SHOULD DIAGNOSTIC HYSTEROSCOPY BE A ROUTINE PROCEDURE DURING DIAGNOSTIC LAPAROSCOPY IN INFERTILE WOMEN ?

Th e aim of this study was to clarify the role of simultaneous combined diagnostic approach using laparoscopy and hysteroscopy in the evaluation of female infertility. In a retrospective study,  infertile women underwent complete fertility evaluation. All the patients were examined by simultaneous combined laparoscopy and hysteroscopy as a part of the routine infertility evaluation. Laparoscopy and hysteroscopy were successful in  patients. Bilateral tubes were blocked in  () and unilateral tubal occlusion were in  (,) of patients. Pelvic adhesions were revealed in  (,), and myomas in  (,) out of that  (,) were revealed by laparoscopy and  (,) by hysteroscopy. Endometrial polyps were revealed in  (,) and Syndrome Asherman in (,) of patients. Uterine anomaly was found in  (,) of cases and out of that septate uterus in  (,), bicornuate uterus in  (,), arcuate uterus in  (,) and uterus unicornu cum cornu rudimentario in  (,) of uterine anomalies. Endometriosis was found in  (,), dermoid cysts in  (,) and in  (,) functional cysts of patients. Also, Fitz-HughCurtis syndrome was revealed in  (,) of our patients. Laparoscopy and hysteroscopy play very important role as diagnostic tools in the infertility women. Combined diagnostic simultaneous laparoscopy and hysteroscopy should be performed in all infertile patients before the treatment.


Introduction
Laparoscopy and hysteroscopy are diagnostic and therapeutic procedures.If pathology is discovered, it can often be treated immediately.Generally, diagnostic laparoscopy and hysteroscopy are not a part of the initial infertility evaluation.Diagnostic laparoscopy is normally a standard procedure performed as the fi nal test in the infertility work up before progressing to infertility treatment.There has been a growing tendency to bypass diagnostic laparoscopy and hysteroscopy after normal hysterosalpingogram and instead of starting direct infertility treatment.A number of reports have shown that laparoscopy is an eff ective procedure for diagnosis and treatment of long-term infertility.Laparoscopy has been suggested as a mandatory step to preclude the existence of peritubal adhesions and endometriosis as the causes of infertility ().Also, diagnostic hysteroscopy is a very important method for investigation of the reasons of female infertility.Anyhow, one can rarely expect to fi nd the defi nite underlying reason for infertility.Diagnostic hysteroscopy should be included routinely in the work-up of invasive examinations for infertile patients ().We consider combined laparoscopy and hysteroscopy to be one of the most important procedures in the evaluation of female infertility.

Materials and Methods
We have done a retrospective study on  patients who underwent laparoscopy and hysteroscopy during investigation for primary and secondary infertility.Laparoscopies and hysteroscopies were conducted between January  and January  in Obstetrics and Gynaecology Clinic in Sarajevo.Before laparoscopy and hysteroscopy women had satisfi ed criteria: hormonal tests, cervical smears, ultrasound report, test for Chlamydia antibody and semen analysis of the husband.Th is procedure was carried out on the follicular phase of the menstrual cycle under general anesthesia.At laparoscopy and dye studies performed with methyl blue.Th e mean duration of infertility was , years, and mean age at the time of procedure was  years, range - years.Forty six of the  women who were underwent combined laparoscopy and hysteroscopy had previous laparotomy (Section Cesarean, appendectomy, after injuries in abdomen, cystectomy, myomectomy and salpingectomy).

Results
In total  infertile women underwent simultaneous combined laparoscopy and hysteroscopy as a part of routine infertility evaluation.Bilateral tubal patency was demonstrated in  (,) patients.Bilateral tubes were blocked in  () and unilateral tubal occlusion had  (,) of patients.Our study revealed myomas in  (,), out of that  (,) by hysteroscopy and  (,) by laparoscopy.Endometrial polyps were revealed in  (,) and Syndrome Asherman in  (,) of patients.Out of  patients who underwent laparoscopy and hysteroscopy for infertility uterine anomaly was revealed in  (, ) of cases.Septate uterus were revealed in  (,) patients, bicornuate uterus in  (,), arcuate uterus in  (,), and uterus unicornu cum cornu rudimentary in  (, ) of uterine anomaly.Among  women that were studied,  (,) were found to have endometriosis,  (,) dermoid cysts, and  (,) functional cysts.Pelvic adhesions were found to be the sole infertility factor in  (,) of our patients.Pelvic pathology was confi rmed by laparoscopy in  (,) of our cases.Also, Fitz-Hugh-Curtis syndrome was revealed in  (,) patients.

