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

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What can you expect to feel after the laparoscopy ?
What are the complications of laparoscopy ?
How can I be sure my doctor will perform the laparoscopy properly ?
Which is better - a laparoscopy or a HSG ?
What happens after the laparoscopy ?

What can you expect to feel after the laparoscopy ?

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, which irritates the phrenic nerve and causes "referred pain" perceived in the shoulder
• 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.

What are the complications of laparoscopy ?

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.

How can I be sure my doctor will perform the laparoscopy properly ?

Unfortunately, many gynecologists are not skilled at performing a laparoscopy properly. In order to choose the best doctor for performing your laparoscopy, you need to ask him 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.
   
   A good doctor has a lot of experience in performing laparoscopies; uses multiple punctures, so he can assess the pelvis properly; and always provides documentation ( in the form of a video, CD or DVD) so the findings can be reviewed by another doctor.

Which is better - a laparoscopy or a HSG ?

Comparing laparoscopy and HSG
In our practise, we prefer using an HSG to document tubal patency, because it is much less expensive; is non-surgical; and provides a hard copy record , which all doctors can refer to later on. Some doctors still believe that both the HSG and laparoscopy are complementary procedures, and you may even need both, especially if your tubes are blocked. 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 two other disorders ( endometriosis and tubal adhesions) inside the abdomen which affect tubal function and which do not show up on HSG can also be diagnosed. However, while it is true that a laparoscopy offers the doctor a chance to diagnose and treat these problems at the same time , it is still unsure whether correcting these problems actually helps to improve the patient's fertility !

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 laparoscopy to which the hapless patient is forced to agree. If your first laparoscopy 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 laparoscopy) 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 laparoscopy for no very good reason, refuse. It's a surgical procedure after all - and it's your body.

Thinking it over
One 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. However, we feel that the routine use of laparoscopy is not called for in treating infertile patients, since a HSG can provide similar information at much less risk and expense. We use the procedure very sparingly in our practise.

What happens 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 ! These help to confirm the diagnosis of "unexplained infertility".
2. Abnormal findings, such as peritubal adhesions or endometriosis,  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).
   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 of these problems, the doctor may advise IVF (for example, for patients with irreparably damaged fallopian tubes).

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