Clinical UM Guideline



Subject: Diagnostic Infertility Surgery
Guideline #:  CG-SURG-34 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description

This document addresses the use of hysteroscopy and laparoscopy for diagnostic work-up of infertility.

Clinical Indications

Hysteroscopy

Medically Necessary:

Hysteroscopy is considered medically necessary in the evaluation of infertility for any of the following indications:

Not Medically Necessary:

Hysteroscopy is considered not medically necessary when the criteria above are not met including, but not limited to all of the following:

Laparoscopy

Medically Necessary:

Laparoscopy is considered medically necessary in the evaluation of infertility for any of the following indications:

Not Medically Necessary:

Laparoscopy is considered not medically necessary when the criteria above are not met including, but not limited to all of the following:

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT  
49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
58555 Hysteroscopy, diagnostic (separate procedure)
   
ICD-10 Procedure  
0UJ84ZZ Inspection of fallopian tube, percutaneous endoscopic approach
0UJ88ZZ Inspection of fallopian tube, via natural or artificial opening endoscopic
0UJD4ZZ Inspection of uterus and cervix, percutaneous endoscopic approach
0UJD8ZZ Inspection of uterus and cervix, via natural or artificial opening endoscopic
0WJJ4ZZ Inspection of pelvic cavity, percutaneous endoscopic approach
   
ICD-10 Diagnosis  
N88.2 Stricture and stenosis of cervix uteri
N96 Recurrent pregnancy loss
N97.0-N97.9 Female infertility
N98.0-N98.9 Complications associated with artificial fertilization
R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum
R93.8 Abnormal findings on diagnostic imaging of other specified body structures
   
Discussion/General Information

The American Society of Reproductive Medicine (ASRM) (2015) defines infertility as the inability to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse. Work-up for the diagnosis of infertility should include a comprehensive medical, reproductive, and family history and a physical exam. Laboratory testing and diagnostic evaluation may also be appropriate with emphasis on a systematic approach beginning with the least invasive methods for diagnosis of infertility.

Tests to rule out uterine anatomic abnormalities include ultrasound, sonohysterogram, and hysterosalpingogram. Ultrasound can be done to diagnose uterine pathology such as myomas. Sonohysterogram which involves injecting saline into the uterine cavity and then using transvaginal ultrasound to view the uterine cavity can detect pathology such as endometrial polyps, submucous myomas, and synechiae. The hysterosalpingogram involves the use of x-rays and injection of a contrast agent into the cervical canal, uterine cavity, fallopian tubes, and peritoneal cavity to look for blockages. Hysterosalpingogram can also show developmental anomalies of the uterus or acquired anomalies such as endometrial polyps or submucous myomas. A definitive method for the diagnosis and treatment of intrauterine pathology is the hysteroscopy. This exam is invasive and is usually reserved for use after less invasive methods have been unsuccessful.

Hysteroscopy

In a retrospective chart review, Acholonu (2011) reported on the comparison of hysterosalpingogram to sonohysterogram for detection of polyps, fibroids, adhesions and septae in infertile women. The reports were then compared to hysteroscopy. All 149 women underwent hysterosalpingogram and hysteroscopy. A total of 110 women had abnormalities found on hysteroscopy; whereas hysterosalpingogram detected abnormalities in 64 women. Ninety-three women had sonohysterogram and hysteroscopy. Of those 93 women, 77 showed abnormalities on hysteroscopy, while sonohysterogram showed abnormalities on 63 women. Those women who showed normal hysterosalpingogram or sonohysterogram did not generally go on to have hysteroscopy. Hysterosalpingogram can be an important screening tool for infertile women in evaluating the architecture and patency of the fallopian tubes while sonohysterogram can be more reliable for the evaluation of intrauterine abnormalities.

In a 2016 randomized-controlled trial by Smit and colleagues, the authors reported on whether routine hysteroscopy before the first treatment cycle of in-vitro fertilization affects the livebirth rate. Participants were included if they had a previous normal transvaginal ultrasound and were scheduled to receive in-vitro fertilization for infertility. The participants were randomized 1:1 to either hysteroscopy and then in-vitro fertilization or immediate in-vitro fertilization. A total of 325 participants received hysteroscopy and then in-vitro fertilization, while 364 participants received in-vitro fertilization only. With an 18 month follow-up, the primary outcome was ongoing pregnancy resulting in livebirth, defined as delivery of a live fetus after 24 weeks gestation. After 18 months, 209 participants who had hysteroscopy followed by in-vitro fertilization met the primary outcome measure while 200 participants who had immediate in-vitro fertilization met the primary outcome measure. The authors concluded that a routine hysteroscopy does not improve livebirth rate in those who have a normal transvaginal ultrasound before receiving in-vitro fertilization, therefore those who have a normal transvaginal ultrasound should be not be offered routine hysteroscopy.

A similar trial in 2016 by El-Toukhy and colleagues also reported on whether or not hysteroscopy done prior to starting a cycle of in-vitro fertilization could improve the outcome in those who had already had two to four unsuccessful cycles of in-vitro fertilization. The included participants had all previously had normal transvaginal ultrasounds. The primary outcome measure was the livebirth rate, defined as those who had at least one live baby beyond 24 weeks gestation after one cycle of in-vitro fertilization. In this randomized controlled trial, 301 participants received hysteroscopy prior to in-vitro fertilization and 290 participants received in-vitro fertilization only. A total of 133 participants in the hysteroscopy group became pregnant after in-vitro fertilization with 102 participants meeting the primary outcome measure. In the in-vitro fertilization only group, 136 participants became pregnant and 102 met the primary outcome measure. The authors concluded that hysteroscopy (after a normal transvaginal ultrasound) and unsuccessful in-vitro fertilization cycles did not improve livebirth rate.

