Laparoscopy and Hysteroscopoy

A complete examination of a woman's internal pelvic structures can provide important information regarding infertility and common gynecologic disorders. Frequently, problems that cannot be discovered by an external physical examination can be discovered by laparoscopy and hysteroscopy, two procedures which provide a direct look at the pelvic organs. These procedures may be recommended as part of your infertility care, depending on your particular situation. Laparoscopy and hysteroscopy can be used for both diagnostic (looking only) and operative (looking and treating) purposes. Diagnostic laparoscopy may be recommended to look at the outside of the uterus, fallopian tubes, ovaries, and internal pelvic area. Diagnostic hysteroscopy is used to look inside the uterine cavity. If an abnormal condition is detected during the diagnostic procedure, operative laparoscopy or operative hysteroscopy can often be performed to correct it at the same time, avoiding the need for a second surgery. Both diagnostic and operative procedures should be performed by DOCTOR with surgical expertise in these areas. The following information will help patients know what to expect before undergoing any of these procedures. .

Diagnostic Laparoscopy

Laparoscopy can help DOCTORS diagnose many gynecological problems including endometriosis, uterine fibroids and other structural abnormalities, ovarian cysts, adhesions (scar tissue), and ectopic pregnancy. If you have pain, history of past pelvic infection, or symptoms suggestive of pelvic disease, your physician may recommend this procedure as part of your evaluation. Laparoscopy is sometimes recommended after completing an initial infertility evaluation on both partners. It is usually performed soon after menstruation ends.

Laparoscopy is usually performed as day care procedure under general anesthesia. After the patient is under general anesthesia, a needle is inserted through the navel and the abdomen is filled with carbon dioxide gas. The gas pushes the internal organs away from the abdominal wall so that the laparoscope can be placed safely into the abdominal cavity to decrease the risk of injury to surrounding organs such as the bowel, bladder, and blood vessels. The laparoscope is then inserted through an incision in the navel. Occasionally, alternate sites may be used for the insertion of the laparoscope based upon physician experience or the patient's prior surgical or medical history.

While looking through the laparoscope, the doctor can see the reproductive organs including the uterus, fallopian tubes, and ovaries (Figure 1). A small probe is usually inserted through another incision above the pubic region in order to move the pelvic organs into clear view (Figure 2). Additionally, a solution containing blue dye is often injected through the cervix, uterus, and fallopian tubes to determine if they are open. If no abnormalities are noted at this time, one or two stitches close the incisions. If defects or abnormalities are discovered, diagnostic laparoscopy can become operative laparoscopy.

Operative Laparoscopy

During operative laparoscopy, many abdominal disorders can be treated safely through the laparoscope at the same time that the diagnosis is made. When performing operative laparoscopy, the doctor inserts additional instruments such as probes, scissors, grasping instruments, biopsy forceps, electrosurgical or laser instruments, and suture materials through two or three additional incisions. Lasers, while a significant help in certain surgeries, are expensive and are not necessarily better or more effective than other surgical techniques used during operative laparoscopy. The choice of technique and instrumentation depends on many factors including the physician's experience, location of the problem, and availability of equipment.

Some problems that can be corrected with operative laparoscopy include removing adhesions from around the fallopian tubes and ovaries, opening blocked tubes, removing ovarian cysts, and treating ectopic pregnancy. Endometriosis can also be removed or ablated from the outside of the uterus, ovaries, or peritoneum. Under certain circumstances, fibroids on the uterus can also be removed. Operative laparoscopy can also be used to remove diseased ovaries and can assist in the performance of hysterectomy.

Postoperative Care

Following laparoscopy, the navel area is usually tender and the abdomen may be bruised. Gas used to distend the abdomen may cause discomfort in the shoulders, chest, and abdomen, and anesthesia can cause nausea and dizziness. The amount of discomfort depends on the type and extent of procedures performed. Normal activities can usually be resumed within a few days.

Significant abdominal pain, worsening nausea and vomiting, a temperature of 101° F or higher, or significant bleeding from an incision are potential serious complications requiring immediate medical attention.

Hysteroscopy

Pre IVF Hysteroscopy is a day care procedure done under short general anesthesia in operating theater. It is done to evaluate the uterine cavity and the entry of the womb it is performed soon after menstruation has ended either during the first visit or before stimulation.

Diagnostic Hysteroscopy

Hysteroscopy is a useful procedure to evaluate women with infertility, recurrent miscarriage, or abnormal uterine bleeding. Diagnostic hysteroscopy is used to examine the uterine cavity (Figure 3), and is helpful in diagnosing abnormal uterine conditions such as internal fibroids, scarring, polyps, and congenital malformations. A hysterosalpingogram (an x-ray of the uterus and fallopian tubes), sonohysterogram (ultrasound with introduction of saline into the uterine cavity), or an endometrial biopsy may be performed to evaluate the uterus prior to hysteroscopy.

The first step of diagnostic hysteroscopy usually involves slightly stretching the canal of the cervix with a series of dilators to temporarily increase the size of the opening of the cervix. Once the cervix is dilated, the hysteroscope (a long, thin, lighted, telescope-like instrument) is inserted through the cervix and into the uterus. Skin incisions are not required for hysteroscopy. Carbon dioxide gas or special fluids are then injected into the uterus through the hysteroscope. This gas or fluid expands the uterine cavityand enables the physician to directly view the internal structure of the uterus.

Diagnostic hysteroscopy is an outpatient procedure that is performed in a physician's office or operating room. It is performed soon after menstruation has ended because the uterine cavity is more easily evaluated.

Operative Hysteroscopy

Operative hysteroscopy can treat many of the abnormalities found during diagnostic hysteroscopy. Operative hysteroscopy is similar to diagnostic hysteroscopy except that narrow instruments are placed into the uterine cavity through a channel in the operative hysteroscope. Fibroids, scar tissue, and polyps can be removed from inside the uterus. Congenital abnormalities, such as a uterine septum, may be corrected through the hysteroscope.

Your physician may want you to take medications to prepare the uterus for surgery. At the conclusion of surgery, your physician may insert a Foley catheter or other device inside the uterus. Antibiotics and/or estrogen may be prescribed after some types of uterine surgery to prevent infection and stimulate healing of the endometrium.

Endometrial ablation, a procedure in which the lining of the uterus is destroyed, can be used to treat some cases of excessive uterine bleeding. Ablation of the uterine lining is not performed in women who wish to become pregnant. For more information on this topic, please refer to the ASRM's Patient Fact Sheet "Endometrial Ablation".

Risks of Hysteroscopy

Complications of hysteroscopy occur in about two out of every 100 procedures. Perforation of the uterus (a small hole in the uterus) is the most common complication. Severe or life-threatening complications, however, are very uncommon.

Postoperative Care

Following hysteroscopy, some vaginal discharge or bleeding and cramping may be experienced for several days. Most physical activities can usually be resumed within one or two days. You should ask your physician when to resume sexual intercourse. If a Foley catheter is left in the cavity, it is usually removed after several days. Estrogen may be prescribed for several weeks after surgery.