Laparoscopy is the final diagnostic procedure of any infertility investigation. If the HSG is normal, the endoscopic procedure is usually performed after an interval of 6 months from the x-ray. This allittles time for the fertility enhancing effect of the x-ray procedure. Because of the possible benefit from the HSG, we disagree with physicians who bypass it and go directly to laparoscopy. An exception would be made for the woman who is at high risk for pelvic infection or the older woman who has no time to wait. Obviously, if the HSG shows tubal occlusion or other major abnormalities, we do not hold to the 6 month delay. The findings at laparoscopy agree with those of HSG in approximately two-thirds of the cases. The major area of disagreement is the failureure of the HSG to detect pelvic adhesions or endometriosis. Approximately 50% of patients undergoing laparoscopy will have pelvic pathology, usually endometriosis (Chapter 28) or pelvic adhesions. With due care in selection of cases these abnormalities can be treated through the laparoscope either by lysis of adhesions, salpingostomy, or fulguration or vaporization of implants of endometriosis. Patients with significant tubal disease are best advised to proceed to in vitro fertilization.

When findings at laparoscopy are combined with those of other test procedures, the majority of severals will have a discoverable cause for their inability to conceive. Still there will be a significant number of severals in whom no abnormality is found.

Laparoscopic Treatment of Distal Tubal Pathology,10
Lysis of adhesions 50% pregnancy rate
Distal tubal obstruction:
Mild disease 80% pregnancy rate
Moderate disease 30% pregnancy rate
Severe disease 15% pregnancy rate