ACOG updates its recommendations for treatment of Dysmenorrhea and Endometriosis in the Adolescent

The American College of Obstetrics and Gynecology (ACOG) has issued new guidance on diagnosing and relieving dysmenorrhea in adolescents, published in December issue of Journal Obstetrics and Gynecology.

Obstetrician and gynecologists frequently come across adolescents with dysmenorrhea in their practice due to high prevalence ranging between 50% to 90%. It is also responsible for recurrent short-term school absenteeism and reduced quality of life.

Most of the adolescents suffering from dysmenorrhea have primary dysmenorrhea–– painful menstruation in the absence of pelvic pathology.

If the physician suspects it to be primary dysmenorrhea, no pelvic examination or ultrasound is indicated in the initial evaluation. The patient should be put on empirical therapy after a careful history and physical examination.

If the patient does not respond to empirical therapy with NSAIDs and hormonal treatment in 3-6 months, she should be investigated for secondary causes or irregular treatments.

The most common cause of secondary dysmenorrhea is endometriosis, the other being obstructive anomaly of the reproductive tract (hymenal, vaginal, or Mullerian), uterine fibroids and polyps, adenomyosis, cervical stenosis, and adhesions.

Patients who do not respond to treatment for primary dysmenorrhea should be investigated for secondary causes which include pelvic examination and pelvic ultrasound. If pathology is detected, treatment of the cause is warranted.

If no pathology is seen, suspect endometriosis and consider a diagnostic laparoscopy. About 75% of adolescents and young adults with dysmenorrhea who do not respond to NSAIDs and hormonal therapy have endometriosis as the primary pathology. 

Endometriotic lesions present a different appearance in adolescents as compared to a young woman and are typically transparent or red and are challenging to diagnose.   

If a young woman is diagnosed with endometriosis, treatment consists of biopsy of the lesions along with destruction, ablation, or excision of the visible lesions at the time of initial laparoscopy. The patient should also be started on suppressive medical therapy to prevent further endometrial proliferation.

Consideration should be given to placing a levonorgestrel-releasing intrauterine system (LNG-IUS) at the of diagnostic laparoscopy to minimize the pain of insertion later. 

If patients do not respond to conservative surgical therapy and suppressive hormonal therapy, they often benefit from at least six months of gonadotropin-releasing hormone (GnRH) agonist therapy with add-back medicine.

NSAIDs are the principal medications used for pain relief in endometriosis, and there is no role of long-term opioids in the management of endometriosis, besides being used by a specialized pain management team.

ACOG committee opinion No. 760

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Barco launches 27″ 4K Surgical Monitor for the most stunning display in the operating room

Belgium based global technology leader Barco recently launched its 27″ 4K Surgical Monitor for operating room to display the best pictures during the interventional procedures. The MDSC-8427 is specially designed to deliver impeccable quality for 4K visualization of high-quality images that are precise, bright and unparallel color quality.

This surgical display is designed keeping in mind the recent rise of 4K endoscopes and room cameras and matches all the current and new installs. It can also replace the Full HD screen on the surgical cart or dual displays on the monitor arm of a surgical boom.

The monitor comes with a variety of broad future-proof connectivity options like DP, HDMI, 12G-SDI, Quad-SDI, and IP to enable the surgeons to watch a wide array of digital video sources like endoscopic video, patient and surgery information, room and boom camera, and more. The system can display multiple sources at the same time for comprehensive information in the OR.

The wide color gamut and advanced color calibration algorithms result in an accurate, true to life color reproductions of images for real-time imaging during endoscopic surgeries. This results in the accurate display from deep reds to the blackest blacks, which can be viewed with equal precision from any angle in the operating room.

The user-friendly interface displays images in both front and back – making it easy to operate and adjust the viewing as per the preference of the surgical team and the different procedures.

The MDSC-8427 is equipped with an automated failover feature to ensure safe surgery. The smooth, sleek design and splash proof housing make it easy to sterilize and maintain good hygiene.

“The new MDSC-8427 is a first in our next generation of 4K displays for the operating room,” says Johan Stockman, Barco’s VP surgical imaging. “Careful consideration went into the new design. We wanted to create a display that combines surgical aesthetics with surgical precision. This new paradigm of display design shows how fine form can meet function in the operating room”.

