Laparoscopy/ Hysteroscopy

What is Laparoscopy?

Laparoscopy is a versatile diagnostic and therapeutic procedure often used in gynecology to investigate and treat conditions that may contribute to infertility. It provides a direct view of the pelvic and abdominal organs, allowing doctors to identify and sometimes correct abnormalities that may not be detected through non-invasive imaging or tests. Below are the common conditions in which laparoscopy is performed for women with infertility:

 Endometriosis

Laparoscopy is considered the gold standard for diagnosing and treating endometriosis, a condition where tissue similar to the lining of the uterus grows outside the uterus, often causing pain and infertility. The procedure not only confirms the presence of endometriosis but also allows the surgeon to remove or cauterize endometrial implants, adhesions, and cysts (endometriomas), improving fertility outcomes.

 Pelvic Adhesions (Scar Tissue)

Adhesions are bands of scar tissue that can form after infections, surgeries, or conditions like endometriosis. These adhesions can distort the pelvic anatomy, block the fallopian tubes, or prevent the ovaries and eggs from functioning properly. Laparoscopy can both diagnose and treat pelvic adhesions by cutting or removing them to restore normal anatomy.

 Blocked or Damaged Fallopian Tubes

Laparoscopy is used to evaluate the condition of the fallopian tubes, which play a crucial role in natural conception by transporting eggs from the ovaries to the uterus. If blockages or damage are found, the surgeon may attempt to repair the tubes or remove them if they are filled with fluid (hydrosalpinx), which can negatively impact fertility and IVF success.

 Uterine Abnormalities

Structural abnormalities of the uterus, such as fibroids, polyps, or uterine septa, can interfere with implantation or cause recurrent miscarriages. During laparoscopy, fibroids or polyps can often be removed, and uterine septa can be corrected using specialized surgical techniques.

Ovarian Cysts

Laparoscopy is frequently used to diagnose and remove ovarian cysts, such as endometriomas (caused by endometriosis) or dermoid cysts, which may affect ovulation or cause pelvic pain. This procedure can help preserve ovarian function and improve fertility.

Unexplained Infertility

In cases where the cause of infertility remains unclear after routine tests like semen analysis, HSG, and ovulation assessment, laparoscopy can provide valuable insights. It allows the surgeon to identify subtle or hidden conditions, such as mild endometriosis or small adhesions, that may not be visible on imaging studies.

 Ectopic Pregnancy

Laparoscopy is used to manage ectopic pregnancies, where a fertilized egg implants outside the uterus, usually in the fallopian tube. The procedure allows the surgeon to remove the ectopic pregnancy and repair or remove the affected fallopian tube.

 Evaluation of Pelvic Pain

Chronic pelvic pain, which may be associated with conditions like endometriosis, adhesions, or pelvic inflammatory disease, can also be evaluated and treated through laparoscopy. This is particularly useful when pelvic pain is suspected to be contributing to infertility.

Pelvic Inflammatory Disease (PID)

PID, often caused by sexually transmitted infections, can lead to scarring and blockage of the fallopian tubes. Laparoscopy helps assess the extent of damage and, in some cases, allows for treatment to improve the chances of conception.

Ovarian Drilling for PCOS

For women with Polycystic Ovary Syndrome (PCOS) who are resistant to ovulation-inducing medications, laparoscopy can be used to perform ovarian drilling. This involves creating small holes in the ovary’s surface to reduce androgen production and help restore ovulation.

 Tubal Sterilization Reversal

Women who have undergone tubal ligation (a form of permanent contraception) and wish to conceive again can undergo laparoscopy to assess the possibility of reversing the procedure and reconnecting the fallopian tubes.

By addressing these conditions through laparoscopy, doctors not only gain valuable diagnostic information but can also perform immediate surgical interventions to enhance fertility. This makes laparoscopy an indispensable tool in the comprehensive evaluation and treatment of infertility, especially in cases where other diagnostic methods fall short.

Procedure of laparoscopy

How is laparoscopy performed?

Laparoscopy is done under general anesthesia, meaning the patient is asleep during the procedure. A small incision is made near the belly button, and a thin, telescope-like instrument called a laparoscope is inserted to visualize the abdominal and pelvic organs. The abdomen is inflated with carbon dioxide gas to create space for better visibility. Additional small incisions may be made to insert surgical instruments if corrective work is needed, such as removing endometriosis, fibroids, or adhesions. Once the procedure is complete, the instruments are removed, the gas is released, and the incisions are closed with stitches or surgical tape.

