The Role of Laparoscopy in Fertility Investigations
For the past 30 odd year’s laparoscopy have been regarded as the gold standard in terms of investigation for diagnosing pelvic pathology especially tubal patency. In the last 20 years since evolution of ultrasound scanners its eminence has now been challenged. Many fertility experts will chose to do other tests (mainly 3D pelvic USG) instead of the invasive and expensive laparoscopy.
What happens in a laparoscopy?
1. It is a major surgery (but “day-care”) done under general anesthesia..
2. The peritoneal cavity is first distended with carbon dioxide gas after thatlaparoscope is introduced through a small nick in the navel (umbilicus). The Laparoscope is connected to a camera and the entire peritoneal cavity is now visible on a screen.
3. Tubal patency is now checked by pushing saline mixed with a water soluble dye which can be seen emerging through the fallopian tube if they are patent.
4. Other problems that can be diagnosed include ovarian cysts, endometriosis, adhesions between various organs especially following infections or prior surgery and distention of the tubes and hydrosalpinx.
5. By using operative instruments through other small nicks. Various surgeries can be done by laparoscopic techniques. For example surgeons can remove gall bladders and appendix and in older woman hysterectomies can be done as well. Surgeries related to fertility include the following.
♦ Adhesiolysis – breaking down of adhesions by which various organs stick to each other.Removal of ovarian cysts includes dermoid cysts.
♦ Myomectomy or removal of fibroids in the uterus.
♦ Other tubal surgeries.
Problems and complications of laparoscopic surgery
♦ It is major operation since it requires incubation as a part of the anesthesia it causes more morbidity- sore throat etc. Typical post-operative shoulder pain due to the gas irritating diaphragm.
♦Laparoscopy is regarded as major operations and can have complications ranging from bleeding, trauma to intestines etc
As a major operation with full general anaesthesia though the surgery is only a day guess it can get quite expensive.
What are the limitations of Laparoscopy?
1. With better ultrasound scanners in the market, we can get a more than adequate idea about the anatomy through this cheaper than safer option.
2. The focus currently is on the working of organs not just physical appearance. So the patency of the tube is not something that will relieve our concerns – we need to be sure that the functioning of the tube is good i.e. its internal cellular lining and secretions those are not accessible by laparoscopy.
3. Polycystic ovarian disease was earlier (70’s and early 80’s) diagnosed by the pearly white appearance of the ovary at laparoscopy. An ultrasound scans is a far better way to get diagnostic picture.
4. Ovarian cysts can be diagnosed easily by ultrasound scan and if their fluid is clear or has blood or other secretions can be judge on ultrasound scan more easily. The role of laparoscopy is to remove it if needed.
So what is the role of laparoscopy in today’s fertility investigations?
Our team would use laparoscope in perhaps one or two out of ten cases of infertility. The most common reason for deciding on a laparoscopy is history or symptoms suggestive of pelvic infection or endometriosis. Adhesions in the pelvis can’t be easily diagnosed by ultrasound scan and those in spite of tubal patency can affect fertility. A laparoscope can only confirm the presence of these adhesions but also, treat those.
Similarly endometriosis (where the lining of the womb grows outside of the womb in the peritoneal cavity) is a diagnosis better made by using a laparoscope and not a scan. The ability to treat these deposits at the same time as the diagnosis makes it a one stop procedure.