Definitions of the grades of the recommendations (A, B, C) and the levels of evidence (I, II, III) are provided at the end of the "Major Recommendations" field.
General Recommendations for Diagnostic Laparoscopy
Diagnostic laparoscopy (DL) is a safe and well tolerated procedure that can be performed in an inpatient or outpatient setting under general or occasionally local anesthesia with intravenous sedation in carefully selected patients. Diagnostic laparoscopy should be performed by physicians trained in laparoscopic techniques who can recognize and treat common complications and can perform additional therapeutic procedures when indicated. During the procedure, the patient should be continuously monitored, and resuscitation capability must be immediately available. Laparoscopy must be performed using sterile technique along with meticulous disinfection of the laparoscopic equipment. Overnight observation may be appropriate in some outpatients.
Diagnostic Laparoscopy for Primary and Secondary Infertility
Technique
The lithotomy position is employed so that cervical manipulation can be used. When cervical manipulation is not needed, standard prone positioning is used. A primary trocar site is placed in the periumbilical region, and additional trocars are placed in the right and or left lower quadrants as needed. Methylene blue or other dye can be injected into the fallopian tube to check for patency. Peritoneal fluid can be obtained to check for endometriosis. Endometriosis observed should be biopsied and classified with tools such as the American Society for Reproductive Medicine Guidelines. Adhesions can be identified and classified as mild, moderate, or severe. Pathology affecting the fallopian tube can be classified as mild (a superficial vascular pattern suggesting congestion or inflammation and/or minimal kinking, and/or minimal fibrosis), moderate (salpingitis, isthmica, nodosum, distal phimosis, high degrees of vascular change, fibrosis, ampullary dilation after visualization with chromotubation), or severe (obstruction of the tube proximally or distally). Treatment of identified pathology can be initiated at this time.
Indications
Infertility particularly after normal hysterosalpingography.
Recommendations
Diagnostic laparoscopy (DL) can be used safely in female patients with infertility (Grade B). DL may be considered in appropriately selected infertile patients even after normal hysterosalpingograms, as important pelvic pathology may be identified in a significant number of patients (Grade C). The paucity of available data and the low level of evidence do not substantiate a firm recommendation for the procedure.
For details of the rationale for the procedure and its diagnostic accuracy, see the original guideline document.
Definitions:
Levels of Evidence
Level I |
Evidence from properly conducted randomized, controlled trials |
Level II |
Evidence from controlled trials without randomization
Or
Cohort of case-control studies
Or
Multiple time series, dramatic uncontrolled experiments
|
Level III |
Descriptive case series, opinions of expert panels |
Scale Used for Recommendation Grading
Grade A |
Based on high-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel |
Grade B |
Based on high-level, well-performed studies with varying interpretation and conclusions by the expert panel |
Grade C |
Based on lower-level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel |