As the son and brother of general surgeons I am often put in the position of defending the low volume of surgery that I perform as a reproductive endocrinologist. In years past, fertility physicians were often in the operating room spending hours repairing damaged fallopian tubes in an attempt to improve a patient’s fertility. However, as IVF technology has improved the need for laparoscopy has dwindled. I explain it to patients in this fashion: If I do a laparoscopy and find significant adhesions (scar tissue) and endomteriosis then IVF is your best option. And if I find minimal endometrosis and minimal scar tissue then IVF is your best option. And if I find that everything is normal then IVF is your best option.
So almost all roads lead to IVF so why do the laparoscopy? Well, not all patients can afford IVF or wish to try IVF. They may be afraid of the drugs, of OHSS, of multiples and I agree that those are good things to fear….and yet IVF really works better than our other options. Natural cycle IVF can remove some risk is more acceptable to some patients but it doesn’t work as well as stimulated cycle IVF. So do I need a laparoscopy? That is the topic of today’s question from 100 Questions and Answers about Infertility. So to honor my general surgeon father in light of the rapid approach of Father’s Day…here is my response…and it pretty much proves that I am not a “real” doctor in his eyes…
11. What is a laparoscopy, and do I need one?
A laparoscopy is an outpatient surgery usually performed under general anesthesia. Most laparoscopies are completed in a hospital, but some physicians utilize freestanding outpatient surgery centers. During a laparoscopy, the physician inserts a small fiber-optic telescope into the abdominal cavity through an incision made in the patient’s umbilical area (belly button). Most physicians initially distend the abdomen using carbon dioxide gas with a needle (Veres needle) to create what is called a pneumoperitoneum. A trocar—an instrument with a diameter similar to that of a pencil—is then passed through the umbilicus, allowing for introduction of the telescope (called a laparoscope) into the abdomen.
Using the laparoscope, a gynecologic surgeon can inspect the uterus, fallopian tubes, and ovaries. The appendix and upper abdomen are carefully inspected as well. Additional instruments may be inserted into the abdomen through incisions (ports) made along the hairline above the pubic bone. For example, the physician may use graspers, scissors, or suction irrigators to rinse the tissue and remove blood and fluids as needed. Some physicians insert a slightly larger telescope through the umbilical port, which allows them to use a carbon dioxide laser to cut scar tissue or destroy implants of endometriosis. Besides the laser, other instruments can be used to cut or burn abnormalities such as endometriosis or scar tissue.
During a laparoscopy, the physician typically introduces a blue dye into the uterine cavity while directly visualizing the fallopian tubes. If the fallopian tubes are patent (open) but are located in an abnormal location because of scar tissue, then the surgeon may try to free the fallopian tubes to improve the patient’s fertility. If abnormal ovarian cysts such as endometriomas are present, then the physician may remove them during the course of the laparoscopy or, if necessary, perform a laparotomy.
A laparotomy is a surgery performed through a larger incision, usually made along the bikini line. It may require the patient to stay 1 to 3 days in the hospital following the surgery. In addition, a laparotomy requires a longer recovery period and may create more new scar tissue than laparoscopic surgery. Certain abnormalities cannot be easily treated through laparoscopy, including exceedingly large ovarian cysts, ovarian cysts that are suspicious for cancer, and fibroids that are deeply embedded in the wall of the uterus. Patients with these problems are probably better served by a laparotomy.
For many years, all women who were seeking fertility care underwent laparoscopy as part of the initial evaluation. In recent times, this practice has faded with increased utilization of IVF. Although IVF has essentially replaced tubal surgery in patients with tubal factor infertility, laparoscopy is still used to correct certain problems in patients prior to undergoing IVF. Complications of laparoscopy are rare but can include injury to the bowel, bladder, and blood vessels; a need for laparotomy; and even death.