3
2
2022
1682060070609_2992
173-178
https://journal.smdc.edu.pk/index.php/journal/article/download/112/71
https://journal.smdc.edu.pk/index.php/journal/article/view/112
INTRODUCTION:
Subfertility is defined as any form of reduced fertility with extended time of undesirable non-conception. Subfertility affects around 10-15% of couples in reproductive age group all over the world.1 World Health Organization (WHO) reports that the overall prevalence of primary subfertility in developing countries is 10- 25%. Primary subfertility is reported to have a higher prevalence (57.5%) as compared to secondary subfertility (42.5%).2 Worldwide, primary subfertility has psychosocial effects
173 J Shalamar Med Dent Coll July-Dec-2022 Vol 3 Issue 2
on the women's quality of life and is a matter of concern for the gynecologists throughout the world.
Management of subfertility is largely dependent on the underlying cause. Multiple causes have been identified leading to primary subfertility. These include ovulatory dysfunction, tubal blockage due to adhesions, uterine factors, endometriosis, male factor infertility, and immunological diseases. Despite the absence of above factors, 25% of the couples suffer from unexplained subfertility.3 It is important to identify the factors so that appropriate treatment can be started. It has been proven that the time between diagnostic testing, and further management for subfertility can influence the success of treatment results.
Laparoscopy has been regarded as the gold standard for diagnosis of tubal blockage as well as early diagnosis of endometriosis and pelvic adhesions. Diagnostic laparoscopy allows the direct visualization of the abdominopelvic organs along with identification of other causes like adhesions and endometriosis. A tubal test performed at the end of the procedure can also help to diagnose tubal patency. On the other hand, diagnostic hysteroscopy is the gold standard for diagnosing the intracavitary uterine abnormalities like uterine fibroids, endometrial polyp, and uterine septum as well as the ostia.4
It has been seen that laparoscopy detects more abnormalities than hysteroscopy in both primary and secondary subfertility. In a study conducted by Varlas et al. laparoscopy detected 35% of cases while hysteroscopy led to identification of cases in 17% of cases in patients with primary subfertility.4 Further
in another study, it was shown that combined hystero-laparoscopy could detect abnormalities in 26% of patients with either primary or secondary subfertility.5 This led to the idea of having a combined diagnostic hystero-laparasocopy in patients with subfertility to look for causative factors, hastening the diagnosis and early intervention where required.
This study aimed to identify the causative factors of primary female subfertility through combined diagnostic hystero- laparoscopy.
METHODS:
This cross-sectional study was conducted in department of Obstetrics and Gynecology of Hameed Latif Hospital, Lahore, Pakistan, from December 2021 to May 2022. Hameed Latif Hospital is a 324 bedded tertiary care hospital equipped with advanced infertility management in Lahore, Pakistan. Ethical approval from the Intuitional Review Board was taken before commencement of the study (HLH/HRD/2021-01). Archival record of all the female patients who presented with primary subfertility and underwent the combined diagnostic hystero-laparoscopy in the years 2020-2021, was taken and the information was recorded on a proforma designed for present study.
The information recorded on the study proforma included patient's age, duration of subfertility, and the operative findings of diagnostic hystero-laparoscopy. Any record with missed data was removed from the study.
Statistical Analysis
The data was analyzed through SPSS software, version 23. The numerical data
was presented as mean and standard deviation whereas categorical data was presented as frequencies and percentages.
RESULTS:
Causative Factors
The mean age of the patients was 25±5.0 years. The mean duration of subfertility was 3.8+0.55 years. Regarding duration of subfertility, 3.77% has complaints for less than 2 years. While 53.48% patients had subfertility for past 2-5 years, followed by 35.36% patients having history of the sub- fertility for 6-10 year and 7.26 % of the patients having subfertility for more than 10 years (Table 1).
Fig:1 show distribution of patients according to operative findings. According to this figure, 284 out of 344 patients (82.56%) had been found to have abnormal findings, whereas 60 out of 344 patients (17.44%) had normal findings during the operative procedure. Out of 284 patients, 94(34%) one identified factor while 190 (66%) patients had two or more identified factors for primary subfertility.
