Laparoscopy

Who it’s for

Laparoscopy suits three broad groups. The first is women with pelvic pain, painful periods or painful sex where endometriosis is suspected. If you have lived with that pain for years and been told it is normal, this is often the operation where someone finally looks directly and names it. The second is women whose tubal patency test showed a blockage, a hydrosalpinx or a picture that needs a direct look. The third is women heading for IVF with a hydrosalpinx seen on scan.

A smaller fourth group has PCOS and has not ovulated on letrozole or clomifene. For them, laparoscopic ovarian drilling is an alternative to injections, covered in ovulation induction.

Endometriomas are where the decision needs most care. If a cyst is small and not causing pain, many fertility specialists now leave it alone and go straight to IVF, because surgery can lower ovarian reserve. If it is large, painful, growing, or blocking access to the follicles at egg collection, operating makes more sense.

A diagnostic laparoscopy on its own is done less often than it once was. Ultrasound, HyCoSy and MRI now answer many of the questions it used to. Where a look is needed, the best plan is one operation that can treat whatever it finds.

Eligibility is the usual surgical list: a recent ovarian reserve test, a BMI in range, and no smoking. See eligibility.

Before you agree to surgery

Ask what this operation is for, in one sentence. Pain relief, a better IVF chance, or a diagnosis all justify it, and knowing which one is yours keeps the decision clear when the ovaries are involved.

How it’s done

You are asleep under general anaesthetic. The abdomen is gently inflated with carbon dioxide so the organs separate, the camera goes in at the navel, and two or three small ports go in along the bikini line. A fine instrument through the cervix can move the uterus around to give the surgeon a full view.

For endometriosis there are two approaches. Excision cuts the deposits out, which also gives tissue to confirm the diagnosis. Ablation burns them off the surface. Specialist centres favour excision for deeper disease. An endometrioma is either peeled out of the ovary or drained and treated in place, which spares more tissue but recurs more often.

The dye test, often called a lap and dye, passes blue dye through the cervix and watches whether it spills from the end of each tube. Adhesions, bands of scar tissue tying organs together, are cut free where it helps.

A hydrosalpinx is dealt with in one of two ways. Salpingectomy removes the damaged tube completely. Where the pelvis is too scarred to reach it safely, the tube is clipped where it meets the uterus, so its fluid can no longer reach an embryo.

Ovarian drilling is for PCOS. The surgeon makes a handful of tiny holes in the surface of each ovary with a fine needle and heat. That lowers the hormones that block ovulation, and many women then ovulate on their own or respond to tablets again. Fewer punctures per ovary protect reserve.

At the consultation

Ask what the surgeon will do if they find an endometrioma they were not expecting, and agree it before you sign. Having the plan for the ovary settled in advance means nothing important is decided while you are asleep.

After laparoscopy

Most people are surprised by the shoulder-tip pain. It comes from the gas under the diaphragm, not the wounds, and it fades over a day or two with walking and peppermint tea. The small cuts are sore and the belly feels bloated for a few days.

After a diagnostic look you are usually home the same day and back at a desk within the week. After excision of endometriosis, expect a week or two of tiredness and a heavier ache, with a gradual return to energy. Light spotting is normal.

Ring the hospital for a fever, a hard swollen abdomen, vomiting or pain that gets worse rather than better.

The week before

Stock up on loose high-waisted clothing and peppermint tea, and plan short walks for the first few days. The gas pain catches people off guard, and moving gently is the quickest way to ease it.

Laparoscopy scars

Two to four cuts, each roughly a centimetre. One sits inside the navel and usually vanishes there. The others sit low on the abdomen near the bikini line.

They start pink and slightly raised, then fade to fine pale marks over a year. Longer excision operations sometimes need a fourth port, but the scars stay the same size.

Risks and complications

The early risks are those of any keyhole operation: bleeding, infection in a wound or the pelvis, and the shoulder pain that comes with the gas. Serious injury to the bowel, bladder or a large blood vessel is uncommon, but it is the reason deep endometriosis belongs with a specialist team.

