Investigation of the infertile couple - Should diagnostic laparoscopy be performed after normal hysterosalpingography in treating infertility suspected to be of unknown origin?

Traditionally, a diagnosis of unexplained infertility is established only when all standard clinical investigations yield normal results. When tubal patency has been established by hysterosalpingography (HSG), laparoscopy has been suggested as a mandatory step to preclude the existence of peritubal adhesions and endometriosis as causes of infertility. In women without a previous history suggestive of tubal disease and who have a normal HSG, it was demonstrated that the probability of clinically relevant tubal disease or endometriosis is very low and that laparoscopy does not seem justified or cost effective. In the minority of these cases, laparoscopy might reveal minimal or mild endometriosis or peritubal adhesions. In these cases, either surgery or medical treatment has not been proven to improve fecundity. With the current success rates of assisted reproductive technologies (ART) and the relatively low contribution of diagnostic laparoscopy to the decision-making process of treating patients with a normal HSG, we suggest that laparoscopy should be omitted in couples suspected of having unexplained infertility. These patients should be treated by 3-6 cycles of combined gonadotrophins and intrauterine insemination, and if unsuccessful switched to ART.