The preoperative diagnosis is critically important in deciding on the type and extent of surgery to be considered. Therefore, a careful pre-operative evaluation is desirable and can enlist non-surgical tools (including the woman's history and physical examination, radiologic tests, and blood tests) to gather as much useful information as possible. Ideally, a pre-op consult between the physician and the patient will include a thorough review of surgical and nonsurgical treatment alternatives (with specific risks and benefits of each).
My preoperative evaluation for infertility couples typically includes documentation of ovulation (and ovarian reserve when appropriate), a semen analysis (even with a past history of fertility), a postcoital test, and a hysterosalpingogram (HSG). The HSG is very important since it will indicate the presence of any large filling defects (possibly fibroids, polyps, a septum or adhesions) in the uterine cavity and will also determine tubal patency. If the fallopian tubes are blocked then the extent of dilatation (size of the hydrosalpinx) and condition of the inner lining of the tubes can be assessed and the couple can be advised about the prognosis for pregnancy if a repair is performed. In this way, a couple can be appropriately counseled about treatment options preoperatively and discussions between the couple and the infertility specialist will often allow the specialist to make decisions intraoperatively that best suit the particular couple's goals.
Historically, a basic infertility evaluation has included a diagnostic laparoscopy. The goal of the diagnostic laparoscopy was to assess the pelvis for abnormalities (including endometriosis and adhesions) that are not identifiable with nonsurgical infertility tests. After completing the diagnostic laparoscopy, the findings were usually discussed with the couple and a decision made about the utility of a laparotomy (open surgery using a large abdominal incision).
Advances in operative laparoscopy and hysteroscopy have essentially eliminated the use of diagnostic laparoscopy in the infertility evaluation since most of the surgery that previously required a laparotomy can now be accomplished via the laparoscope. Today, infertility specialists will typically discuss likely findings at laparoscopy at a preoperative visit so that the couple can allow the surgeon to make informed intraoperative decisions about the type and extent of repair desired by the couple. Then, the laparoscopy can easily include operative interventions as needed.
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