Comparison of hysterosalpingography and laparoscopy in predicting fertility outcome
Ben W.J. Mol1,2,5, John A. Collins3,4, Elizabeth A. Burrows4, Fulco van der Veen2 and Patrick M.M. Bossuyt1
1 Departments of Clinical Epidemiology and Biostatistics and 2 Reproductive Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands, Departments of 3 Obstetrics and Gynaecology and 4 Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Room 3N52, Hamilton, Ontario, Canada L8N 3Z5
In a meta-analysis comparing results of HSG and laparoscopy for the diagnosis of tubal pathology, HSG had a sensitivity of 65% for the diagnosis of tubal occlusion, in cases where laparoscopy was presumed to be the `gold' standard (Swart et al., 1995). This finding indicates that 35% of the tubes that were found to be occluded at laparoscopy showed patency at HSG. That particular finding made the choice of laparoscopy as the `gold' standard questionable, since patency at HSG in our opinion proves that laparoscopy was incorrect in diagnosing tubal occlusion in these patients. The results of the present study seem to indicate that laparoscopy is a better predictor for infertility than HSG, albeit not a perfect one. However, this conclusion is hampered by the fact that the median interval to laparoscopy after normal HSG was 10 months, compared to 4.5 months in cases where HSG was two-sided abnormal. Thus, the difference in prognostic capacity between HSG and laparoscopy is likely to be overestimated. Only prognostic studies in which HSG and laparoscopy are performed at the same moment can overcome this issue.
There seems to be no straightforward explanation for the difference in predictive capacities of HSG and laparoscopy that were found in the present study. Possibly, the direct visualization of methylene blue in relation to the Fallopian tubes, as compared to the indirect visualization of contrast at HSG might be responsible for this difference. Despite the fact that laparoscopy seems to be a better predictor for infertility than HSG, we postulate that HSG should keep its place in the diagnostic work-up for subfertility. Normal HSG reduces the probability that a tubal factor plays a role in future fertility prospects. Only in 5% of the patients with normal HSG was double-sided tubal occlusion detected at laparoscopy. Although fertility prospects in these couples were virtually zero, we think that a probability of 1 in 20 to detect severe abnormalities at laparoscopy – observed after a median time between HSG and laparoscopy of 10 months – is so low that earlier laparoscopy is not justified. It should be kept in mind that the median delay of laparoscopy of 10 months implicates that the fraction of abnormal laparoscopy among all patients with a normal HSG is even lower than 5%. When deciding about a delay of laparoscopy, one should also take into account other aspects of the prognostic profile of the couple, of which female age is the most important. In case female age is >36 years, the success rates of IVF–embryo transfer are expected to decline and delay of diagnosis and treatment is not justified (Templeton et al., 1996; Van Kooij et al., 1996).
In contrast, laparoscopy performed after a two-sided abnormal HSG showed no abnormalities in 42% of the patients. Since fertility prospects in these patients were only slightly impaired, whereas patients with two-sided occluded HSG and laparoscopy showing bilateral occlusion had strongly impaired fertility prospects, laparoscopy performed after a two-sided abnormal HSG could be very useful, since it divides patients with a two-sided occluded HSG into a large group in whom fertility prospects are slightly impaired and a large group in which fertility prospects are strongly impaired.
Apart from HSG and laparoscopy, other tests are available for the assessment of the status of the Fallopian tubes. Atalas et al. (1997) recently demonstrated that sonohysterography performed better than HSG in the detection of intrauterine abnormalities, using laparoscopy as the reference strategy. The functional approach of the Fallopian tubes might be evaluable with radionuclide HSG, although a recent report on this method indicates that at present it does not seem to be a reliable method in the infertility work-up (Lundberg et al., 1997). Transvaginal hydrolaparoscopy allows direct visualization of the ovaries and Fallopian tubes in an outpatient setting (Gordts et al., 1998). However, all these techniques have been evaluated in relatively small groups of patients, and the prognostic capacity for fertility has not been established yet. Before their implementation in clinical practice, their capacity to predict future fertility should be assessed, preferably in a direct comparison with HSG and/or laparoscopy, as was done in the present study.
When comparing HSG and laparoscopy, we should keep in mind that both procedures provide more information than the condition of the Fallopian tubes alone. Whereas HSG provides information on the status of the intrauterine cavity, laparoscopy allows inspection of the intra-abdominal cavity, for instance to see if endometriosis is present. The latter has become especially important, since it was recently shown that laparoscopic treatment of endometriosis improves fertility prospects by 13% (Marcoux et al., 1997). Thus, in the final decision on the clinical value of HSG and laparoscopy, one should consider issues other than solely tubal pathology. However, such an analysis is beyond the scope of this study. When focusing on tubal pathology, we conclude that laparoscopy should not be considered as perfect in the diagnosis of tubal pathology. For clinical practice, we recommend that laparoscopy can be postponed until at least 10 months after a normal or one-sided abnormal HSG, whereas laparoscopy provides useful information immediately after a two-sided abnormal HSG.
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