The tests include obtaining a semen analysis from the woman’s partner, undergoing an evaluation for ovarian function, having a pelvic sonogram, and undergoing a hysterosalpingogram (HSG). The final diagnostic test is a laparoscopy. However, this procedure is not always necessary. On the other hand, if an abnormality is found with the other diagnostic tests, such as an ovarian cyst suggestive of an endometrioma, fibroids that should be removed, and/or evidence of fallopian tube blockage, it seems clear that laparoscopy will be very beneficial. When all of the basic tests are normal, it is not so obvious if it is worthwhile for a woman to undergo a laparoscopy.
Several studies in the past have looked at the likelihood of finding pelvic abnormalities at laparoscopy in patients considered to be “unexplained”. Patients were considered to have “unexplained infertility” if they had a normal basic fertility evaluation. Years ago, several investigators offered those patients with unexplained infertility a diagnostic laparoscopy to determine if a cause for the infertility could be discovered that was not evident from any of the basic infertility tests. In these studies, abnormities were found in 40% of couples. In the group where something was found, approximately 65% of the couples had endometriosis and the 35% of the couples had pelvic adhesions. With the results of studies like this, laparoscopy became a standard diagnostic procedure for couples trying to discover why they were not becoming pregnant.
However, if during the investigation a semen analysis reveals the man has a very low sperm count and the woman has no other symptoms to suggest the presence of endometriosis and/or pelvic adhesions, then it is unlikely that a laparoscopy will be helpful. It this situation, the man should be evaluated by a urologist to determine if a treatment is available that might increase sperm production in the male. If not, then the couple should proceed with in vitro fertilization (IVF), unless the couple decides to undergo artificial insemination with donor sperm or proceed with adoption. Women with fallopian tube obstruction may chose to proceed directly to IVF, rather than undergo a laparoscopy in hopes of opening her fallopian tubes. Also, some couples who were found to have normal finding on the basic fertility tests may choose to try one of the treatments known to increase the chance of conceiving even when the cause of infertility has not been discovered and forego a laparoscopy. They may choose to try clomiphene (or letrozole) with intrauterine insemination (IUI), superovulation with gonadotropins combined with IUI, or IVF. In this situation the couple is gambling that laparoscopy would not reveal any abnormalities and want to move directly to these treatments.
Laparoscopy is one of the great tools that is available for treating many gynecological problems, including infertility. However, it is not always necessary for it to be a part of the evaluation of infertility. If you have any questions as to whether a laparoscopy will be helpful for your infertility evaluation, do not hesitate to ask your physician.