Sunday, April 13, 2008

Should we still be doing a laparoscopy for infertile women ?

When we first started practice , a laparoscopy was considered to be a basic tool in the evaluation of an infertile woman. Laparoscopy was considered to be a major advance , because it allowed us to inspect the pelvis and actually look at the fallopian tubes and ovaries to accurately diagnose anatomical problems. It was considered to be minor surgery , because it was minimally invasive; and we performed them routinely for all our patients.

Doctors routinely continue to perform a laparoscopy for all infertile couples. However, we have not performed a laparoscopy for the last 5 years in our clinic ! Why the change ? And why are other specialists doing so many unnecessary laparoscopies ?

I think there are many reasons for this. For one , gynecologists like doing surgery, and are quite happy to do as many of them as possible. Also old habits die hard. They have been so conditioned to thinking of a laparoscopy as a basic tool in the evaluation often an infertile couple , that some still believe that without a laparoscopy , the evaluation is incomplete.

However I think laparoscopies are overused and misused , and often create a lot of harm. For the doctor, all surgery is minor surgery. However, the reality is that is an operation which carries definite risks, and these should not be glossed over.

The key questions are - Do we have a better alternative ? and How will doing a laparoscopy change the infertile couple’ s treatment plan ? After all, if a laparoscopy is an investigation, then like all diagnostic tools, it should be used only when it changes treatment options !

Today , the truth is that a laparoscopy is of very little use to an infertile couple. It is much cheaper and easier to confirm tubal patency by doing a hysterosalpingogram; which means that patients do not need to be subjected to the risk of a laparoscopy just to find out if their tubes are open or not. Another justification for a laparoscopy is that it allows us to correct problems such as endometriosis or peritubal adhesions, thus improving the patient's fertility. However there is very little evidence that these procedures actually increase the patient's fertility. While doing surgical procedures can be enjoyable for the doctor , this is not a good reason to do them ! Controlled studies have shown that operative laparoscopy does not actually improve a patient's fertility ; and that there is no need to correct minor endometriosis or a few adhesions.

Even if a patient has already had a laparoscopy elsewhere, many doctors will insist on repeating the laparoscopy, because they want to see “ with their own eyes”. This is adding add insult to injury ! Others will “diagnose” subtle problems ( which no one else can see !) on ultrasound scans, and use these as a justification for doing a laparoscopy !

In our clinic our treatment plan is formulated without doing a laparoscopy. If the hysterosalpingogram shows the tubes are blocked, then a laparoscopy cannot help to correct this problem. If, on the other hand, the HSG confirms the tubes are open , then there is no need to do a laparoscopy. Our philosophy is not to diagnose problems, but to solve them ! We do not think a laparoscopy helps to do this, which is why we have stopped doing them !

1 comment:

  1. Dear Dr
    Please dont let out all your secrets...

    Anyway I liked your discussion


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