Discussion
Infertility is defi ned as a failure to achieve pregnancy within a year of regular unprotected intercourse.Intracavitary pathology includes submucous leiomyomas and endometrial polyps.Those pathologies often result in abnormal uterine bleeding, infertility or both.Congenital anomalies of the female reproductive system are associated with higher rate of infertility.Diagnostic hysteroscopy offers a reliable evaluation of the uterine cavity and subsequent detection of intrauterine disease ().Complication rates of diagnostic hysteroscopy are low as of , ().Incidence of uterine congenital anomalies is not accurately known.Discrepancy is a result of inaccurate diagnostic methods, lack of uniform system of classification and many of them are asymptomatic.Mean prevalence of uterine malformation in general population and in the population of fertile women is approximately ,, in infertile patients approximately , and in patients with recurrent pregnancy losses approximately  ().Th e incidence of uterine anomaly is , ().Our study had shown that the incidence of uterine anomaly was ,.Septate uterus is the most common uterine anomaly with a mean incidence is approximately , followed by bicornuate uterus approximately  and arcuate uterus approximately  ().Our results show septate uterus in ,, bicornuate uterus in , , unicornu uterus cum cornu rudimentario in , and arcuate uterus in , of uterine anomaly in infertile patients.Reliable diagnosis of the septate uterus depends on accurate assessment of the uterine fundal contour ().Anomalies of the uterus are considered to be one of the reasons for infertility in women, and for this reason we believe diagnostic hysteroscopy is fundamental in screening for infertility ().
In infertile patients about  of hysteroscopic examinations show some grade of intrauterine abnormalities ().With the view of the low complication rates, minimal time requirement, and a negligible eff ect on the postoperative course, hysteroscopy could be performed on all infertile patients undergoing diagnostic laparoscopy.Th e hysteroscopy showed a normal cavity in  cases, giving a false negative rate of  for hysterosalpingography ().Routine diagnostic hysteroscopy should be a part of an infertility work up in primary and secondary infertility.Laparoscopy was helpful in making a decision to go to assisted reproductive technology particularly when infertility had been of long duration and in older women ().Our results at laparoscopy and dye studies performed with methyl blue, presented bilateral tubal patency in  (,), bilateral tubal block in  () and unilateral tubal block in  (,) of patients.At laparoscopy bilateral tubal patency was demonstrated in , but  had bilateral tubal blocked tubas and  patients had unilateral tubal occlusion ().Laparoscopy very often revealed pelvic pathology as endometriosis, pelvic and periadnexal adhesions that resulted in change of treatment decision.Our study revealed pelvic adhesions in  (,).Women whose basic infertility survey revealed no abnormalities, laparoscopy confi rmed in overall , of patients evidence of pelvic disease ().Cundiff et al. also showed that pelvic pathology was found in  of patients who under-went laparoscopy and recommended that laparoscopy be carried out after a normal hysterosalpingography if pregnancy had not occurred within one year because of high incidence of pelvic pathology ().Pelvic endometriosis was the most common pathology accounting for , of all pelvic disease ().Our study revealed pelvic endometriosis in ,, dermoid cysts in , and functional cysts in , of patients.In our study, pelvic pathology by laparoscopy was confi rmed in  (,) of our cases (Table ).In many cases, evidence of perihepatitis and adhesions between liver and anterior abdominal wall or diaphragm could be confi rmed only by laparoscopy.Fitz-Hugh-Curtis syndrome presents in , in infertility patients ().Our study revealed Fitz-Hugh-Curtis syndrome in  (,) of patients.Th erefore, laparoscopy should be carried out in all patients to look for a tubal or pelvic cause of infertility when all other examinations performed were normal.In  patients who underwent hysteroscopy intrauterine fi nding were endometrial polyps in  and submucosal myoma in  patients ().Our study revealed myomas in , by hysteroscopy and , on laparoscopy.We found endometrial polyps in , of infertile patients.Hysteroscopy could be performed on all infertile patients undergoing diagnostic laparoscopy ().It is very important to perform combined simultaneous diagnostic laparoscopy and hysteroscopy in all infertile women.

Conclusion
From the results of our study, we conclude that diagnostic methods are very important for investigation of the causes of female infertility.In the view of low complications rates, minimal time requirement and negligible eff ect on the post operative course, combined diagnostic simultaneous laparoscopy and hysteroscopy should be performed in all infertile patients before treatment.Many diagnostic tests for female infertility only have screening value and the gold standards are laparoscopy and hysteroscopy.

TABLE 1 .
Pelvic pathology revealed by laparoscopy