The availability of assisted reproductive technology has reduced the need for reproductive surgery as a primary surgical treatment of infertility. When fertility surgery is indicated, operative laparoscopy results in outcomes as good as those from similar procedures performed via open laparotomy and is associated with a shorter hospital stay, lower incidence of ileus, and faster recovery. In addition, there is less contamination of the surgical field with glove powder or lint, bleeding is reduced due to tamponade of small vessels by the pneumoperitoneum, and drying of tissues is minimal because surgery occurs in a closed environment. All of these factors contribute to reduce postoperative adhesion formation and its associated morbidity (eg, pain, impaired fertility, bowel obstruction). Today, reproductive surgery can be divided into three categories: surgery as a primary conventional surgical treatment of infertility, surgery to enhance the pregnancy outcome of in vitro fertilization, and surgery for fertility preservation .
Laparoscopic surgery for the treatment of female infertility is reviewed here. The evaluation and nonsurgical treatment of female infertility are discussed separately. (See "Evaluation of female infertility" and "Overview of treatment of female infertility".)
The role of diagnostic laparoscopy in the management of infertility is limited. However, it can be useful in the infertility evaluation of young women with a history of pelvic inflammatory disease, ectopic pregnancy, pelvic surgery, or chronic pelvic pain. In our practice, we usually perform diagnostic laparoscopy or in vitro fertilization (IVF) treatment if three cycles of gonadotropin ovulation induction with intrauterine inseminations are unsuccessful. If adhesions or endometriosis are found during diagnostic laparoscopy and the patient has been appropriately consented, then an operative laparoscopic procedure for improving fertility can be undertaken at the same time.
Diagnostic laparoscopy can be avoided in older women and those with multiple infertility factors. These women are better served by in vitro fertilization, instead of a surgical approach to treatment. The presence of endometriosis and adhesions does not markedly influence the effectiveness of IVF. Today, we rarely perform diagnostic laparoscopy in infertile women. (See "In vitro fertilization".)
Chromopertubation — When laparoscopy is performed for diagnostic or therapeutic purposes in women with infertility, chromopertubation (instillation of dye through the fallopian tubes) is often performed to assess tubal patency. To perform this procedure, a dilute solution of methylene blue dye is instilled through a transcervical cannula (typically through a patent cannula used for uterine manipulation (picture 1)). Spillage of the dye from each tube is noted as a confirmation of tubal patency. If a repair procedure for tubal occlusion is performed, chromopertubation is repeated at the end of the procedure.