Clinical UM Guideline

 

Subject: Diagnostic Infertility Surgery
Guideline #:  CG-SURG-34 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

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 2018).

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. Armstrong SC, Showell M, Stewart EA, et al. Baseline anatomical assessment of the uterus and ovaries in infertile women: a systematic review of the evidence on which assessment methods are the safest and most effective in terms of improving fertility outcomes. Hum Reprod Update. 2017; 23(5):533-547.
  3. 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.
  4. 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.
  5. Komori S, Fukuda Y, Horiuchi I, et al. Diagnostic laparoscopy in infertility: a retrospective study. J Laparoendosc Adv Surg Tech A. 2003; 13(3):147-151.
  6. Robabeh M, Roozbeh T. Comparison of hysterosalpingography and laparoscopy in infertile Iranian women with tubal factor. Ginekol Pol. 2012; 83(11):841-843.
  7. Schrager S, Falleroni J, Edgoose J. Evaluation and treatment of endometriosis. Am Fam Physician. 2013; 87(2):107-113.
  8. 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.
  9. 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 2018.
  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 May 11, 2018.
  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 May 11, 2018.
  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 May 11, 2018.
  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 May 11, 2018.
Websites for Additional Information
  1. American Society for Reproductive Medicine. Available at: http://www.asrm.org/. Accessed on May 11, 2018.
History

Status

Date

Action

Reviewed

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References section.

Reviewed

08/03/2017

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.