Background: Infertility is defined as one year of frequent unprotected intercourse during which pregnancy has not occurred. Causes of infertility in the female partner include disorders of ovulation, tubal disease, and uterine or cervical factors. Endometriosis also has been implicated as an independent cause of infertility. Owing to its non invasive nature and low cost, hystero- salpingography (HSG) is widely used as a first line approach to assess the patency of the fallopian tubes and uterine anomalies in the routine fertility workup. However, the inadequacy of HSG in determining the state of tubal patency emphasizes the need for laparoscopy. Diagnostic laparoscopy is the gold standard in diagnosing tubal pathology and other intra-abdominal causes of infertility.
Objectives: This study tries to evaluate the role of hysteroscopy and laparoscopy in women with an apparently normal hysterosalpingography study. It tries to provide evidence to enable clinicians to counsel such couples with regard to the usefulness of hysterolaparoscopy in their further management.
Patients and methods: In the current study, 80 patients with primary infertility were selected and proved to be normal on physical examination and trans-vaginal ultrasound. All patients had essentially normal hysterosalpingogram, denoting bilateral tubal patency and an apparently normal uterine cavity. Diagnostic hysterolaparoscopy was performed to provide direct visualization of the uterine and peritoneal cavities.
Results: Hysteroscopy detected abnormalities in 55% of the studied group and likewise, laparoscopy revealed a 51.3% rate of abnormalities. Collectively, only 25% of the studied population had normal hysteroscopy and laparoscopy, in agreement with the normal HSG. The list of abnormalities detected with hysteroscopy involved, endometrial and cervical polyps, submucous myomas, small septa, cervical stenosis in addition to intrauterine adhesions and evidence of chronic endometritis. The last two defects are thought to affect infertility in some way. These were detected in 11 women (13.8%) which is considered a direct additive value of hysteroscopy to diagnosis of infertility in the studied group. However, submucous myomas and endometrial polyps (21 cases) might be a cause of implantation failure. In contrast to hysteroscopic findings, laparoscopy revealed a large number of lesions having impact on infertility, namely endometriosis (25 cases) and peritubal adhesions (11 cases). Hysteroscopy can diagnose intrauterine adhesions and chronic endometritis and laparoscopy can visualize endometriosis and peritubal adhesions, a blinded area for HSG. The three tools are complementary rather than competitive in diagnosis of infertility.
Conclusion: We can conclude that HSG is still considered of first line diagnostic tool in infertility work up. However, normal HSG does not mean totally normal tubes and uterine cavity. Direct visualization of the uterine cavity and pelvis using hysteroscopy and laparoscopy reveals abnormalities in a substantial proportion of cases diagnosed as normal by HSG.
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