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 or hysteroscopy, two procedures which provide a direct look at the pelvic organs. These procedures have become integral aspects of a complete infertility evaluation. Laparoscopy and hysteroscopy can be used for both diagnostic (looking only) and operative (looking and treating) purposes.

Laparoscopy
Laparoscopy can help physicians diagnose many gynecological problems including endometriosis, uterine fibroids and other structural abnormalities, ovarian cysts, adhesions (scar tissue), and ectopic pregnancy. Many infertile patients require laparoscopy for a complete evaluation. Generally, the procedure is performed after the basic infertility tests, although the presence of pain, the history of a past infection, or other problems may signal a need to perform diagnostic laparoscopy sooner in the evaluation. The procedure is usually performed soon after menstruation in case a hysteroscopy is also necessary. The uterine cavity is more easily evaluated immediately after menstruation and there is little risk of interrupting a pregnancy.

After the medical history and physical examination are completed, laparoscopy is usually performed on an outpatient basis, under general anesthesia, and with minimal discomfort. 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 avoid injury to surrounding organs such as the bowel, bladder, and blood vessels. The laparoscope, a long, thin, lighted telescope-like instrument, is inserted through an incision in the navel.

While looking through the laparoscope, the physician can see the reproductive organs including the uterus, fallopian tubes, and ovaries. A small probe is usually inserted through another one or two incisions above the pubic region in order to move the pelvic organs into clear view. Additionally, a blue solution 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.

During operative laparoscopy, many abdominal disorders can be safely treated through the laparoscope at the same time that the diagnosis is made. When performing operative laparoscopy, the physician inserts additional instruments such as probes, scissors, grasping instruments, biopsy forceps, electrosurgical or laser instruments, and suture materials through two or three incisions in the area above the pubic bone.

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 from the outside of the uterus, ovaries, or peritoneum. Under certain circumstances, fibroids on the uterus can also be removed.

Risks of Laparoscopy
Serious complications of diagnostic and operative laparoscopy are rare. The major risk is damage to the bowel, bladder, ureters, uterus, major blood vessels, or other organs, which would require emergency surgery to repair. The chance that emergency surgery will be required is two to four per 1,000 procedures. Injuries can occur during the insertion of various instruments through the abdominal wall or during operative treatment. Certain conditions may increase the risk of serious complications. These include previous abdominal surgery, especially bowel surgery, and a history or presence of bowel/pelvic adhesions, severe endometriosis, pelvic infections, obesity, or excessive thinness.

Hysteroscopy
Hysteroscopy is an important tool in the study of infertility, recurrent miscarriage, or abnormal uterine bleeding. Diagnostic hysteroscopy is used to examine the inside of the uterus, also known as the uterine cavity 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) or an endometrial biopsy may be performed before or after diagnostic hysteroscopy.

The first step of diagnostic hysteroscopy involves slightly stretching the canal of the cervix with a series of dilatators. Once the cervix is dilated, the hysteroscope (a narrow lighted viewing instrument similar to but smaller than the laparoscope) is inserted through the cervix and into the lower end of the uterus. Clear solutions are then injected into the uterus through the hysteroscope. The solution expands the uterine cavity, clears blood and mucus away, and enables the physician to directly view the internal structure of the uterus. Diagnostic hysteroscopy is usually conducted on an outpatient basis with either general or local anesthesia. Diagnostic hysteroscopy is usually performed soon after menstruation because the uterine cavity is more easily evaluated and there is no risk of interrupting a pregnancy.

Operative hysteroscopy can treat many of the abnormalities found during diagnostic hysteroscopy. Treatment may be performed at the same time as diagnostic hysteroscopy or at a later date. Operative hysteroscopy is similar to diagnostic hysteroscopy except that a wider hysteroscope is used to allow operating instruments such as scissors, biopsy forceps, electrosugical or laser instruments, and graspers to be 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 also be corrected through the hysteroscope. After surgical repair of the uterine cavity, a balloon spacer or device may be placed inside the uterus to prevent the uterine walls from fusing together and forming scar tissue. Antibiotics and/or hormonal medication may also be prescribed after hysteroscopy to help prevent infection and stimulate healing of the uterine lining (endometrium).

Risks of Hysteroscopy
Complications of hysteroscopy are rare and seldom life-threatening. Perforation of the uterus (a hole punctured in the uterus) is the most common complication, but the hole usually heals on its own, without requiring additional surgery. When operative hysteroscopy is planned, diagnostic laparoscopy may be performed at the same time to allow the physician to see the outside as well as the inside of the uterus.

Complications occur in one or two out of every 100 operative hysteroscopy procedures, with uterine perforation and bleeding being the most common. Some complications related to the liquids used to distend the uterus include pulmonary edema (fluid in the lungs), breathing difficulties, blood clotting problems, decreased body temperature, and severe allergic reactions. Severe or life-threatening complications, however, are very uncommon.