 How long does the surgery take?

The duration of laparoscopy depends on the complexity of the case. A diagnostic laparoscopy typically takes 20–30 minutes, while an operative laparoscopy to treat conditions like endometriosis, adhesions, or fibroids can take 1–4 hours.

 How long do I need to stay in the hospital

Most women are discharged on the same day as the procedure, typically a few hours after surgery, once the anesthesia wears off and they are stable. In some cases, especially if the surgery is more complex, an overnight stay may be required.

What is the recovery time after laparoscopy?

Recovery time varies depending on the extent of the surgery. Most women can resume light daily activities within 2–3 days. Full recovery, including returning to work and more strenuous activities, usually takes 1–2 weeks. However, if the procedure was extensive, such as for severe endometriosis or multiple fibroid removal, recovery may take up to 2 weeks.

What can I expect during post-laparoscopy recovery?

After the procedure, mild discomfort, bloating, and shoulder pain (caused by the gas used to inflate the abdomen) are common and typically subside within a few days. Pain at the incision sites may last for up to a week. Women are advised to avoid heavy lifting, intense exercise, or sexual activity for at least 1–2 weeks or until cleared by their doctor.

Laparoscopy is a minimally invasive procedure with a relatively quick recovery, allowing most women to return to their normal routine within a short period.

What are the complications of laparoscopy?

Complications associated with laparoscopy include the possibility of damage to other structures in the pelvis such as the bladder, ureter, bowel and blood vessels. Unexpected open surgery (larger incision) is always a possibility, but is very uncommon. Any surgery can have an anesthesia-related complication or be associated with post-operative infection, such as a skin infection at an incision site. Fortunately, all of these complications are very unusual when laparoscopy is expertly performed on healthy women.

What is Hysteroscopy ?

Hysteroscopy is a surgical procedure in which a small telescope (the size of a pencil) is used to inspect the inside of the uterus. A camera is attached to the end of the telescope and the image is viewed on a video monitor. Surgery is carried out while looking at this monitor.

When is Hysteroscopy required to be done?

Hysteroscopy may be recommended for evaluation of

1. Infertility

2. abnormal uterine bleeding

3. absent/ scant menses

4. recurrent pregnancy loss

5. abnormal findings on a hysterosalpingogram, ultrasound, or pelvic exam

6. uterine fibroids

7. polyps

8. septums [divisions]

9. the cavity of the uterus before ET in an IVF/ ICSI cycle.

10. Intrauterine adhesions

11. Cornual block

How is Hysteroscopy done?

The first step involves dilating the mouth of the uterus (cervix). The cervical opening must be enlarged to allow passage of the hysteroscope. Once inside the uterus, gas or fluid is used to distend the cavity. The Doctor then inspects the uterine walls, openings of the fallopian tube, and overall architecture of the womb.

What is Diagnostic Hysteroscopy?

Diagnostic hysteroscopy can be performed with a smaller instrument. This procedure is generally shorter and can be done under mild sedation or short general anaesthesia for better comfort The procedure is quick and inexpensive.

What is Operative Hysteroscopy?

Operative hysteroscopy is performed under general anaesthesia. This allows the physician to both diagnose and treat most findings, which are encountered at the time of the procedure.

The Operative Hysteroscope has ports, which allow the physician to insert operating tools, such as, scissors, cautery devices or a laser fiber. These may be used to resect or cauterize specific abnormalities under direct visualization. The hysteroscope is also valuable in treating some forms of tubal occlusion.

What should I expect after a Hysteroscopy?

Complications are infrequent from hysteroscopy. Some patients may experience mild cramping. This usually is the result of the need to dilate the cervix for insertion of the scope. In general, patients are able to return to their normal activity level in 1-2 days after surgery.

What are the possible risks after a Hysteroscopy?

The possible risks of hysteroscopy include bleeding, infection and uterine perforation. Fortunately, these risks are infrequent. Occasionally, Gynaecologists utilize a simultaneous Laparoscopy to aid in the prevention of uterine perforation if extensive hysteroscopy surgery is planned.

What are the advantages of a hysteroscopy over a plain D&C?

Nowadays it is rare for a D&C to be done alone. It is usually combined with a hysteroscopy. This is because it is conclusively proven that a D&C [which is really a "blind" procedure] even in the best of hands gets only about 50% of the lining of the uterus while there may be a disease in the remaining portion which has been missed.A hysteroscopy allows the gynaecologist to view the inside of the uterus and take a biopsy from the area which is worst affected and to localize the area and extent of the disease too.