Here is a video about various features of 4K in the operating room

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Cuff closure by Laparoscopic vs transvaginal route significantly cuts down vaginal dehiscence after Total Laparoscopic Hysterectomy

Laparoscopic cuff closure after laparoscopic hysterectomy is associated with a nearly 3-fold reduction in vaginal dehiscence as compared to vaginal cuff closure reports the result of first randomized control trial published in May issue of American Journal of Obstetrics and Gynecology.

Total Laparoscopic Hysterectomy (TLH) is rapidly gaining popularity among surgeons and patients as the desired route for performing hysterectomies. It results in better cosmetic outcomes and quick return to normal activities as compared to open surgery.

However, it is also associated with higher incidence of vaginal cuff dehiscence (5–10 times higher) compared with the abdominal and/or vaginal hysterectomy. It may be because of thermal damage, difficult laparoscopic suturing techniques, reduced suture width because of magnification, or early resumption of intimacy and daily activities.

An earlier meta-analysis of case series and case-control studies suggested that a transvaginal approach of vault closure after TLH reduces the incidence of vaginal cuff dehiscence. But, these studies have drawbacks of retrospective data collection and lack of standardized protocol for post-operative data collection.

This is the first multicenter RCT carried out at 8 Italian institutions over a period of 2.25 years (NCT02453165). All women above 18 years of age, with benign condition scheduled for elective TLH up to colotomy stage, were included in the study.

A total of  1395 women were randomized in 1:1 to receive either transvaginal(TV) cuff closure (695 women) or laparoscopic (LPS) closure (700 women). The vaginal cuff closure in both the arms was done by the single-layer technique with braided and coated 0-polyglactin suture on a half-circle HR26 needle. In LPS arm intracorporeal knot-tying technique was used.

All women were advised to avoid intercourse for 2 months and they were followed up 3 months postoperatively because almost all vaginal cuff dehiscences after TLH occur within 2 months after surgery.

The researchers looked at the rate of vaginal cuff dehiscence as the primary outcome while vaginal bleeding, vaginal cuff hematoma, postoperative infection, vaginal resuturing, and any reoperation were secondary outcome studied.

Patients in the TV arm had a significantly higher incidence of vaginal dehiscence and any vaginal complications, cuff hematoma, vaginal bleeding, post-operative infection and vaginal resuturing (P<.05).

Women who were premenopausal or smoked were at higher risk of vaginal dehiscence independent of the route of closure.

The findings were so striking that the data monitoring committee ordered the trial to be terminated early.

The study was endorsed by Italian Society of Gynecologic Endoscopy which ensured that the surgical procedures were efficiently performed. Randomized design, large sample size and good follow-up program ensured the reliability and robustness of the study data.

The study has some limitations in terms of using only one type of suture, and not taking into account the role of barbed sutures. Finally, in accordance with other surgical trials, unavoidable human surgical skill variations may play a role in the results. 

The authors concluded, “LPS closure of the vaginal cuff at the end of TLH has been proven to be associated with less vaginal dehiscence, vaginal cuff hematomas, vaginal bleeding, vaginal resuture, and postoperative infections, compared to the TV suturing route. This study may change practice due to its impact and represents an important step toward an evidence-based approach to TLH, and more so in general, toward a standardization of gynecological surgical procedures.”

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Blob and Bagel sign on Ultrasound can be labelled as definitive for Ectopic Pregnancy

. blob sign of ectopic pregnancy.

Women with the Blob and Bagel ultrasound sign should be reclassified from having ‘probable’ ectopic pregnancy (EP) to ‘definitive’ EP and should be treated as such reports the result of a large retrospective cohort study published March 11, 2018, in Journal of Ultrasound in Obstetrics and Gynecology.

Ectopic Pregnancy is still the leading cause of first-trimester maternal deaths and constitutes 4% of all pregnancy-related deaths. The incidence of ectopic is highest in women undergoing In-Vitro Fertilization(IVF) and ranges from 4% to 11% of all pregnancies.

The broken arrow depicts the right ovary and the solid arrow shows ectopic pregnancy characterized by the ‘bagel sign’.

With the advent of high-resolution transvaginal ultrasound (TVS), more ectopic pregnancies are diagnosed at clinically early and hemodynamically stable stages that are amenable to various modes of management. In modern times TVS has replaced laparoscopy as the diagnostic tool of choice.

