54.3% of patients had duration of infertility of more than 5 years.

In the present study maximum 165 (79.7%) had normal size uterus. Out of which 8 (3.86%) had bicornuate uterus. Similarly, Thankam R, et al. (1978),13 quoted bicornuate uterus in 2.63% of patients. In the present study, 6.28% subjects had large size uterus. Out of which 5.80% had fibroid and 0.48% had adenomyosis. Similar results reported by Khaula et al.14 from Lahore. The incidence of myoma in women with infertility without any obvious cause of infertility is estimated to be 1-2.4%. 1.96%subjects had Meyer –Rokitansky – Kuster -Hauser syndrome.

In the present study, 16.90% had hydrosalpinx however Gupta et al. (1984),15 quoted in 6.4%. This may be due to high prevalence of tuberculosis in our region. 11.59% subjects had beaded tube. In the present study, 4.80% subject had tubercles over pelvic organs.

Diagnostic Laparoscopy was significantly beneficial in detection of normal uterine pathologies and all ovarian pathologies but not significantly beneficial in detection in small and large uterine pathologies.

Incidence of patent tubes onLaparoscopy with chromopertubation is significantly better than HSG in diagnosing patency and pathologies of fallopian tubes. Sarogi et al (1981),16 quoted bilateral blockage in 17.5% and unilateral in 9.16% of patients. Hutchins (1977),17 reported 10.3% of bilateral and 10.1% of unilateral tubal block.

In present study, 14% subjects had tubal adhesions while 3% had ovarian adhesions and 13.04% subjects had both tubal and ovarian adhesions. Similarly Mahmoud F, et al (1978),18 quoted pelvic adhesions in 30.35%. In 9% subjects, there was mild endometriosis and in 3.38% subjects, there was moderate to severe endometriosis. 77 subjects had free fluid in pouch of Douglas / abdomen. Thankam R et al (1978)13 reported in 12.03%.

Endometriosis may lead to female infertility, although it has not been confirmed whether endometriosis can be the sole cause of infertility or it is only contributory factor that leads to it. Nevertheless, most women who are infertile suffer from endometriosis. The clinical signs and symptoms that make on of endometriosis (dysmenorrhea, dyspareunia, abnormal uterine bleeding, chronic pelvic pain and/or pelvic mass, utero-sacral ligament nodularity) are not reliable enough to justify diagnosis and treatment. Current thinking dictates visual and/or microscopic confirmation through laparoscope before diagnosing or treating a patient for endometriosis.

Conclusion

According to the findings of the present study, Laparoscopic diagnosis and hysteroscopy is a better modality for diagnosing uterine, tubal and ovarian causes of infertility compared to hysterosalpingography and ultrasonography. Most of the patients had normal ultrasonographic, hysterosalpingographic and laparoscopic findings. In most of the patients, structural adhesions were the most common cause of infertility among women in reproductive group.

Source of Funding

None.

Conflict of Interest

The authors declare no conflict of interest.

References

1 

MC Inhorn Global infertility and the globalization of new reproductive technologies: illustrations from EgyptSoc Sci Med2003569183751

2 

T Bushnik JL Cook AA Yuzpe S Tough J Collins Estimating the prevalence of infertility in CanadaHum Reprod201227373846

3 

JO Omoaregba BO James AO Lawani O Morakinyo OS Olotu Psychosocial characteristics of female infertility in a tertiary health institution in NigeriaAnn Afr Med2011101192410.4103/1596-3519.76567

4 

PC Adamson K Krupp AH Freeman JD Klausner AL Reingold P Madhivanan Prevalence & correlates of primary infertility among young women in MysoreIndia. Indian J Med Res20111344406

5 

N Sami TS Ali S Wasim S Saleem Risk factors for secondary infertility among women in Karachi, PakistanPLoS One201274e3582810.1371/journal.pone.0035828

6 

I Tsuji K Ami N Fujinami H Hoshiai The significance of laparoscopy in determining the optimal management plan for infertile patients with suspected tubal pathology revealed by hysterosalpingographyTohoku J Exp Med201222721058

7 

M Robabeh T Roozbeh Comparison of hysterosalpingography and laparoscopy in infertile Iranian women with tubal factorGinekol Pol201283118413

8 

MN Sakar T Gul AE Atay Y Celik Comparison of hysterosalpingography and laparoscopy in the evaluation of infertile womenSaudi Med J200829913158

9 

Majidah Sajeda Parveen Khanam Role of Combined Diagnostic Laparoscopy And Simultaneous Diagnostic Hysteroscopy For Evaluation Of Female Subfertility FactorsJournal Of Surgery Pakistan (International)2010151

10 

PC Adamson K Krupp AH Freeman JD Klausner AL Reingold P Madhivanan Prevalence & correlates of primary infertility among young women in Mysore, IndiaIndian J Med Res201113444406

11 

SK Shetty H Shetty S Rai Laparoscopic evaluation of tubal factor in cases of infertilityInt J Reprod Contracept Obstet Gynecol2013234103

12 

Mehreen Babar Et Al Diagnostic Significance Of Laparoscopy In Infertility & Identification Of Various Unsuspected Factors Associated With Infertility In FemalesJ. Pharm. Sci. & Res201028499505

13 

TR Verma H Murphy Diagnostic value of laparoscopy in gynaecology197828128https://jogi.co.in/articles/files/filebase/Archives/1978/feb/1978_128_135_Feb.pdf

14 

K Khaula Role of diagnostic laparoscopy in evaluation of female subfertilityServ Inst Med Sci20053314

15 

S Gupta P Gupta A Taly R Das Comparative study: Hysterosalpingography and laparoscopy in 120 cases of infertilityJ Obstet Gynaec India198434685

16 

RM Sarogi VR Ambiye MY Rawal Comparision of Hysterosalpingography and Laparoscopy in the evaluation of tubal function in infertilityJ Obstet Gynaec198131630

17 

C Hutchins Laparoscopy and hysterosalpingography in the assessment of tubal patencyObstet Gynaec197749325

18 

MF El-Minawi M Abdel-Hadi AA Ibrahim O Wahby Comparative evaluation of laparoscopy and hysterosalpingography in infertile patientsObstet Gynecol19785112932



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© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Original Article


Article page

437-442


Authors Details

Garima Bagga Arora*, Ritesh Bodade, Asmita Dhurve, Lohit S Vaishnao, Gourav Bagga


Article History

Received : 20-09-2021

Accepted : 07-10-2021

Available online : 26-11-2021


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