Laparoscopy

According to the ASRM (2015), a laparoscopy is indicated if there is suspicion for advanced stage endometriosis, tubal occlusive disease or peritoneal factors. A 2012 retrospective review by Tsuji and colleagues reported on 127 women with suspected tubal pathology who underwent hysterosalpingogram and subsequent laparoscopy. All of the women had suspected tubal pathology found on hysterosalpingogram and 90 women were then found to have tubal pathology on laparoscopy.

A retrospective review by Robabeh and colleagues (2012) reported the findings of 181 women who had both hysterosalpingogram and laparoscopy. A total of 99 women had findings from hysterosalpingogram and laparoscopy reported as normal and 37 women had findings reported as abnormal (136 women with similar findings by the 2 methods). Forty-five women had dissimilar findings. Three women had normal hysterosalpingogram and abnormal laparoscopy, 42 women had abnormal hysterosalpingogram findings but normal findings on laparoscopy. An abnormal finding was defined as any evidence of occlusion of the fallopian tube(s) irregardless of the site of the problem. In this particular study, 75.1% of women were accurately diagnosed by hysterosalpingogram, whereas 24.9% of women had discrepant diagnoses. The authors concluded that hysterosalpingogram can be performed first, therefore limiting the use of laparoscopy to suspected etiologies other than intratubal such as endometriosis and peritubal adhesions.

The Society of American Gastrointestinal and Endoscopic Surgeons address the use of diagnostic laparoscopy in the 2007 guidelines and based on expert opinion, state that it is indicated for infertility, particularly after a normal hysterosalpingography.

Endometriosis is a chronic gynecologic condition in which symptoms include chronic pain and infertility. It is thought to occur by the attachment and implantation of endometrial glands and stroma on the peritoneum from retrograde menstruation. Endometriosis is associated with infertility and in advanced disease anatomic abnormalities can result in abnormal tubal function. Initial treatment includes a variety of medications. If initial treatment fails, a diagnostic laparoscopy may be offered to confirm the presence of endometriosis (American College of Obstetrics and Gynecologists [ACOG], 2010, reaffirmed 2016).

Definitions

Adnexal mass: A tumor or mass that occurs on any of the organs next to the uterus.

Dysmenorrhea: Painful menstrual cramps.

Hydrosalpinx: A blocked, dilated, and fluid-filled fallopian tube.

Hysteroscopy: A surgical procedure used to diagnose or treat problems of the uterus. A hysteroscope is a thin, lighted telescope-like device that is inserted in the vagina and then into the uterus. The hysteroscope transmits the image of the uterus onto a screen and can assist with diagnosis of uterine problems.

Laparoscopy: A way of doing surgery without making a large incision in the skin. A thin tube known as the laparoscope is inserted into the abdomen through a small incision. The laparoscope allows visualization of the pelvic organs.

Myoma: A benign tumor of the smooth cells of the myometrium.

References

Peer Reviewed Publications:

  1. Acholonu UC, Silberzweig J, Stein DE, Keltz M. Hysterosalpingography versus sonohysterography for intrauterine abnormalities. JSLS. 2011; 15(4):471-474.
  2. El-Toukhy T, Campo R, Khalaf Y, et al. Hysteroscopy in recurrent in-vitro fertilisation failure (TROPHY): a multicentre, randomised controlled trial. Lancet. 2016; 387(10038):2614-2621.
  3. Indraccolo U, Greco P, Scutiero G, et al. The role of hysteroscopy in the diagnostic work-up of infertile asymptomatic patients. Clin Exp Obstet Gynecol. 2014; 41(2):124-127.
  4. Robabeh M, Roozbeh T. Comparison of hysterosalpingography and laparoscopy in infertile Iranian women with tubal factor. Ginekol Pol. 2012; 83(11):841-843.
  5. Schrager S, Falleroni J, Edgoose J. Evaluation and treatment of endometriosis. Am Fam Physician. 2013; 87(2):107-113.
  6. Smit JG, Kasius JC, Eijkemans MJ, et al. Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial. Lancet. 2016; 387(10038):2622-2269.
  7. Tsuji I, Ami K, Fujinami N, Hoshiai H. The significance of laparoscopy in determining the optimal management plan for infertile patients with suspected tubal pathology revealed by hysterosalpingography. Tohoku J Exp Med. 2012; 227(2):105-108.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Obstetrics and Gynecologists (ACOG). Practice bulletin no. 114: Management of endometriosis. Obstet Gynecol. 2010; 116(1):223-236. Reaffirmed 2016.
  2. American College of Radiology. Practice guideline for the performance of hysterosalpingography. 2014. Available at: http://www.acr.org/Quality-Safety/Standards-Guidelines. Accessed on June 21, 2017.
  3. American College of Radiology. Practice guideline for the performance of sonohysterography. 2015. Available at: http://www.acr.org/Quality-Safety/Standards-Guidelines. Accessed on June 21, 2017.
  4. American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. 2015. Available at: http://www.asrm.org/special-pages/search-results/?q=committee+opinion. Accessed on September 21, 2017.
  5. Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for diagnostic laparoscopy. 2007. Available at: http://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/. Accessed on June 21, 2017.
Websites for Additional Information
  1. American Society for Reproductive Medicine. Available at: http://www.asrm.org/. Accessed on June 21, 2017.
History

Status

Date

Action

Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References sections.
Reviewed 08/04/2016 MPTAC review. Updated Description, Discussion/General Information, Definitions and Reference sections. Removed ICD-9 codes from Coding section.
Reviewed 08/06/2015 MPTAC review. Updated Discussion/General Information and References.
Reviewed 08/14/2014 MPTAC review. Updated References.
New 08/08/2013 MPTAC review. Initial document development.