Table 1: Demographic characteristics of the study participants |
||
Demographic characteristics |
Cases (n=284) |
Percentage (%) |
Age in years |
|
|
Up to 20 |
3 |
0.87 |
21-30 |
203 |
59.01 |
31- 40 |
132 |
38.37 |
>40 year |
4 |
1.16 |
Duration of |
13 184 122 25 |
3.77 53.48 35.46 7.26 |
subfertility |
||
<2 years |
||
2-5 years |
||
6- 10 years |
||
>10 years |
||
Identified factor |
|
|
Single factor |
94 |
34 |
≥2 factors |
190 |
66 |
Figure 2: Frequency of causative factors for female primary subfertility
Table 2: Types of tubal blockade as identified during procedure |
||
Tubal Blockage |
Cases (n=81) |
Percentage (%) |
Unilateral Block Tube |
35 |
43.2% |
Bilateral Blocked Tubes |
46 |
56.8% |
Figure 1: Distribution of patients according to operative findings
Fig: 2 shows the identified causative factors for female primary subfertility in this study. Polycystic ovaries were seen in 128 out of
284 patients (37.21%), followed by tubal blockade in 81 patients (23.54%). Peri tubal adhesions/hydrosalpinx were seen in 58 patients (16.86%), uterine fibroids in 50 patients (14.53%), endometrial polyps in 43
patients (12.5%), endometriosis in 39
patients (11.33%), cervical stenosis in 24 patients (6.97%) and uterine septum in 18(5.23%) patients. Polycystic ovaries were the most commonly identified factors followed by tubal blockade and adhesions/hydrosalpinx. Table 2 shows the type of tubal blockade seen while carrying out tubal patency test during the procedure. Out of 81 cases of tubal blockade, 35 were with unilateral tubal block and 46 were with bilateral tubal blockade.
DISCUSSION:
This study aimed to determine the causative factors for primary female as diagnosed by combined hystero-laparoscopy. A data of 344 patients was studied for this purpose. In the present study, 284 (82.54%) patients had one or more abnormal findings. This was an important aspect to consider as the remaining 60(15.46%) patients did not have any findings and may be a case of the 'unexplained subfertility'. Infertility was identified to be single factorial in 34 percent of cases as compared of being multifactorial in 66 percent of patients.
Another important observation in present study was polycystic ovarian disease (PCOD) being the most common causative factor of female subfertility. Worldwide, polycystic ovarian syndrome accounts for 5-
15 % of female subfertility with an ovulatory infertility6, however, these rates are much higher in Pakistani population as quoted by Azhar et al (52%).7 Present study reported that 37.21% of the patients presenting to the private hospital, had PCOS. This is in accordance with the study conducted by Fatima et al who reported the
overall incidence of PCOS to be 54% among Pakistani women.8
Tubal blockade was the second common causative factor in the present study found in 81 (23.54%) of the patients. Worldwide, the overall incidence of tubal blockade is 30- 40% accounting for subfertility 9, which was similar to our findings. However, WHO reported an increased incidence of tubal blockade in one out of four patients with female subfertility in developing countries.10 Tubal factor seemed to be more common in Pakistan as compared to the data provided by WHO. Possible explanation may include poor hygiene, low immunity, and susceptibility to recurrent pelvic infections. Among infections, tuberculosis has been inflicted to be a major cause of secondary tubal blockage in Pakistan.11 Other pathologies influencing tubal patency include peri tubal adhesions and hydrosalpinx which was reported in 58(16.8%) of cases.
All the above-mentioned factors were diagnosed by diagnostic laparoscopy. However, other factors like uterine fibroids- whether indenting the uterine cavity-could only be diagnosed during hysteroscopy. Hence, performing a combined diagnostic hystero-laparascopy hastens the early diagnosis and timely intervention in female patients with subfertility.12–14 Zhang et al reported that combined hystero-laparoscopy allows the gynecologists to identify the cause and do any necessary therapeutic intervention, if needed.13
CONCLUSION:
Primary female subfertility in Pakistan is caused by multiple factors. Diagnostic hystero-laparoscopy is an effective
diagnostic procedure for evaluation of female factor subfertility and can guide treating gynecologists for further successful management plans.
Limitations
This retrospective study was single centered, and data was collected over limited time duration. Further studies are recommended with data collection from multiple centers all over the country as well as outside the country to compare the results to see recent updates in causative factors for female subfertility.
Conflicts of interest
All authors declared no conflict of interest.
Contributors
YLK: Idea conception, Manuscript writing, critical review
SI: Data collection, data analysis, and manuscript finalization, critical review
ZS: Data analysis, manuscript writing and critical review.
All authors approved the final version and signed the agreement to be accountable for all aspects of work.
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Article Title | Authors | Vol Info | Year |