The basic evaluation for couples struggling to become pregnant includes a semen analysis, blood tests to evaluate ovarian function, a hysterosalpingogram and a pelvic sonogram to evaluate the uterus and fallopian tubes. It is not uncommon for couples to undergo this basic evaluation for infertility and find that all of their tests are normal. At that point, couples are wondering why they cannot conceive. After all, if the couple is having trouble getting pregnant, something must be wrong. It turns out that despite a normal examination, normal sonogram and hysterosalpingogram, there is a chance that the woman may have endometriosis and/or pelvic adhesions in the pelvic cavity that would not have been diagnosed by the basic tests.
In the early 70s, couples who had a normal fertility evaluation were offered a laparoscopy to simply look inside the pelvis to see if any additional information could be learned. 40% of the women who underwent the laparoscopy were found to have an abnormality. Two thirds of the women who were found to have abnormalities at laparoscopy had endometriosis and one third of them had pelvic adhesions. These abnormalities were present without any symptoms other than having difficulty conceiving. Many women will assume that they cannot have endometriosis because they do not have pain. Pain is not required for endometriosis to be present. Women struggling to become pregnant, even without pain, do have a symptom of endometriosis – infertility. Therefore, in some situations of “unexplained infertility”, it may be very appropriate for the woman consider a laparoscopy prior to proceeding with fertility treatments.
Options for treatment of unexplained infertility include clomiphene citrate or Femara combined with intrauterine insemination, injectable gonadotropins combined with IUI and in vitro fertilization. These treatments have been demonstrated to increase the chance of conceiving even when the cause of the infertility is not known. However, some couples feel like they want to be sure that all diagnostic tests have been completed and known causes of infertility have been corrected prior to beginning treatments. These patients are good candidates for laparoscopy. Certainly if there are other symptoms of endometriosis and/or scar tissue in addition to infertility, then laparoscopy may be more indicated. For instance, if the patient does have severe dysmenorrhea (painful menstrual periods) or pelvic pain and/or if she has had a history of pelvic infections in the past, then laparoscopy would be even more likely to reveal an abnormality.
When undergoing a laparoscopy, it is very important that the physician be able to not only perform the laparoscopy to diagnose these abnormalities, but also be prepared to treat the disease. Usually the best surgical tool for treatment of endometriosis and pelvic adhesions is a CO2 laser. This instrument can be used to destroy, resect and/or correct the abnormalities. The laser is a better tool than an instrument that coagulates or burns the disease. Coagulation of endometriosis can destroy normal tissue next to the disease. The laser is much more pinpoint and accurate and is associated with less injury to the surrounding tissues.
It is certainly possible that a laparoscopy may be recommended to couples who have had trouble conceiving without any other symptoms to suggest endometriosis and/or pelvic adhesions. Abnormalities found at laparoscopy can commonly be treated with a CO2 laser. It is always worthwhile to discuss this procedure with your physician.
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Clomiphene citrate, CO2 laser, diagnosing endometriosis, endometriosis, infertility, infertility evaluation, laparoscopy, pelvic adhesions, surgical correction of infertility
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