**1. Introduction**

## **1.1. Dilemma of definition of Unexplained Infertility (UI)**

Infertility is a continuous challenge for all gynecologists worldwide. Unexplained infertility (UI) is infertility in which the cause of the fertility impairment cannot be detected by use of standard diagnostic measures like semen analysis, tests for ovulation and tubal patency. It remains a clinical and scientific challenge [1]. Unexplained infertility is a source of anxiety for couples desiring pregnancy. It can be diagnosed after a complete evaluation [2]. The Practice Committee of the American Society for Reproductive Medicine (ASRM) has published guidelines for a standard infertility evaluation [3]. UI does not mean there is no physical explanation for the infertility, but that is just, medical tests have not identified any specific problems [4, 5]. A quarter of infertility range (25%) cannot be explained because of current tests are not perfect in finding all problems., the problem preventing pregnancy is not covered by the usual range of tests for assessing infertility, or causes which are not yet understood by scientists [4]. In the past decades, tremendous advancement in the field of infertility has been made. The development of better methods of diagnosis due to better understanding of physiology of ovulation, advent of ultrasound, endoscopy and other modern equipments have changed the whole approach to this problem. [6]. Possible Etiologies for UI may include hostile cervical mucus [7], subtle ovulatory dysfunction [8], luteal-Phase Defect [9], impaired fertil‐ izing ability of oocytes specially when associated with raised LH levels, hyperprolactinemia [10], sperm dysfunction and antisperm Antibodies (151endometrial Steroid receptor defects [12], some genetic [13], psychological [14] or immunological Causes [15]. Prospective studies appear to have clearly demonstrated the substantial importance of even minimal endometrio‐ sis, which has been shown to be associated with impaired fertilization ability of oocyte and presumably impaired follicular function. Changes in the intraperitoneal environment leading to an inflammatory process in the absence of visible abnormalities have been suggested as

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being causal in some cases of unexplained infertility [11]. Scientific curiosity must take second place to a more pragmatic approach, which takes into account the clinical and financial costs of making a more accurate diagnosis [5]. Laparoscopy is generally accepted as a good standard for diagnosing tubal pathology or other pelvic reproductive diseases, such as adhesions and endometriosis. Once identified, appropriate surgical treatment can be given, enhancing the chance of spontaneous conception. Furthermore, in cases with poor prognosis, laparoscopy could accelerate the commencement of (IVF), bypassing unnecessary cycles of ovulatory stimulation with or without intrauterine insemination [16].

#### **1.2. Is it logic to omit laparoscopy and hysteroscopy from the definition of UI?**

There is a general consensus among gynecologists that tubal patency at HSG is quite assuring about tubal factor and they proceed to investigate other factors or advise patients to try assisted reproduction. On reviewing literature, Kahyaogla [17] found that laparoscopy can be omitted if there is no risk factor for pelvic pathology while it is recommended if suspected endome‐ triosis or tubal pathology. Likewise, Bonneau et al. [16] examined 114 cases with UI by laparoscopy and detected abnormalities in 83.4% (n=95) of patients. More and more studies in addition to our day practice experience prefer to include laparoscopy and hysteroscopy in the evaluation of cases with UI. We believe that diagnostic laparoscopy is an integral step of the diagnostic work-up of any infertile couple before saying the term "unexplained". Laparoscopy can demonstrate previously undetected stage I or II endometriosis or periovarian or peritubal adhesions in a substantial proportion of women. Detection of these abnormalities may result in alternative treatment plans, such as surgery for endometriosis or direct referral to an IVF program if there are peritubal adhesions. The following factors would affect implication of laparoscopy as a routine test in all cases of UI including the availability of resources, the risk associated with laparoscopy, the knowledge that laparoscopy demonstrates abnormalities not otherwise detected by other infertility tests, and laparoscopic treatment of minimal and mild endometriosis enhances fecundity.

#### **1.3. When to perform endoscopy?**

Timing of performing combined laparoscopy and hysteroscopy for cases of UI is a controver‐ sial issue as well. In one study, they recommended that transvaginal hydrolaparoscopy and minihysteroscopy can be performed after a waiting period of 6-12 months in older women and particularly in women experienced infertility awareness methods [18]. In our practice, timing is a matter of individualization. If you have a patient with a persistent TVS abnormality that requires Endoscopic assessment, it is a waste of time to defer the decision. This decision is of high importance particularly if all other possible causes were excluded.

#### **1.4. Current role of gynecologic endoscopy in UI**

Including laparoscopy and hysteroscopy as a basic investigation for cases of UI would be expected to detect the following:

**•** Missed fallopian tubal causes.


being causal in some cases of unexplained infertility [11]. Scientific curiosity must take second place to a more pragmatic approach, which takes into account the clinical and financial costs of making a more accurate diagnosis [5]. Laparoscopy is generally accepted as a good standard for diagnosing tubal pathology or other pelvic reproductive diseases, such as adhesions and endometriosis. Once identified, appropriate surgical treatment can be given, enhancing the chance of spontaneous conception. Furthermore, in cases with poor prognosis, laparoscopy could accelerate the commencement of (IVF), bypassing unnecessary cycles of ovulatory

There is a general consensus among gynecologists that tubal patency at HSG is quite assuring about tubal factor and they proceed to investigate other factors or advise patients to try assisted reproduction. On reviewing literature, Kahyaogla [17] found that laparoscopy can be omitted if there is no risk factor for pelvic pathology while it is recommended if suspected endome‐ triosis or tubal pathology. Likewise, Bonneau et al. [16] examined 114 cases with UI by laparoscopy and detected abnormalities in 83.4% (n=95) of patients. More and more studies in addition to our day practice experience prefer to include laparoscopy and hysteroscopy in the evaluation of cases with UI. We believe that diagnostic laparoscopy is an integral step of the diagnostic work-up of any infertile couple before saying the term "unexplained". Laparoscopy can demonstrate previously undetected stage I or II endometriosis or periovarian or peritubal adhesions in a substantial proportion of women. Detection of these abnormalities may result in alternative treatment plans, such as surgery for endometriosis or direct referral to an IVF program if there are peritubal adhesions. The following factors would affect implication of laparoscopy as a routine test in all cases of UI including the availability of resources, the risk associated with laparoscopy, the knowledge that laparoscopy demonstrates abnormalities not otherwise detected by other infertility tests, and laparoscopic treatment of minimal and mild

Timing of performing combined laparoscopy and hysteroscopy for cases of UI is a controver‐ sial issue as well. In one study, they recommended that transvaginal hydrolaparoscopy and minihysteroscopy can be performed after a waiting period of 6-12 months in older women and particularly in women experienced infertility awareness methods [18]. In our practice, timing is a matter of individualization. If you have a patient with a persistent TVS abnormality that requires Endoscopic assessment, it is a waste of time to defer the decision. This decision is of

Including laparoscopy and hysteroscopy as a basic investigation for cases of UI would be

high importance particularly if all other possible causes were excluded.

**1.4. Current role of gynecologic endoscopy in UI**

**1.2. Is it logic to omit laparoscopy and hysteroscopy from the definition of UI?**

stimulation with or without intrauterine insemination [16].

4 Contemporary Gynecologic Practice

endometriosis enhances fecundity.

**1.3. When to perform endoscopy?**

expected to detect the following: **•** Missed fallopian tubal causes.

