Hysteroscopy & Laparoscopy Forms of Female Fertility Testing

Hysteroscopy & laparoscopy at a glance

• When less invasive fertility tests do not provide a conclusive diagnosis of the cause for female infertility, pelvic pain or abnormal uterine bleeding, a specialist may perform minimally invasive surgery to better evaluate the reproductive organs.
• Minimally invasive surgery can be diagnostic or operative, meaning the problem identified during the diagnostic procedure can be corrected at the same time using special operating instruments.
• Hysteroscopy is the most common form of this surgery and involves inserting a hysteroscope with light and camera through the vagina and into the uterus so the endometrial cavity organ is projected clearly onto a monitor that the surgeon views.
• Laparoscopy utilizes similar instruments, but the laparoscope is inserted through small incisions in the woman’s belly and allows a comprehensive view of all reproductive organs.
• These more detailed inspections of the female reproductive anatomy help determine the proper fertility treatment or cause of pain and bleeding for the individual.

Minimally invasive surgery to diagnose infertility in women

A fertility specialist may determine that in addition to noninvasive fertility tests, such as blood tests, physical exam, hysterosalpingogram and ultrasound, a patient’s uterus needs to be examined directly. This kind of evaluation is extremely effective in cases of heavy bleeding, irregular bleeding and recurrent miscarriage – all possible contributors to female infertility.

Minimally invasive surgery may be required to fully evaluate the causes of infertility, especially if the patient has associated symptoms of pelvic pain. Minimally invasive surgery means that the physician will use techniques that require the fewest cuts and stitches for the body.

This type of surgery offers less risk for infection, less time in the hospital and a speedier recovery. The most common minimally invasive surgical procedures used in fertility testing for women are hysteroscopy and laparoscopy.

Hysteroscopy for female fertility testing

Hysteroscopy involves inserting a thin tube (hysteroscope) through the vagina and cervix into a woman’s uterus. The tube has a light and a tiny video camera attached to the tip and allows the physician to see the cervix and inside the uterus with great clarity. Saline is pushed through the hysteroscope to expand the uterus to provide even greater visibility of the uterine lining and the openings of the fallopian tubes.

Hysteroscopy will verify or rule out any abnormalities suspected on other tests such as hysterosalpingogram (HSG), sonohysterography or ultrasound. If abnormalities such as uterine polyps, fibroids or a septate uterus are confirmed, small surgical instruments can be introduced through the hysteroscope to remove tissue or correct abnormalities and obstructions.

Hysteroscopic surgery can be performed either in an outpatient surgical suite or a doctor’s office. A patient may be given medicine to relax but she will remain awake during the procedure, or go under general anesthesia.

After the procedure, a patient may experience mild cramping or bleeding for about a day. Most women require minimal pain medicine after surgery and can return to work the following day.

Laparoscopic surgery for infertility in women

Laparoscopy is often the last means of testing, and is sometimes performed when other diagnostics have failed to deliver conclusive results. It is good for evaluating endometriosis and obtaining biopsies or removing of growths like fibroids or cysts.

At Tennessee Reproductive Medicine, we reserve laparoscopy for specific cases: patients who are experiencing pelvic pain in whom other testing has not yielded a conclusive result, and for patients who have abnormalities on ultrasound, HSG or physical examination.

Laparoscopy is a minimally invasive surgery involving a fiberoptic tube (laparoscope) with a light and camera on the end of it. The procedure involves the doctor creating an incision, either near or in the belly button, then inserting the laparoscope into the pelvic cavity.

Similar to the hysteroscopy, carbon dioxide is used to inflate the pelvic area, creating space around the organs temporarily to increase visibility. As the doctor moves the laparoscope, images from the camera appear on a monitor screen and still pictures can be taken. If fibroids, scar tissue or endometriosis are detected, small surgical tools can be inserted through additional small incisions in order to remove the abnormalities seen.

Patients are put under general anesthesia for the procedure, which is outpatient and runs between 1-2 hours in most cases.
Learn About Minimally Invasive & Robotic Surgery

Declining laparoscopic surgery for fertility testing

If a woman has a normal HSG test, no history of pelvic pain and a normal ultrasound, the chance is small that laparoscopy will change either the infertility management or treatment outcome. For example, in couples with unexplained infertility (normal sperm, normal HSG and proof of ovulation), there is a 20% chance that the woman has endometriosis, a condition that can make it more difficult for women to get pregnant.

Studies have shown that removing endometriosis in women with mild to moderate endometrial disease does improve pregnancy rates, but unfortunately, the success rates of surgery are modest. Two major studies have been performed to evaluate the benefit of surgical treatment of endometriosis among infertility patients, with somewhat different results, one showing a more positive impact than the other. One study showed that after surgical treatment of endometriosis, about twice as many patients conceived in a six-month follow-up period (29% vs. 17% if untreated).

Another showed minimal difference between the treated and untreated groups but may not have had enough patients in the study to show a real difference between the groups. Evaluating the studies together, the general consensus is that if we had 12 patients with mild to moderate endometriosis and we surgically removed the endometriosis, three of those women would become pregnant within the next 12 months if they were trying. Three out of 12 women conceiving over a 12-month period is not a high pregnancy rate, especially compared with other therapies.

Furthermore, if instead of operating on these women we had watched them expectantly to see how many conceived, 2 of the 12 would have conceived in the same 12-month period. This means a doctor would have to perform surgery on 12 women just to get one pregnancy we would not have seen otherwise.

Given the modest effect of surgery on improving fertility, the decision to proceed with laparoscopy is a highly individualized discussion between the patient and her provider. This should incorporate her symptoms (whether she has pain or abnormal bleeding), her desire to have a definitive diagnosis as to the possible cause of her infertility, and her desire to potentially exhaust less invasive ways to conceive prior to pursuing more advanced treatments like in vitro fertilization (IVF).

Learn More About the Causes of Infertility