This study assessed infertility using hystero-laparoscopy in 504 patients over 3 years. Key findings include: Tubal factors were the leading cause of infertility (35%). Hysteroscopy found endometrial polyps in 5% and adhesions in 4%. Laparoscopy found endometriosis in 20% and thickened tubes in 13%. Hystero-laparoscopy allowed diagnosis of factors missed by other tests and endoscopic management such as adhesiolysis, myomectomy, or polycystic ovarian drilling. The study concluded hystero-laparoscopy is a feasible one-time approach for infertility assessment and treatment.

1. ASSESSMENT OF INFERTILITY
USING HYSTERO-
LAPAROSCOPY

3. INTRODUCTION
• Failure to conceive a desired pregnancy after
12 months of unprotected sexual intercourse
• Male and female are equally affected

4. INDIAN PERSPECTIVE
• “Barrenness amid plenty”
– Increased incidence in countries with high fertility rates
• Developing countries- 6.9-9.3%*
– Primary infertility: 1/3
– Secondary infertility: 2/3
• Developed countries- 3.5-16.7%*
*Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility prevalence and
treatment-seeking: potential need and demand for infertility medical care. Hum Reprod 2007;
22(6):1506-12.

6. CAUSES OF INFERTILITY
Tubal and
pelvic
pathology-
35%
Male
problems
35%
Ovulatory
dysfunction-
15%
Unexplain
ed
infertility
10%
Unusual
problems
5%

7. ENDOMETRIAL FACTORS
• Intrauterine adhesions
• Endometrial polyp
• Submucosal fibroid
• Congenital malformations
• Endometrial Receptor defects
MYOMETRIAL FACTORS
• Leiomyomas
• Adenomyosis
CERVICAL FACTORS

8. AIMS & OBJECTIVES
• Assess the etiopathology of infertility
– Uterine factors
– Tubal factors
– Ovulatory factors
– Cervical factors
• Study the distribution of infertility in the population
• Use hystero-laparoscopy as a tool in the diagnosis and
management of infertility

9. MATERIALS AND METHODS
• Study Design
• Prospective Study
• Institute
• L.T.M.M.C. and L.T.M.G.H
• Cases Studied
• 504
• Study Period
• 3 years

10. INCLUSION CRITERIA
• Women aged 20-40 years
• Duration of marriage>1 year
• Couples who had undgergone complete
infertility assessment
• Male factor ruled out

11. EXCLUSION CRITERIA
• Active generalised infection
• Bowel obstruction
• Abdominal wall hernia
• Tubercular peritonitis with adhesions
• Large pelvic masses
• Cardiorespiratory diseases

12. PARAMETERS STUDIED
• Age
• Married life
• Regularity of menstrual cycles
• Duration of infertility
• Hystero-laparoscopic findings
• Operative intervention

13. METHODOLOGY
• Hysteroscopy
– Panoramic view of the
uterus, ostia, endocervical
canal
• Laparoscopy
– Abdominal cavity
– Uterus
– Fallopian tubes
– Ovaries
– Pouch of Douglas
– Uterovesical Pouch
– Tubal Patency Test

14. STATISTICAL ANALYSIS
• Observational study
– Percentage calculations

15. DISTRIBUTION OF INFERTILITY
PRIMARY
INFERTILITY
65%
SECONDARY
INFERTILITY
35%

16. AGE-WISE DISTRIBUTION
0 10 20 30 40 50
<20
20-25
25-30
>30
6
50
30
14
5
21
50
24
SECONDARY INFERTILITY
PRIMARY INFERTILITY
Percentage

17. DURATION OF INFERTILITY
0
10
20
30
40
50
60
70
80
<5 YRS 5-10 YRS >10 YRS
77
18
5
69
27
4
PRIMARY INFERTILITY
SECONDARY INFERTILITY

18. RESULTS
• Normal per speculum examination: 77%
• Normal per vaginal examination: 83%
• Regular menstrual cycles- 67%
• Past history
– Tuberculosis- 7%
– Curettage- 3%

19. ETIOLOGICAL FACTORS
25
11 6 5
53
32
15
7 4
42
0
10
20
30
40
50
60
70
80
90
100
TUBAL OVARIAN PERITONEAL COMBINED UNEXPLAINED
SECONDARY INFERTILITY
PRIMARY INFERTILITY

20. HYSTEROSCOPIC FINDINGS
77
5
4
3
3
2 2
1 11 1 Normal
Thickened endomerium
Endometrial polyp
Cervical stenosis
Asherman syndrome
Narrow cavity
Adhesions
Uterine Septum
Bicornuate uterus
Complete vaginal
septum

21. LAPAROSCOPIC FINDINGS
KOCH'S
20%
TO MASS
24%
UNILATERAL
HYDROSALPINX
12%
BILATERAL
HYDROSALPINX
9%
ENDOMETRIOSIS
20%
THICKENED TUBES
13%
MULLERIAN
AGENESIS
2%

22. CHROMOPERTUBATION
Bilateral
spill
91%
Unilateral
spill
5%
No spill
4%

23. OPERATIVE INTERVENTION
0 10 20 30 40 50 60
ADHESIOLYSIS
PCOD DRILLING
MYOMECTOMY
ENDOMETRIOTIC SPOT ABLATION
ENDOMETRIOMA DRAINAGE
FIMBRIOPLASTY
SALPINGOSTOMY
52
15
18
8
4
2
1

24. OPERATIVE INTERVENTION
0 10 20 30 40 50 60 70 80 90
Only diagnostic
Cervical dilatation
Endometrial Polypectomy
Hysteroscopic septal resection
Vaginal septum resection
82
7
7
3
1

25. OUTCOME
Successful pregnancies in
21%

26. CONCLUSION
• Hystero-laparoscopy- Third eye of the Gynaecologist
• Feasible and acceptable procedure- "one time
approach”
– Diagnosis of factors missed by any other method such as
by ultrasound or hysterosalpingography
– Endoscopic management (cystectomy, myomectomy,
septum resection or polycystic ovarian drilling) in the
same sitting