The necessity of laparoscopy for unexplained infertility.

Performing laparoscopy may have priority over assisted reproductive technology.

Key Points

Importance:

• The utility of diagnostic laparoscopy in unexplained infertility may be skeptical if it only involves the surgical correction of endometriosis and peri adnexal adhesions.

Highlights:

• The first choice is ovarian stimulation/intrauterine insemination for unexplained infertility if tubal patency and motile sperm are confirmed. 
• Laparoscopy should be the first choice before starting ART, especially in women with suspected endometriosis.

What's done here:

• A literature-based priority algorithm for ART modalities versus diagnostic laparoscopy for the treatment of unexplained infertility is provided to guide the clinicians. 

Main Remarks: 

• When tubal patency and sperm motility are confirmed, diagnostic laparoscopy is being increasingly bypassed before deciding ART for unexplained infertile couples due to cost-benefit inconvenience, especially in the countries that offer government programs or private health insurance plans.
• When it comes to endometriosis as the cause of unexplained infertility, there might be a great difference in the rate of abnormal findings that can be noted between laparoscopy and non-invasive tests: Diagnostic laparoscopy becomes essential due to the role of peritoneal fluid and cytokines such as (IL-6, TNF-a) that cause infertility in endometriosis and the cumulative pregnancy rate increases after laparoscopic surgery in women < 35 years with mild-moderate endometriosis.
• In terms of comparing HSG to laparoscopy, HSG has a sensitivity of 40-50% to detect bilateral tubal occlusion: false-negative rates for proximal or distal tubal occlusion are high (50% and 60%). For patients with a high risk of tubal disease, laparoscopy should be preferred.
• Physiologically dysfunctional fallopian tubes may appear patent under high pressure, hence a laparoscopic approach will be helpful for neo-salpingostomy to increase the spontaneous pregnancy.
• PID, chlamydial infection, age and duration of infertility, secondary infertility, previous surgery, and the risk factors for laparoscopy should be taken into account.

Lay Summary

The standard for accepting a couple as "infertile" is the inability to conceive after 12 months of regular unprotected intercourse. When this condition is met, assessing the number of motile sperm in the male partner and certifying the patency at least in one tube in the woman partner becomes important. After confirming these criteria, we can talk about "unknown infertility". Additional clinical tests such as postcoital cervical mucus detection, endometrial biopsy, ovarian reserve assessment,  serum prolactin levels, immunological factor screening are used to be done to identify the underlying reason.

The unexplained infertility prevalence rate is 30% and could be lowered if diagnostic tools with high detection rates like laparoscopy would be implemented correctly. Timing for laparoscopy is still an area of debate. There is no common consensus between societies and trained infertility specialists whether diagnostic laparoscopy is a mandatory step to ensure unexplained infertility. Although laparoscopy reveals the underestimated pelvic pathologies that contribute to subfertility and create a positive effect on spontaneous conception through surgical correction, the cost-effectiveness and unproven prognostic utility of the procedure are the major obstacles to prefer it as a routine.

Arab et al. from the Department of Obstetrics Gynecology of Saint Joseph University, Beirut, Lebanon, presented and discussed a literature-based algorithm for managing unexplained infertility in his recently published paper in the journal JBRA Assisted Reproduction.

An algorithm for priority to select ART or laparoscopy was given to lead the way to cure unexplained infertility. According to this algorithm, laparoscopy is the first choice for women who have risk factors. If the patient is young and has no risk, the therapy could be started with OS-IUI and in case of failure after 3 years laparoscopy will be the choice. For older-aged and no-risk women the only therapy model would be IVF in this algorithm.

This algorithm based on appropriate selection criteria concerning the utility of laparoscopy minimizes the questioning diagnosis on behalf of unexplained infertility and leads to establishing a new management paradigm.

Research Source: https://pubmed.ncbi.nlm.nih.gov/34751015/