Barnhart et al have published a recent consensus statement of nomenclature, definitions, and outcome of pregnancy of unknown location (PUL) in Journal Fertility and Sterility. In which, research papers originating from the US diagnose EP based on findings of an extrauterine gestational sac with the visualization of a yolk sac or embryo, while literature from the UK and European countries diagnose EP based on finding of an extrauterine inhomogeneous mass (blob sign), or an extrauterine empty gestational sac (bagel sign). 

   

This study was undertaken with an aim to determine whether these ultrasound markers can be used to definitely predict EP, instead of just raising a probability of its presence. The study recruited 849 of 7490 consecutive women who attended the Early Pregnancy Unit (EPU) of the Nepean Hospital, Sydney, Australia over a period of 10 years.

At TVS, 240 of 849 women were diagnosed as probable EP, of which 174 (72.5%) exhibited the blob sign and 66 (27.5%) exhibited bagel sign. The rest 609 were labeled as PUL, of which 47 received a final diagnosis of EP (including 24 blob signs, 19 bagel signs and four gestational sacs with embryo/yolk sac.

Nearly 51% of patient with blob sign and 59% of patients with bagel sign underwent laparoscopic salpingectomy, and HPE proved the diagnosis in 97% of patients with blob sign and 96% of patients with bagel sign.

The sensitivity for the blob and bagel signs in the prediction of definite tubal EP was 89.8% and 83.3%, respectively, the specificity was 99.5% and 99.6%, PPV was 96.7% and 95.2% and NPV was 98.3% and 98.6%.

All the parameters were comparable to the corresponding parameters of the extrauterine gestational sac with yolk sac and/or embryo on TVS used in the prediction of definite tubal EP.

The authors concluded that Blob and bagel signs are the commonest presentation of tubal ectopic on TVS, and because of high PPV of >95%, it can be used for the definitive diagnosis of EP. Majority of women who present with EP during early pregnancy can have a definitive diagnosis with only standalone TVS, with laparoscopy being used as the treatment modality.

Abstract

Consensus statement

Media courtesy: Wikimedia Commons, research gate 

Endometriosis fertility index can accurately predict a women’s chances of conception after laparoscopy

courtesy:Can stock photos

The Endometriosis fertility index can accurately predict the possibility of non-ART conception or the need of ART for achieving pregnancy after surgical resection of moderate-severe (Stage III–IV) endometriosis reports the results of study published in Human Reproduction. The study confirmed that adnexal function is deciding factor in evaluation of fertility prognosis after the surgery.

There is no evidence based guidelines about post-surgery fertility management of women who have undergone surgery for severe endometriosis. Physicians differ in their approach about the length of conservative treatment and that sometimes add years and causes unnecessary delays.

The researchers in this study from Australia, led by Dr. Sarah Maheux-Lacroix of the Royal Hospital for Women in Randwick, looked into data of 279 women who had undergone laparoscopic surgery for stage III-IV and were trying to become pregnant.

Endometriosis fertility index was first published in 2010 and is a robust tool to predict fertility after surgical staging of endometriosis.

https://image.slidesharecdn.com/

The EFI is combines obstetrical and surgical factors to predict a woman’s chance of becoming pregnant. In addition to all the components of the revised-American Society of Reproductive Medicine score, it also includes a detailed evaluation of the fallopian tubes, fimbriae, and ovaries, and accounts for any adnexal dysfunction after surgery.

The researchers calculated EFI for all these women based on detailed operative reports and surgical images plus the obstetric history of women.

The average follow-up was 4 years during which 147 women (63%) gave birth, of which 94 conceived naturally without ART.

None of the women with EFI 0-2 conceived, while 91% women with EFI 9-10 had live births in 5 years period after surgery.

Similarly, women with EFI 0-2 had a success rate of 38% with ART, while those with EFI 9-10 had a success rate of 71%.

So, low EFI was significant in predicting failure to conceive (P = 0.003) in addition to other factors which adversely affected the pregnancy rates like being older than 40 years (P = 0.027), having uterine fibroids (P = 0.037) and history of previous resection (P = 0.019) or incomplete resection (P = 0.028).

The only drawback of the study was its retrospective nature.

The researchers concluded that the tool can be used to predict the fertility prognosis in women after surgery for endometriosis. Depending on the EFI score, the obstetrician can advise patients about timed intercourse or refer the patients  for ART, without wasting precious years.

Abstract

Uterine transposition: A novel option to preserve fertility in patients requiring pelvic chemoradiation

Courtesy: University of Queensland.

