Laparoscopic Findings of Infertile Women at Bangabandhu Sheikh Mujib Medical University

Background: Laparoscopy is an important component of infertility work up. It is the gold standard for evaluation of pelvic pathology and assessment of tubal patency. Objective: The objective of the study was to analyze the laparoscopic findings of infertile women presenting at Infertlity unit of Bangabandhu Sheikh Mujib Medical University. Method: We had a retrospective cross-sectional study on laparoscopic findings of 110 women. Results: Out of all patients 22.7Vo women had endometriosis. Various degrees of adhesion of pouch of Douglus was present n L6.4 7o. Regarding tubal patency,26.4%ohadunilateralblockand2S.2%ohadbilateralblock.Conclusion:Asignificantnumberofinfertilewomen at the Infertitty unit of BSMMU has tuboperitoneal disease and bilateral tubal block and ultimately need in vitro fertillzation.


Introduction:
Laparoscopy enables a detailed visuali zationof pelvis.It allows identification of pelvic pathology and also assessment of tubal patency by chromopertubation.A free spill atthe fimbrial end is reassuring but distension of tube with blockage at the fimbrial end indicates hydrosalphinx formation.Investigation of subfertility is not complete without laparoscopy.' Subfertility is the inability of a couple to achieve concep- tion after 1 yeff of unprotected intercourse.Primary infertility is the absolute state of infenility whereas secondary infertility is the same state developing after an initial phase of fertility.: 95-98] expenses of private infertility centres.The infertility unit of the University offers laparoscopy to all women who have prolonged infertility, abnormal hysterosalpingo_gram and partners with nonnal semen analysis.An analysis of the lapiroscopic findings of these women will help determine the frequency of tubal and pelvic factors which are more likely to require assisted reproductive techniques, procedures not available at the moment in the University.
The study was undertaken to analyse the laparoscopic findings and to find out the possible female factors causing infertility in our patient population.The findings will help in the assessment of the needs of the couples we ffie expected to serve.

Methods:
This retrospective cross sectional study was done on patients who underwent laparoscopy in the Infertility unit, Dept of Obstetrics & Gynaecolgy of Bangabandhu Sheikh Mujib Medical University during the year 2010.A total 110 women were taken for study.
In the yea.r 2010, & total of 2844 infertile couples attended the lnfertility unit outdoor at BSMMU for the first time.
With a prevalence of infertility at 157o, the sample srze was estimated to be 192.The total number of women undergoing laparoscopy in 2010 was 110 , So was the sample size of our study with pu{posive sampling.
Women suffering from primary and secondary infertility, whose husbands are normospermic, duration of inferitility > 2 yrs with no previous history of surgery or had abnormal hysterosalphingogram had laparoscopy for evaluation of infertility.
Laparcsopy was performed under general anaesthesia.
Pneumoperitoneum was created by direct trochar inser- tion and panoramic evaluation of pelvic cavity was made sequentially of ovaries, uterus,fallopian tubes, pelvic peritoneum and pouch of Douglus.Laproscopic dye test was performed with methylene blue and the findings were recorded.Diagnostic D& C was carried out to exclude tuberculosis but the findings are not included in the present study.
Consent was taken from the department and hogpital authority for analyzing available document related to laparoscopy.Data was collected in a pretested semi- structured questionnaire from patients history sheet and operation theatre notes.Data was analyzed using SPSS software version 18.