The risk specific to fertility surgery is the ovary. Cutting out an endometrioma removes some normal tissue with it, and the AMH level often falls afterwards. The drop is larger with bigger or repeated cysts, and when both ovaries are operated on. That is why specialists usually leave a small, painless cyst alone before IVF.

Endometriosis can also return. Recurrence over the following years is common, and repeat surgery on the same ovary costs more reserve each time.

Adhesions can re-form after any pelvic operation. Good technique keeps that to a minimum.

Laparoscopy results

For pain, a well-done excision gives many women years of real relief. For fertility, the picture depends on the stage. With mild endometriosis, treating it at laparoscopy modestly improves the chance of natural conception in the months that follow.

For a hydrosalpinx, the result is clear. The fluid in a damaged tube is toxic to embryos and can wash them out of the uterus. Removing or clipping the tube before IVF brings implantation rates back towards those of women without the problem, and I think of it as one of the easiest decisions on the fertility side.

What tends to disappoint is expecting surgery to fix everything. With moderate or severe disease, or lower reserve, IVF is often still the next step, just on a better footing.

Alternatives to laparoscopy

For endometriosis, hormonal treatment controls pain for many women while they are not trying to conceive, though it does not help fertility directly. For an endometrioma that is not causing pain, going straight to IVF without surgery is often the better route, because it protects the egg supply.

If reserve is already low, or you are older, ask about egg freezing or an IVF egg collection before any ovarian surgery. That banks eggs first, so the operation cannot cost you the ones you have.

For blocked tubes, IVF bypasses them entirely, and is usually the more reliable route past the mid-thirties.

Combining laparoscopy with other treatment

Timing with IVF is the main thing to coordinate. A hydrosalpinx is usually dealt with before the cycle, so the embryo goes back into a clean uterus. An endometrioma is often better left until after egg collection, unless it blocks the needle's path to the follicles.

A hysteroscopy is commonly done under the same anaesthetic, to look inside the uterus as well. In Bangkok's private hospitals the IVF clinic and the gynaecological surgeons often sit in the same building, which makes this sequencing much easier to arrange.

Laparoscopy cost

Quotes vary more with what is done than with the hospital. A diagnostic laparoscopy is a short day case. Excision of deep endometriosis can take hours, needs a specialist and sometimes a colorectal surgeon on standby, and is priced accordingly.

Ask whether the quote is a package covering surgeon, anaesthetist, theatre, the night if needed and histology, or a surgeon's fee with the rest billed separately. Ask too what happens to the price if the surgeon finds more disease than expected.

Thailand is a strong option here. Package prices at accredited Bangkok hospitals are typically a fraction of US self-pay figures, and recovery is short enough to fit within a two-week stay.

Read more: Fertility Surgery

Choosing a clinic for laparoscopy

For a simple diagnostic look, most gynaecologists who operate regularly are fine. For endometriosis, and especially anything near the bowel or bladder, you want someone who does excision routinely, ideally in a team that treats endometriosis as a specialty.

Ask two things: how many endometriosis excisions they do a year, and how they protect ovarian tissue when removing a cyst. A surgeon who talks about AMH without being prompted is thinking about your fertility, not just the operation.

The question that reveals the most is when they would not operate. Every good surgeon I have put this to in Bangkok has an answer about small endometriomas and IVF ready. If a surgeon tells you they always remove cysts, get a second opinion.

At the consultation

Bring your latest AMH result and ask how the surgeon expects it to change after the operation. Their answer tells you how much thought has gone into protecting your egg supply.

Frequently asked questions

Will surgery on my endometrioma lower my AMH?

It can, because some healthy tissue comes out with the cyst. The effect is larger with bigger or repeat cysts. See risks.

Should I have my hydrosalpinx removed before IVF?

In most cases yes. Removing or clipping it improves the chance of each embryo implanting. See results.

Why does my shoulder hurt after keyhole surgery?

It is the carbon dioxide used to inflate the abdomen, pressing under the diaphragm. It fades within a couple of days. See afterwards.

How soon can I start IVF afterwards?

Often within one to three months, depending on what was done. Plan it with both teams. See combining.