Laparoscopy & hysterosalpingogram

Dear Professor Winston

I have been really glad to have this resource over the last few months; it is very valuable and has helped inform me. I am 39 and my husband is 42. After trying to conceive naturally for 18 months my husband and I were referred for investigations. These showed I have normal AMH levels, evidence of monthly ovulation, a normal hysterosalpingogram and normal vaginal scan. My husbands sperm sample was normal. The conclusion was unexplained infertility and our consultant added us to the IVF waiting list in September 2013 and encouraged us to try to conceive naturally in the meantime. I had a chemical pregnancy in October 2013 and started IVF treatment in April 2014. I responded well to the fertility drugs, final scan showed 17 follicles, 14 eggs retrieved, 10 fertilised, 2 embryos transferred with none of good enough quality left for storage. I bled heavily on day 9 after a 3 day embryo transfer and sadly the cycle did not result in a pregnancy. A friend of a friend recently shared her experience which intrigues me and I am curious if it is an option for me. She and her husband were also diagnosed with unexplained infertility. After 2 failed cycles of IVF she saw a consultant privately who suggested an option open to her was have a laparoscopy and hysterogram – to establish if there were undetected issues and to hopefully give a spike in fertility following the procedure in terms of conceiving naturally. She took this course of action and fell pregnant and had a baby boy. One year later after having the procedure again she became pregnant again and had another little boy! In a case of unexplained infertility such as ours and where these procedures had not been included in the diagnostic phase I have wondered if it is worth pursuing this avenue? I understand you cannot give a recommendation but wondered if you could comment on the phenomenon of pregnancy following a laparoscopy and hysterogram? In your view is this happy coincidence or an occurrence supported by evidence? Any insight would be much appreciated. Regards, E.

Dear E,

Let me be quite clear. This is not a criticism of your consultant, but a matter of real general concern. I strongly deprecate those clinics which make a ‘diagnosis’ of unexplained infertility. It is, of course, not a diagnosis at all but a failure of diagnosis. And this failure should be admitted. For a huge proportion of cases this failure is because both partners have not been adequately investigated. As I have said elsewhere (I hope I am not boring you) there is no other area of medical practice where it would be regarded as good medicine to simply treat without making a diagnosis first. Of course, there are situations where making a diagnosis is impossible but far too often sloppy investigation in reproductive medicine at least is an excuse for offering expensive treatment by IVF. This is costing both patients and the NHS a huge sum of money but it goes on unregulated. Yet again, this seems an area where the government’s own regulatory body seems powerless or unable to help – I cannot believe it is mere indifference.

Of course, unexplained infertility is a real issue and sometimes, after extensive investigation, no genuine cause can be identified. Under these circumstances IVF is a boon because it offers the chance of pregnancy and because quite often it throws up an indication of what is the underlying cause of the infertility. But nobody can be said to have unexplained infertility without the key tests first and this certainly includes a hysterosalpingogram (HSG) and a laparoscopy. Why? Because a hysterosalpingogram, properly done, can reveal not merely blocked tubes, but damage to the wall of the tubes or its lining. Moreover, amongst other things it can identify congenital abnormalities of the uterus which are surprisingly common, adhesions inside the uterus which often occur particularly after a failed pregnancy, fibroids which affect a huge proportion of infertile women, endometrial polyps and adenomyosis, which is a not uncommon form of endometriosis associated particularly with rather painful periods, sometimes bleeding between periods, and infertility. Unfortunately too few units now have radiologists of sufficient experience to identify these abnormalities and many ‘experts’ in reproduction ignore them because the HSG is not always thought of as an investigation of sufficient importance for the clinician to examine the x-rays carefully himself. The patient is simply sent for IVF. And the cruel paradox is that with many of these abnormalities make success at IVF much less likely, and a miscarriage or ectopic more likely. And sadly, many of these conditions are undoubtedly treatable.

With regard to laparoscopy, in my view it is the single most important investigation in female infertility. Why? Because it offers a direct look at the uterus from the outside, the tubes and the blood vessels supplying the pelvis, and of course the ovaries in detail. Such inspection, carefully done can reveal all kinds of relevant information of which probably most important are adhesions. And adhesions can be treated simply in most cases without the need for IVF. Moreover laparoscopy should include inspection of the upper abdomen too, because this can often reveal tell-tale signs of inflammation from the past, inflammation which often starts in the pelvis and results in the tubes, though open, not working properly. And it is most important that photographs are taken as an accurate record of what was seen down the telescope.

Now to answer your specific question. There is plentiful evidence, admittedly most of it anecdotal, that the dye test done both during HSG or laparoscopy, seems to be associated with a spontaneous pregnancy afterwards in a number of wornen. Why this happens is not clear; some people have postulated that it may stimulate the tubes and uterus in some way, or possibly wash out areas of mucus.

I am sorry that fertility medicine is not better taught and so casually applied in some centres. My feeling is that it up to patients themselves to be much more assertive. I also think they should have a right to have a copy of their x-rays, copies of laparoscopic photographs and a copy of their clinical records. Patients, themselves must need to get much more involved with their care. And this website, and the Genesis Research Trust, will continue to support the view that you have a right, as in any other medical practice, for proper efforts to be made to identify the cause of a distressing symptom – in your case, of course, infertility.

Best wishes
Robert Winston