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for postinflammatory tubal infertility. Fertil Steril 1988;50:855–9.

(12) Carey M, Brown S. Infertility surgery for pelvic inflammatory

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PO, Hamberger L. Hydrosalpinx and IVF outcome: a prospec-

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evidence. Obstet Gynecol Surv 2001;56(8):483–91.

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Rony Abdallah *, Isaac Kligman

The Center for Reproductive Medicine and Infertility,Weill Medical College of Cornell University,

NewYork,

NY, USA*Address: The Center for Reproductive Medicine and

Infertility, Weill Medical College of Cornell University,M.D. 1305 York Avenue, New York, NY 10021, USA.

Tel.: +1 646 962 2764.E-mail: rta9002@med.cornell.edu

150 Debate

Comment by: Ahmed Nasr

1. Introduction

Around the globe, gynecologists are far from reaching a unan-imous agreement about the role of laparoscopy in infertility

management. Unanswered remains the all-important questionof when to perform laparoscopy, if ever, in the infertility work-up. The currently available evidence generates a great deal of

uncertainty, controversy, cynicism and skepticism amongpracticing gynecologists and infertility specialists. Pragmaticuse of diagnostic laparoscopy for the evaluation of all cases

of female infertility is a contentious issue. Ten years ago, al-most 90% of all reproductive endocrinologists in the USA rou-tinely performed a laparoscopy in the diagnostic work-up ofinfertility (1). However, in up to two thirds of women, no def-

inite pathology was witnessed or only minimal and mild endo-metriosis (2). In the mid-1990’s, the test ‘diagnosticlaparoscopy’ failed to be an ideal predictor for infertility (3).

Consequently, routinely performing this procedure has beenseriously challenged (4). In many IVF clinics worldwide, diag-nostic laparoscopy is increasingly bypassed in an endeavor not

only to avoid potential complications but also to reduce costs(3). Strong advocates of the procedure highly praise laparos-copy as a gold standard diagnostic tool that can be combinedwith hysteroscopy and endometrial biopsy as part of day care

surgery with the potential of performing both diagnosis andtherapy. Counter-agonists, on the other hand, focus on otherless invasive diagnostic substitutes as well as disadvantages

including the need for general anesthesia, patient’s anxietyand the possibility of adhesion formation (3). With the swingof the pendulum, equipoise is still out of reach.

2. Could laparoscopy be reliably replaced by unconventional

diagnostic procedures in the evaluation of tuboperitoneal

infertility?

Hysterosalpingography (HSG) has been classically used fordecades for the evaluation of tuboperitoneal infertility. Hys-

terosalpingo Contrast Sonography (HyCoSy) is an attractiveultrasonography-based tool for outpatient screening for tubalpatency. Besides lack of exposure to X-rays or iodinated con-trast media, assessment of tubal patency was as good as con-

ventional HSG (5). A new imaging technique called salineintraperitoneal sonogram (SIPS) has been demonstrated as asafe, quick, and potentially cost-effective method for evaluat-

ing pelvic adhesive disease in an outpatient facility in womenwith unexplained infertility and a normal HSG (6). DynamicMR-hysterosalpingography with cervical cannulation and

intracavitary gadolinium injection has allowed assessment ofthe uterus, fallopian tubes, and extra-uterine pelvic structures,while avoiding all ionizing radiation (7). Based on symptoms

suggestive of previous pelvic inflammatory disease (PID), ahistory of abnormal vaginal discharge and a previous diagno-sis of a lower genital tract infection, the positive predictive va-lue of thorough history taking, was only 56%, 59%, and 35%,

respectively, in predicting tuboperitoneal infertility (3,8).Given the fact that Chlamydia trachomatis is the most impor-tant etiologic factor in PID, screening for Chlamydia antibod-

Debate 151

ies (by Chlamydia antibody testing or CAT) has been pro-posed as a primary screening tool for infertility due to tubalpathology (9). In endometriosis, however, the situation is more

vexing. Many women with pelvic endometriosis are symptom-free (10). Lack of satisfactory non-invasive tests for endometri-osis has given laparoscopy the credit of being the gold stan-

dard for diagnosis, preferably with histologic confirmation (11).