Uterine transposition is an interesting and novel technique not ever reported in literature. This is the first case report of uterine transposition and technique published in August issue of Journal Fertility and Sterility.

All gynecologists are familiar with transposing ovaries to preserve fertility and avoid premature menopause in patients who require radiation treatment to the pelvis for cervical cancer.

Dr Reitan Ribeiro from Brazil reports the case of a 26-year-old woman diagnosed with rectal adenocarcinoma located 5 cm from the anal margin. The patient was young and did not have any children and wanted to preserve her fertility.

Dr Ribeiro offered the patient a repositioning of the uterus outside the pelvic cavity called along with the ovaries outside the pelvic cavity, to save them from harm due to pelvic radiation.

The maximum tolerated radiation dose for the ovaries is 15 Gy; for uterus and cervix it is 20 Gy to 30 Gy. But, the radiation dose for curing rectal cancer is significantly higher and is approximately 50 Gy, at which all the pelvic organs will be certainly damaged.

After the radiation treatment was complete the uterus was repositioned back into the pelvic cavity.

The entire procedure was carried out laparoscopically (key hole surgery) without a big abdominal incision. The basis for this procedure is that the blood vessels to the ovaries provide also good blood supply for the uterus at the same time.

The uterus and ovarian functions were preserved as evident by 2 menstrual period that began after 2 weeks of repositioning the uterus back and the cyclic ovarian hormonal variation was maintained at the time of neoadjuvant therapy.

At per speculum examination at 6 weeks the cervix was entirely normal looking and at 18 months follow up the uterus appeared to be normal.

The paper was also presented by Dr. Ribeiro at Society of Gynecologic Oncology 2017Annual Meeting from 10 to 14 March in Washington D.C.

He did acknowledge that further studies are warranted to establish the safety and efficacy of the procedure. The spread of tumor to a location not easily amenable to treatment was a major concern.

Dr Riberio and colleagues have launched a Uterine Transposition: Feasibility Study  and will shortly start recruiting patients.

This prospective nonrandomized multicenter phase I study, will evaluate the feasibility of performing uterine transposition before chemoradiation for rectal cancer and uterine reimplantation after the treatment. 

The authors concluded that, “Uterine transposition might represent a valid option for fertility preservation in women who require pelvic radiotherapy and want to bear children.” 

Related link: Ovarian Transposition: A novel laparoscopic surgical method video by Cleveland Clinics.

https://obgynupdated.blogspot.com/2017/03/ovarian-transposition-novel_17.html

A minimal invasive approach in management of symptomatic post–cesarean section isthmocele: a video case report.

courtesy: researchgate.net 

The cesarean section scar defect, also known as an isthmocele, is a reservoir-like pouch defect on the anterior wall of the uterus, located at the site of a previous cesarean delivery scar. It exact incidence is unknown because of scarcity of data about the condition.

It is commonly found on ultrasound examination (24%-88%). It could range from just thinning of the uterine myometrium to large defects leading to complete absence of myometrium.

It could present with abnormal uterine bleeding(AUB), pelvic pain and infertility in post-operative period. Several obstetric complications such as scar dehiscence, placenta accreta, and ectopic scar pregnancy are increasingly reported along with rising cesarean rates.

It is commonly repaired by vaginal surgery, operative hysteroscopic, combined laparoscopic-vaginal, or minimal invasive laparoscopic approach.  In absence of randomized studies, the efficacy of these approaches or superiority of one over another is not known.

A review of data showed that hysteroscopy is able to correct the scar defect but does not increase the uterine wall thickness, whereas laparoscopy is able to increase the uterine wall thickness.  

This video case report by Aimi G. et al. published in June issue of Fertility and Sterility describes a minimal invasive laparoscopic approach for correcting the scar defect.

A 36-year-old woman with history of 2 previous section presented with persistent postmenstrual spotting and chronic pelvic pain. A transvaginal sonography identified a 20.0 × 15.6 mm defect at the place of previous scar with a 2.6 mm remaining myometrial thickness over the defect.

In this case Isthmocele excision and myometrial repair was performed laparoscopically. After mobilization of the bladder, the isthmocele was identified by transrectal intraoperative sonography. Once identified, the isthmocele pouch was excised and contents drained. The cesarean section scar is excised with the help of cold scissors till healthy myometrium is visible. The defect was closed with a single layer of interrupted 2-0 Vycril sutures. A Hegar dilator was placed in cervix to maintain the continuity of uterus with the cervix.  Finally, visceral peritoneum was closed. Total operative time was 70 minutes.

