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Infertility has been notorious for its time-consuming and prolonged explorations and the resultant delay in diagnosis. This delayed diagnosis adds to the burden of the patient and, in spite of the higher pregnancy rate and lower cost reported with traditional treatment algorithm as first-line therapy compared with liberal referral to assisted reproduction technologies (ART) (Karande et al., 1999), has stimulated physicians and specialized centres to promote the latest approach. This strategy has the additional problem, especially for developing countries, that ART carry a higher risk of neonatal and maternal morbidity than natural conception, even in the absence of multiple pregnancy (Helmerhorst et al., 2004; Ombelet et al., 2005, 2006). Recent observations demonstrate that exploration of the female reproductive tract is not only useful for diagnosis and treatment but also necessary for enhancing the in vitro fertilization—embryo transfer (IVF-ET) results. Indeed, a Cochrane review including three RCT shows that laparoscopic salpingectomy prior to IVF-ET in patients with hydrosalpinges improves pregnancy, ongoing pregnancy and live birth rates (Johnson et al., 2002). Furthermore, the incremental cost of the surgical intervention to achieve this higher live birth rate was reported to be beneficial (Strandell et al., 2005). Everybody agree on the value of an accurate exploration of the female reproductive tract for the management of infertility but opinions greatly differ as how and to which extent these investigations should be performed. In current practice hysterosalpingography (HSG) is still used as a first-line investigation, although it is not a pain-free (Tur-Kaspa et al., 1998) and riskfree procedure and even when its sensitivity, specificity and prognostic values for the management of the infertility are debatable (Glatstein et al., 1997; Swart et al., 1995; Mol et al., 1997, 1999). This option is largely based on the absence of alternatives since endoscopic procedures (e.g. conventional laparoscopy and hysteroscopy) demanding high skills and sophisticated equipments do not fulfil the criteria of being minimally invasive, affordable and accessible. Although conventional laparoscopy is considered the gold standard for the exploration of the female reproductive tract, it is for several reasons not suitable as a first-line investigational technique. Laparoscopy is an expensive procedure requiring hospitalization, operating room and general anaesthesia, as in open abdominal surgery. The procedure is invasive and not without morbidity and mortality. Indeed, even in experienced hands the blind transabdominal access can cause major blood vessel and bowel injury (Jansen et al., 1997; Brosens et al., 2003), whereas the distension medium (i.e. CO2 pneumoperitoneum) causes discomfort and additional hazards (Molinas and Koninckx, 2000; Molinas et al., 2001; Nguyen et al., 2002; Kissler et al., 2004). Furthermore, the see-and-treat possibility of laparoscopy requires the presence of a high skilled reproductive surgeon at the diagnostic screening procedure, which is not always feasible. The exploration of the female reproductive tract should be as easy as HSG and as accurate as standard laparoscopy. No conclusive answer has been given until now, but the transvaginal ultrasound and endoscopic procedures offer probably the most efficient and accurate solution to the problem. The challenge is for both developed as developing countries identical: to find a low cost and easily accessible diagnostic procedure with operative possibilities for offering the fastest and minimal invasive lane to pregnancy. In this article we outline a challenging concept for the management of infertility in both developed and developing countries: a model based on ambulatory endoscopic techniques (i.e. modern mini-hysteroscopy and transvaginal laparoscopy) for the exploration of the female reproductive tract, describing their diagnostic and operative possibilities and limitations.

Modern endoscopic-based exploration of the female reproductive tract: a model for developing countries?