3. Role of laparoscopy in ovarian-factor infertility

There is a serious lack of evidence regarding routine use ofdiagnostic laparoscopy before the onset of ovulation inductiontreatment or after several failed ovulation induction cycles;

only few retrospective and non-controlled studies are avail-able. A recent Cochrane review concluded that laparoscopicovarian drilling (LOD) was a satisfactory second-line treat-

ment strategy in women with clomiphene citrate-resistantPCOS that proved to be as effective as gonadotropin treatmentwith similar live birth and miscarriage rates. Potential advan-tages of LOD over gonadotropins include ease and conve-

nience of the treatment, reduction in OHSS and multiplepregnancy rates, increased responsiveness of the ovary to oralovulation induction agents after the procedure, sustainability

of ovarian activity as evidenced by consecutive spontaneousovulations resulting years after LOD and the added value ofmaking a laparoscopic assessment of the pelvis (12).

4. Role of laparoscopy in endometriosis and pelvic adhesive

disease

In a recent Cochrane review, Jacobson and co-workers (13)concluded that use of laparoscopic surgery in the treatmentof subfertility related to minimal and mild endometriosis

may improve future fertility. However, no RCTs or meta-anal-yses are available for laparoscopic treatment of moderate andsevere endometriosis, albeit it is generally accepted that thoseshould be treated by surgery (10). A negative correlation be-

tween the stage of endometriosis and the spontaneous cumula-tive pregnancy rate (CPR) after surgical management has beenreported (3). Regarding laparoscopic adhesiolysis, only one

non-randomized controlled study documented higher CPRafter the procedure (14).

5. Laparoscopic myomectomy

Compared with laparotomy, laparoscopic myomectomy hasthe advantages of small incisions, short hospital stay, less post-

operative pain, rapid recovery and good assessment of otherabdominal organs. Laparoscopic myolysis causes severe adhe-sion formation. Laparoscopic myomectomy is still the besttreatment option for symptomatic women with uterine fibroids

who wish to maintain their fertility (15). Laparoscopic sutur-ing is more demanding. This can be overcome by robotic-as-sisted laparoscopic myomectomy (16).

6. Role of laparoscopy in assisted reproductive technology

(ART)

Tremendous advancements in ART have undoubtedly en-croached upon the role of reproductive surgery; some authors

strongly advocate immediate treatment with ART after a lim-ited and non-invasive infertility work-up in all patients (17).Two critical issues remain controversial. First, should the diag-

nostic infertility work-up be completed with a laparoscopyprior to ART? Second, what is the precise role of laparoscopyfollowing repeated ART failures? The vast majority of repro-

ductive surgeons do, however, agree that hydrosalpinx andovarian endometriotic cysts have to be managed laparoscopi-cally prior to IVF. Two RCTs have documented increased

implantation and pregnancy rates in IVF cycles after salpin-gectomy for ultrasonically visible hydrosalpinges; eight womenwould have to undergo salpingectomy prior to IVF to gain oneadditional live birth (18). In cervical factor, unexplained and

mild male infertility, IUI is an effective fertility enhancingtechnique. Contentious issues in the setting of IUI treatmentinclude the role of laparoscopy in tailoring and timing of treat-

ment plans, being performed prior to or only after several IUIfailures. Paucity of randomized trials addressing these issuescall for an urgent need for further randomized studies to come

up with plausible reproducible conclusions (19).

7. Conclusion

Pragmatic resort to laparoscopy for the evaluation and treat-ment of all cases of female infertility is currently controversial.Time has now come, more than ever before, for a rethink on

unrestricted use of the procedure in the eon of evidence-basedmedicine (EBM). Laparoscopy should not be considered ‘rou-tine’. Selective use is a policy that should be praised and

encouraged. This is particularly pertinent to developing na-tions, where any reduction in the overall cost and procedure-related morbidity has substantial repercussions. Whereas cur-rently available evidence indicates that laparoscopy might have

a beneficial and fertility enhancing impact in few clinical set-tings, its decisive role in many others is far from being evi-dence-based. The overwhelming need for further prospective

randomized studies to confirm or refute a potential benefitcould not be overemphasized. Moving on from theory to prac-tice, a competent gynecologist is expected to show a great deal

of expertise, and above all wisdom, when deciding to performa laparoscopy. I do recommend that every one of us asks him-self/herself one important question: is laparoscopy indispens-ably needed, or could we do equally well with less invasive

maneuvers? If so, should it be carried out right now?

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Ahmed Nasr

Women’s Health Center, Dept. of Obstetrics and Gynecology,Faculty of Medicine, Assiut University,

P.O. Box 1, 71516 Assiut, Egypt

Tel.: +20 10 5212140/88 2185437; fax: +20 88 2368377.E-mail: a_nasr02@lycos.com