Results :
A total of 110 infertile women undergoing laparoscopy during the year 20L0 was taken for study of which 70.97o (n=78) had primary infertility and 29.LVo (n-32) had secondary infemility.Age range of the women was 20-40 years, mean 28+4.L0.
Table I shows the laparoscopic findings of the ovaries.
Enlarged pearly white smooth surface ovaries suggestive of polycystic ovary syndrome was present in 46.47o 96 (n=51).Chocolate cysts suggestive of moderate and severe endometriosis was present in 13.67o (n=15).
Table II shows the findings regarding uterine mobility and uterine anomalies.There is restricted mobility of uterus in 15.57o and fixed retroversion in 1.8%o.adenomyosis ( smoothly enlarged uterus with posterior bossing) was present in L3.6%o, fibroid uterus in 12.77o.Right and left fallopian tubes are variably affected, the left tube appearing a little more frequently abnormal than right tube (39.lVo vs 35.5Vo).Table V shows the dye test of both tubes.The dye test was negative in 30Vo of right tubes and 39.1%o of left tubes.The objective of the study was to analyze the laparoscopic findings of the infertile women in the Infertility unit at BSMMU.A total of 110 women was taken for the study.
About ovaries , 46.4%o of the women had enlarged pearly white smooth surface ovaries suggestive of polycystic ovary syndrome.These women could potentially benefit from laparoscopic ovarian drilling, a procedure rarely practiced at this center because of the risk of ovarian adhesion and premature ovarian failure.Chocolate cyst was present in only 4.57o , probably because larger cysts were treated by laparotomy rather than operative laparos- copy.
About uterus, fibroid was visible in 12.77o.most of them was subserous and intramural.Submucous fibroid were likely to be missed because laparoscopy was not always accompanied with hysteroscopy.Adenomyosis ( uniformly enlarged uterus with posterior bossing) was visible in 13.47o.This warranted further evaluation with UH^f for confirmation of the diagnosis of adenomyosis which has significant adverse effect on fertility.I During chromopertubation or dye test 7.47o of the left tube and 12.7 Vo of the right tube had patency after several push.This can be ascertained that these patients had the added benefit of enhanced fertility with laparoscopy over hysterosaphingography, a procedure without anaesthesia that does not permit repeated syringing of dye.
When tubal patency is considered, unilateral block was 26.47o and bilateral block was 28.2Vo.In a similar study carried out on 55 infertile women in Bangladesh Medical College Hospital having laparoscopy during the year 2002-20042, bilateral block was 3.64Vo.Unilateral block was 14.56Vo, of which right sided tubal block was 5.46Vo and left sided tubal block was 9.L0Vo.The findings are much lower than that of our study.In another study3 done about 20 yrs back in the same institution as our study right sided tube was blocked in l47o and left tube was blocked in L5.5%o,so that unilateral block was 29.57o findings more or less similar to that of our study.An study carried out on 253 infertile women in a University Teaching Hospital in Nigeria , bilateral tubal occlusion was in 38.3Vo and unilateral tubal occlusion in zz.l%o.The finding is not far different than then that of ours.aAnwary SA et als carned out a study on the 73 tnfertile women who had laparoscopy in Bangabandhu Sheikh Mujib Medical University between February 2007 and April 2009.In that study dye test was negative in 23.3Vo of the right tubes and 15.17o of the left tubes, whereas in our study dye test was negative in 30Vo of the right tubes and 39.L%o of the left tubes.The number is higher in our study probably because more women with tubal pathology are referred to this hospital now.The pouch of Douglus was obliterated rn 2I.87o in the previous study whereas in our study it is in 4.5Vo.Thts is probably because more women are now treated earlier for pelvic infection.

Conclusion :
The study reveals that there is a high prevalence of tuboperitoneal factors among the infertile women presenting at BSMMU.Those patients with tubal disease have less success with the usual fertility treatments that we provide here at BSMMU eg ovulation induction with timed intercourse and intrauterine insemination.We are able to counsel them accordingly.The laparoscopic findings help us identify those patients with severe endometriosis and severe tubal disease including bilateral tubal block who need in vitro fefirhzation.The infertility wing aIBSMMU should be developed into a complete @rtraty level care with full facilities of assisted reproductive techniques eg in vitro fertrhzation.Since majority of theses couples cannot afford assisted reproductive techniques, they can be alternatively counseled for adoption or childless living.
Bangabandhu Sheikh Mujib Medical University offers treatment to the infertile couples who cannot afford the Address for Correspondence: Dr. Shakeela Ishrat , Assistant Professor, Infetility unit, Department of Obstetrics & Gynaecology, BangabandhuShekh Mujib Medical University.Cell phone: 0172989722L

Table
III describes the endometriosis, pouch of Douglus and tubal patency.A total of 25 patients out of 110 ( 22.1%o ) had endometriosis of which 3.67o was minimal and 5.57o was mild endometriosis.Pouch of Douglus was normal in most cases.Various degrees of adhesion of Pouch of Douglus was present in 16.47o.Regarding tubal patency, 26.47o had unilateral block and 28.27o had bilateral block.Table IV describes the appearance of fallopian tubes.

Table - I
Laparoscopic findings of ovaries in infertile women Findinqs Of Infertile Women At Bmqabandhu Sheikh Muiib Medical Universitv Shakeela Iskat et al LaparoscoDic

Table - II
Laparoscopic findings of uterus in infertile women