Fertility outcomes following laparoscopic surgery in women seen for infertility;experience of the private sector

Gynecology and Obstetrics, The University of Yaounde 1
June, 2017


Background and rationale: Infertility is a global health problem; it affects 10% - 20% of the world’s reproductive age population. Its highest prevalence is in low resource countries, which includes Africa particularly in sub-Saharan Africa, where tubal damage following pelvic infection is the commonest cause. In Africa, secondary infertility is predominant and its main cause is tubal damage, which contributes to about 42% to 77% of tubal infertility. Laparoscopy has become an integral part of gynecologic surgery for the diagnosis and treatment of abdomino-pelvic disorders of the female genital tract. Their management in developed countries is done by modern sophisticated methods (laparoscopy, medically assisted procreation...) which are rarely available in developing countries. In Africa, there are very few infertility specialists and specialized centers. Laparoscopy is perceived as a minimally invasive surgical technique that provides a panoramic and magnified view of the pelvic organs. Gynecologic surgical laparoscopy was introduced in Cameroon in the early 1990s at the Yaoundé General Hospital. And, previous studies in low resource countries have reported that infertility has been the main indication for diagnostic and therapeutic gynecological laparoscopy. Operative procedures, such as lysis of adhesions, ablation of endometriosis, tuboplasty and salpingectomy for hydrosalpinx or pyosalpinx at the time of laparoscopy can enhance conception, spontaneously or with further reproductive techniques like intra uterine insemination or in vitro fertilization. These studies have been proven in standard public health facilities but few have been done to evaluate the private sector if they meet conventional results as far as infertility is concerned. In addition, few publications exist in Africa and particularly in Cameroon on the results of this management in this specific context, which justifies our work. The aim of this study was to evaluate the fertility outcome following laparoscopy surgery as a therapeutic tool in the management of infertile women in the private sector.
Methods: We undertook a retrospective and analytical study at the Women’s Health Promotion Infertility Clinic, Biyem-assi, Yaoundé. 354 files were studied after ruling out others for not meeting criteria, sampling was consecutive. Pretested questionnaires were made and validated. This questionnaire established the socio-demographic status of the participants, gravidity and parity, anthropometric parameters, complaints at time of consultation, identified their contributing past histories and associated risk factors, para-clinical findings, clinical and surgical diagnosis, per-operative findings, post-operative follow up and fertility and pregnancy outcome. Cases lost from sight or whose outcomes were not included in file, administrative authorization was gotten from the director of the clinic and phone calls were made.
Results: Our results revealed that our predominant population was those between 26-35 years (200), with mean age being 32.81±5.29 years (range 16-48), and 96.3% were married. Secondary infertility was most diagnosed type (69%) with main factor being tubo-peritoneal (65.3%), chlamydia sero-prevalence was 21% and the frequency of per-operative findings was dominated by pelvic adhesions (85.3%) and tubal obstruction (82.2%). Per-operative techniques were predominantly adhesiolysis (83.3%) and tuboplasty (75%). Our post-operative period was marked by a cumulative fertility rate of 60% (212) and this was significantly dependent on patients age (p=0.04), per-operative findings like adhesions and tubal damage (p<0.001).Uterine myomas and ovarian cysts showed no statistical significance. There was also a statistical difference in fertility outcome for the per-operative techniques used (adhesiolysis and tuboplasty p<0.001) and post-operative hydrotubation follow up (p=0.002).

Conclusion: Fertility rate is increased after laparoscopic surgery even in the private setting, secondary infertility remain the predominant type diagnosed and tubo-peritoneal causes are the main causes of infertility in low resource countries.
Fertility outcome after laparoscopic surgery is significantly influenced by the reproductive age, per-operative findings, severity of tubal damage and adhesions, per-operative technique used and post-operative follow up by hydrotubation.

Key words: Infertility, Laparoscopic surgery, Tubal obstruction, Ovarian cysts, uterine myomas, Fertility outcome, Pregnancy outcome, Hydrotubation.