Chapter 10b
Laparoscopy -- The Kinder Cut

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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After the operation, there may be some discomfort. This may include:

• Mild nausea as a result of the medication or the surgical procedure
• Pain in the neck and shoulder due to the gas inside the abdomen
• Pain in the areas where the instruments passed through the abdominal wall
• A scratchy throat and hoarse voice if a breathing tube was used during general anesthesia
• Cramps, like menstrual cramps
• Discharge like a menstrual flow for a day or two
• Muscle aches

Most of these minor symptoms will disappear within a day or two after surgery. The abdomen may feel swollen for a few days. Any unusual or peculiar symptoms should be reported at once to the doctor.

To really appreciate the benefits of laparoscopy, one should remember that the alternative is major surgery (laparotomy) which involves a large abdominal incision, a four to six day hospital stay, and four to six weeks of postoperative recovery time.

While the doctors may term laparoscopy as being "minor" surgery, remember that for the patient all surgery is major! The risk of laparoscopy are minimal. But certain conditions increase the possibility of complications. If there has been previous surgery in the abdomen, especially involving the bowel, there is an increased risk. Other conditions that lead to a higher risk of complications are evidence of an infection in the abdomen, a large growth or tumor within the abdomen, and obesity.

Complications among young, healthy women under going laparoscopy are rare and occur only in about three out of 1000 cases. These complications can include injuries to structures in the abdomen such as the bowel, a blood vessel or the bladder. Most often, these injuries occur when the laparoscope is placed through the navel. If such an injury occurs during the procedure, the physician can perform major surgery and correct the damage through a longer abdominal incision. Sometimes, complications may arise after surgery. If bleeding or pain appears excessive or if high fever develops, the doctor should be informed.

Where to do the laparoscopy

In order to choose the best doctor for performing your laparoscopy, you need to ask the following questions.

1. How many laparoscopies have you done?
    
2. Do you use multiple punctures?
    
3. Do you use a video for recording the operation?
    
4. If you find a problem, will you correct it at the same time? Ideally, if the doctor finds a problem during the laparoscopy, he should correct it at the same time, rather than call you again for a second surgical procedure, which only adds to your expense and risk.

Comparing laparoscopy and HSG

A common question patients ask is if they can go in for an X-ray (hysterosalpingogram) instead of a laparoscopy to find out if their tubes are open? While it is true that an HSG will provide accurate information about whether or not the tubes are open, there are other major benefits which laparoscopy offers and which HSG does not. HSG provides information only about the inside of the tubes and uterine cavity, whereas in laparoscopy, not only can the tubal patency be determined, but other disorders inside the abdomen which affect tubal function and which do not show up on HSG (such as endometriosis and tubal adhesions) can also be diagnosed. Moreover, major bonus in the case of laparoscopy is that it offers the doctor a chance to diagnose and treat the problem at the same time if possible - double bonus! Of course, the advantage of HSG is that no surgery, hospitalization or anesthesia is needed: it is less expensive; and that a hard copy record is provided, which all doctors can refer to later on. In fact both the HSG and laparoscopy are complementary procedures, and you may even need both, especially if your tubes are blocked.

A common problem which patients face in practice is that many doctors will insist on repeating the laparoscopy. One reason for this is that doctors feel that they need to do the laparoscopy for themselves, because they cannot "trust" another doctor's judgment. This is, of course a major problem for patients, who suffer repeated (and unnecessary) laparoscopies. Having a video record should help to minimize this problem. What happens if your laparoscopy was normal and the second doctor wants to repeat it anyway? Sometimes doctors have little to offer in the way of effective treatment and since there is nothing else to do, they suggest a repeat scopy to which the hapless patient is forced to agree. If your first scopy did, in fact indicate you had a problem, a second look laparoscopy may be indicated (and this should have been discussed with you after the first scopy) to determine if the problem has been successfully resolved. Ask the doctor what information he hopes to get by doing the repeat laparoscopy and how this will change your treatment. If you feel the doctor wants to do a scopy for no very good reason, refuse. It's a surgical procedure after all - and it's your body.

Thinking it over

A major benefit of laparoscopy is that in addition to allowing the accurate diagnosis of a problem, if it exists, operative laparoscopy can also be done in the same surgery to correct the problem. Often, the laparoscopy provides reassurance that the woman is normal and that the chances of having a baby are therefore good. In such cases, it even allows the doctor to perform treatment for the infertility in that cycle, if appropriate, by using intratubal insemination or SIFT.

Laparoscopy often leads to an accurate diagnosis which, in turn leads to more appropriate and specific treatment. Once the laparoscopy is over, the doctor will usually have a good idea of what is wrong , and what can it being treated effectively are improved now that the diagnosis is accurate.

After the laparoscopy

At the follow-up visit, discuss with the doctor what he found at the time of the laparoscopy and also how to proceed on the basis of the findings. There are three possible courses of action:

1. Normal findings: Such findings are the commonest result and can be very assuring!
    
2. Abnormal findings: which could be corrected at the time of laparoscopy itself: Perhaps the doctor may suggest a second look laparoscopy or HSG after some time to document that the problem has, in fact been corrected or else in addition medical treatment may be advised to try to correct a residual problem (e.g. antibiotics for pelvic infection, medical treatment for endometriosis) A quandary may arise when the laparoscopy reveals a finding which may be of no relevance to the problem of infertility. For example during laparoscopy the doctor may detect small fibroids, early endometriosis, or an ovarian cyst. These are common disorders and are often found in fertile women as well. Just making a diagnosis of these disorders does not automatically mean that they need to be corrected: they may be red herrings, which do not affect fertility. In fact, unnecessary surgery to remove these disorders can aggravate your infertility
    
3. Abnormal findings: which could not be corrected during the laparoscopy: For treatment, the doctor may advise formal surgery (for example microsurgery for blocked tubes) or IVF (for example, for patients with pelvic TB)

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