**15. Uterine causes of UI**

prevalence of abnormal laparoscopic findings in UI up to 87.2% who described endometriosis lesions, peritubal adhesions and tubal obstruction. In a previous study, 114 women with UI were examined laparoscopically. Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, ptielvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. They could treat 72 patients of them, and 35 of them conceived using their own tubes. However they concluded that diagnostic laparoscopy should be strongly considered in UI work-up, and tubal efficacy should not be underestimated [65]. In this study, positive laparoscopic findings were reported in 33 patients (66 %). We found that laparoscopy can reveal upper genital tract pathology in 30 cases (71.4%) of positive cases with hidden infections (42 cases) and it was negative in 3 cases (37.5%) of negative cases with hidden intrauterine infections (P Value=0.0001). We reported a significant correlation between the positive cases of intrauterine infections and the pathological lesions diagnosed by laparoscopy especially hyperemic uterus, chronic salpingitis and peritubal adhesions (P Value=0.0001). Subsequently, we recommend meticulous screening of women with these abnormal laparo‐ scopic findings for possibility of hidden intrauterine infections. Small sample size of individual types of hidden intrauterine infections and lake of precise description of a particular abnormal laparoscopic finding for each organism are clear limitations of this study. Diagnostic accuracy for Chlamydia detection would be better if we used Nucleic Acid Amplification (NAAT) instead of the only available direct immunofluorescence assay (IFA). From this study, we conclude that despite being an underestimated cause of female infertility, hidden intrauterine infections are frequent and strongly implicated in UI. Laparoscopy is very beneficial in explaining the effect of hidden intrauterine infections on the upper genital tract. We recom‐ mend postoperative screening for hidden intrauterine infections in UI cases with abnormal laparoscopic findings. Further studies are required to test the impact of proper treating these

The ovaries are easily and clearly seen by transvaginal ultrasonogtraphy. Intraovarian and capsular abnormalities can be detected in most of the cases. Despite properly confirmed ovulation in an otherwise normal couple, pregnancy could not be achieved. On doing diagnostic laparoscopy in those cases some tiny ovarian abnormalities could be diagnosed. Subtle surface ovarian endometriosis could be only diagnosed by laparoscopy. In such cases surface coagulation of red, white or vesicular lesions is easy. Moreover, typical black or blue lesions can be only seen and treated by laparoscopy. In some cases, we notice fine periovarian adhesions hindering rupture of the growing folloicles and preventing pick-up of the oocytes. In such cases, fine microsurgical adhesiolysis without capsular injuring using a delicate fine scissors is feasible by laparoscopy. We may see some dense ovarian adhesions to the lateral or anterior abdominal wall that clearly affect fertility In such cases, microsurgical adhesiolysis will regain the normal anatomy. Lastly, we may notice fine or dense adhesions between the ovary and the back of the uterus or the fallopian tubes. All these mechanical factors will not

infections in cases of UI.

20 Contemporary Gynecologic Practice

**14. Hidden ovarian factors of infertility**

Uterine factors account about 20% of all cases of infertility. Manifest uterine causes may include intrauterine adhesions, polypi or uterine cavity malformations. Hidden uterine factors may include thin endometrium, poor endometrial receptivity, and immunological incompatibility which have received the most attention in recent years. Some delicate endometrial lesions could be diagnosed by hysteroscopy as shown in this figure.

We constructed a study [81] aiming to estimate the safety, efficacy and patient acceptability of adding vaginoscopic office hysteroscopy (VOH) to the infertility diagnostic work-up prior to laparoscopy. It was a prospective comparative diagnostic trial done at a tertiary care referral facility and University hospital. A total of 156 infertile patients scheduled for laparoscopy. Seventy eight patients had VOH on one stop bases in addition to the usual infertility work-up were assigned as group B while a similar number was examined by the usual diagnostic workup and assigned as group A. Main outcome measures included the diagnostic accuracy of VOH in diagnosing intrauterine abnormalities and tubal patency in comparison to hysterosalpin‐ gography (HSG) and diagnostic laparoscopy (DL). Combined VOH and HSG or DL assessment for diagnostic accuracy.

There was insignificant difference between both groups regarding sociodemographic and HSG data. Abnormal DL findings were more significant in group A. VOH detected 50% abnormal

endometrial cavity in group B with a significant superiority over HSG. Blocked tubes were diagnosed in 9% and 11.5%, 5.1% and 6.4% and 3.8% and 5.1% using VOH, HSG and DL on right and left sides respectively. There was a high percentage of agreement in the diagnosis of uterine abnormalities between HSG and VOH (96%, k=0.394). n the other hand, the percentage of agreement between VOH and HSG is less (86%, k=0.214) and is much less between VOH and laparoscopy (82%, k=0.148) regarding tubal patency testing. Generally, VOH was an acceptable procedure with mild pain and feasible in most cases.

We concluded that VOH seems feasible, safe, simple, tolerable and quick out-patient proce‐ dure. It can diagnose intrauterine abnormalities in 23.7% of infertile women with normal HSG. VOH achieves marvelous agreement with HSG in diagnosing uterine abnormalities (96%), excellent agreement with HSG (86%) for tubal patency testing and very good agreement with DL (82%) regarding tubal patency. Diagnostic indices including accuracy of either HSG or DL would increase if combined with VOH. We recommend adding OH to the routine diagnostic work-up of infertile couples prior to laparoscopy. Nevertheless, whether its use would increase pregnancy rate among infertile women requires a further longitudinal comparative study.