Post operatively the patient made an uneventful recovery and was discharged home on 2 post-op day. A follow up sonography at 40 days after surgery with transvaginal and transabdominal route showed a complete repair of defect. At 3 months follow-up, postmenstrual spotting and chronic pelvic pain also resolved completely.

The authors concluded that, a laparoscopic approach is procedure of choice when repairing large isthmocele with severe myometrial thinning.  

Here is the video of the surgery

ACOG updates it recommendations for selecting the best route of hysterectomy for benign diseases

ACOG updates its committee opinion for choosing the best route for Hysterectomy in Benign Disease. It replaces the Committee Opinion Number 444, issued November 2009.

In the United States, approximately 600,000 hysterectomies are performed each year, and the procedure is the second most frequently performed major surgical procedure among reproductive-aged women.

More than 50% of benign hysterectomies are performed for uterine fibroids followed by Abnormal uterine bleeding (42%), endometriosis (30%) and prolapse (18%), although some indications are overlapping.

Hysterectomies are performed vaginally, abdominally or laparoscopically (total laparoscopic hysterectomy [with or without robotic assistance] or laparoscopically assisted vaginal hysterectomy).

An analysis of data in between 1998 – 2010 shows a decreasing trend of abdominal route (65% to 54%) in favor of Minimal Invasive Surgery. But, the vaginal approach has shown a consistent decline in use from 1998-2010 (25% to 17%).

The recommendations and conclusions are as follows:

Vaginal Hysterectomy should be the route of choice when feasible. Evidence supports that it is associated with shorter operation time, better outcome and it is also the most cost effective of all procedures. Society of Pelvic Reconstructive Surgeons has issued its own guidelines incorporating the uterine size, mobility, and accessibility of uterus to determine the best route of hysterectomy for a patient.

In patient with adnexal pathology, adhesions or endometriosis vaginal hysterectomy is not feasible, in such patient’s laparoscopic hysterectomy is the alternative of choice over open surgery.

Each patient should be evaluated for the route of hysterectomy based on clinical factors, anatomical characteristics and patient’s individual choice combined with surgeon’s training and experience.

The healthcare provider should discuss with each patient the best possible route for her, and she should be informed the pros and cons of each route based on her clinical situation.

Opportunistic salpingectomy can safely be performed at the time of vaginal hysterectomy.  A 2015 study showed that the procedure can be accomplished in 88% of planned cases by vaginal route.

Prophylactic bilateral salpingo-oophorectomy in cases of genetic mutation represents a total different clinical scenario. The procedure should be performed by laparoscopic or open abdominal approach to get proper tissue margins and inspect the peritoneal surface.

If patient choose to have a supracervical hysterectomy, laparoscopic or abdominal approach is best suited.

In case a laparoscopic approach is decided upon, the uterus can be removed intact or scalpel morcellation. Power morcellation is under scrutiny after Dr Amy Reed and her husband lobbied against its use in Minimal Invasive Surgery. The dangers of power morcellation, contained power morcellation should be discussed with patient and she should be explained about presence of an occult malignancy that may worsen the cancer prognosis.

The committee opinion can be accessed here. 

ACOG statement on power morcellator use in gynecological surgery can be accessed here.

Evidence does not support adhesiolysis as a treatment of chronic pain after gynecological and general surgery: a systematic review and meta-analysis.

courtesy: laparoscopyindia.com

At present, there is little evidence to support the routine use of adhesiolysis to relieve post-operative chronic abdominal pain after gynecological and general surgery according to results of a systematic review and meta-analysis published in current issue of Journal of Human Reproduction Update.

Postoperative adhesions are cause of significant morbidity like bowel obstruction, chronic pelvic pain and infertility in females. Open gynecological surgeries are highest risk factor for adhesions formation.

Chronic pain leads to diminished quality of life post operatively and affects nearly 20-40% of patients who have undergone abdominal surgeries.

This systematic review and meta-analysis investigated the role of surgery in relieving the chronic pain immediately and after extended follow up. It also assessed the safety and complications associated with adhesiolysis.

After literature review a total of 4294 unique studies were identified, out of which 13 studies met the study criteria which included 2 RCTs.

After the pooled analysis of the data, 72% patients reported improvement in pain at follow-up of > 3 months. In about 20% of the patients no cause of pain was found while 4% patients suffered some complications because of laparoscopy.

