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30% except advanced endometriosis, where the pregnancy rate in our series is about 18.5%. This incidence is less than what is reported in literature. This is because of associated adenomyosis, which is a common accompaniment in advanced endometriosis in Eastern India. In minor tubal defects, the pregnancy outcome following laparoscopic correction or ART procedures is comparable (p < 0.01). It is worth-mentioning that in major tubal defects or severe endometriosis, ART procedures produce better (above 25%) than laparoscopic surgery (5.7% for major tubal defect and 18% for advanced endometriosis) pregnancy outcome (p < 0.05) (Table 3). The correction of ovarian pathology or fibroids yields similar success rates (30% as compared to 30.8%). This rate is not high, as other factors of infertility might interfere. The recovery of POD gives better success (40% or more). Relation Table 2: Pregnancy outcome following laparoscopic surgery Laparoscopic surgery Non-ART pregnancy outcome Operation No. Pregnancy % (non-ART) Tubal Major 349 19 5.7 Minor 1405 383 27.4 Ovarian 768 230 30 Fibroid 136 42 30.8 Endometriosis 574 117 21 Recovery of POD 209 84 40 Table 3: Comparison of FPLS and ART pregnancy Treatment Laparoscopic surgery ART Cases No. Pregnancy % No. Pregnancy % Major tubal 349 19 5.7 240 67 28.1 Advanced 308 51 16 377 99 26 endometriosis Table 1: Common pathologies for FPLS Nature of pathologies No. % Tubal defects 1754 49.6 Major 249 Minor 1405 36 Ovarian 768 19.2 Uterine fibroid 136 3.4 Endometriosis III/IV 574 14.5 Adhesion in POD 209 5 Others 395 Nil Fertility Promoting Laparoscopic Surgery: Our Experience Journal of South Asian Federation of Obstetrics and Gynaecology, January-April 2012;4(1):12-16 15 JSAFOG between the pregnancy rate and TOR is not considered here, because it was not possible to find out what was the TOR at the time of conception. The statistical analysis of the pregnancy outcome indicates that there is not much of difference between the success rates, when IVF and ART are compared for minor tubal defects (p < 0.01). But, ART procedure yields much better results compared to surgery (p < 0.05) for advanced pelvic pathology. DISCUSSION Operative laparoscopy is an important procedure to achieve pregnancy in infertile women. It is mostly required for the anatomical correction of pelvic organs to remove any mass from pelvis, hindering fertility. Correction of minor tubal defects and ovarian pathology gives good success rate. Unnoticed minor tubal defects are often stamped as unexplained infertility and subjected to IVF program. The fallopian tube has multiple functions2 in achieving pregnancy. The surgical approach should be directed to get all the tubal functions back in a damaged or diseased tube. It has been observed from the present study that certain simple measures can alleviate tubal pathology to great extent and restore most of the functions. Minor tubal defect may be the result of subclinical or silent inflammation, introduced by Chlamydia trachomatis19 or E. coli. Chlamydia trachomatis, for reasons unknown, may exist in nonreplicating state for prolonged latent period without any symptoms.20 On many occasions, tubal kinks and thereby shortening of the effective tubal length can happen due to minimal or mild endometriosis, a proinflammatory state, causing adhesive disease, leading to subfertility.21 Sometimes, tubal defects are results of postabortal or puerperal infections, as it happens in secondary infertility. Fimbrial pathology is also a cause of concern. If the fimbriae are not inspected properly in video monitor under magnified view, the defects pass unnoticed. Lyses are also very important to get back mobility of the fallopian tubes. After adhesiolysis, bleeding from tubal serosa should be dealt with caution. In most of the cases, bleeding stops on pressure or on its own. If diathermy is necessary, bipolar is a better choice, as there is minimal scattering of coagulated current. Any blood clot or carbon particle produced as a result should be washed out carefully to prevent readhesion. In pelvic adhesion, as it happens in endometriosis mapping of the disease, is very important. Assessment should be made whether adhesiolysis can bring TOR back to normal with functioning POD. If that is difficult, not much of dissection should be made. All attempts should be made to preserve vascular supply to vital pelvic organs, for their functional competence. Fibroids do not mean myomectomy always for infertile women. Indicated cases need myomectomy, while repair may be performed by open procedure. Ovarian cysts, particularly chocolate cysts, should be dealt carefully. Preservation of ovarian function as much as possible is the aim. Combined tubo-ovarian (TO) as well as uterine mass should be dealt with reasonably and preferably at the same sitting. Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion The Ethics Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama In the United States, economic, racial, ethnic, geographic, and other disparities prevent access to fertility treatment and affect treatment outcomes. This opinion examines the factors that contribute to these disparities, proposes actions to address them, and
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