The authors concluded that laparoscopic adhesiolysis relieves pain from adhesions in ~70% of patients for short term only. The evidence does not support adhesiolysis for relieving chronic pain in longer run. It also results in bowel injuries and many laparoscopies turn out to be negative amounting to unnecessary surgeries.

More research should be focused at techniques and materials designed to reduce and prevent postsurgical adhesions and to improve results of adhesiolysis. 

Ovarian Transposition: A novel laparoscopic surgical method video by Cleveland Clinics.

First described in 1958, ovarian transposition is a great way to move ovaries away from the radiation field to preserve fertility and prevent early menopause in reproductive age women undergoing pelvic or low abdominal radiation therapy. These women may also be scheduled to receive chemotherapy, which has low gonadotoxicity after the radiation therapy.

The vascular pedicle remains intact in transposition vs. transplantation. Ovarian stimulation and oocyte retrieval can be easily performed later when the patient desires fertility.  

Oocytes are highly sensitive to radiation and 16 gray (Gy) of radiation will deplete the entire oocyte pool in a 20-year-old.

The most common cancers which require low abdominal radiations are rectal and anal cancers.

A recent article published in forthcoming issue of Fertility and Sterility describes and demonstrate novel surgical method of laparoscopic ovarian transposition. This is a minimal invasive approach in which the ovary is tunneled through a peritoneum.

A 29-year-old female was diagnosed with rectal cancer, the patient underwent laparoscopic ovarian transposition of one ovary followed by ovarian decortication for ovarian tissue freezing of the contralateral ovary, both performed in one laparoscopic surgery, before further chemotherapy and radiation.

The procedure was performed to maintain the ovarian blood supply retroperitoneally and prevent the ovarian vessels taking a sharp turn in pelvic cavity.  

The laparoscopic ovarian transposition has a success rate of 88.6% for preservation of ovarian function as seen from the levels of gonadotropin levels after cancer treatment.

A systematic review and meta-analysis of published in Journal of Ovarian Research concluded that it significantly preserves ovarian function with minimum risk of metastasis to the ovary even in gynecological malignancies.

Here is the video presentation of the surgical procedure by Cleveland Clinics. 

News from American Society for Reproductive Medicine (ASRM) 2016 Scientific Congress— Laparoscopic surgery or ART directly---What comes first in patients with Unexplained Infertility.

Clinical Pearls:

• Both the procedure resulted in pregnancy rate at par with each other, but the researchers advocate doing diagnostic and therapeutic laparoscopy first in patients with unexplained infertility.  

American Society for Reproductive Medicine (ASRM) 2016 Scientific Congress is currently ongoing at (October 15 – 19) Salt Lake City, Utah. Some selected abstract and news from the conference.

It is always an obstetrician dilemma whether to perform laparoscopy first or go for ART in patient diagnosed with unexplained infertility.

 A randomized prospective clinical trial results by Algergawy  A.et al. presented on October 18, 2016 evaluated the outcome of these two approaches.[1]

The study involved a cohort of 423 patients who were diagnosed with unexplained infertility based on normal HSG findings, regular ovulation, normal hormonal profile and normal male partner. These women were randomized into two groups. Women who underwent COH followed by IUI for 3 cycles and then ICSI constituted group 1 (205). The second group (218) consists of women who underwent laparoscopy (Diagnostic and therapeutic).

86 women (41.95%) in the first group conceived within 1 year, 26 cases (12.6%) by IUI. and 60 cases (29.26%) by ICSI.

In the second group, diagnostic laparoscopy revealed multiple pathology like mild to moderate endometriosis, severe endometriosis and hypoplastic fallopian tube. Adhesiolysis, ablation and excision of endometriotic implant was performed. The overall pregnancy rate in group 2 was 84 cases (38.53%). 

Although the pregnancy rate in both group is at par, laparoscopy resulted in better diagnosis of causes of unexplained infertility resulting in better management of cases. It also enabled spontaneous pregnancy in significant number of patients thus avoiding psychological, emotional and physical trauma of ART. It also avoids the many complications of ART like OHSS and multiple pregnancy.

If the patient of unexplained infertility does not conceive after laparoscopy, then ART can always be performed when needed and previous diagnostic laparoscopy facilitates the results of ART.

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[1] http://www.fertstert.org/article/S0015-0282(16)61545-5/fulltext