Infertility affects millions of couples worldwide, and in many cases, the causes lie within the pelvis. Two of the most important factors contributing to infertility are tubal pathology and ovulatory dysfunction, particularly polycystic ovarian syndrome (PCOS). To address these conditions, gynecologists frequently rely on diagnostic laparoscopy, which allows direct visualization of pelvic structures, assessment of tubal patency, and therapeutic procedures such as ovarian drilling in the same sitting.

This combined approach provides both diagnostic and therapeutic benefits, improving the chances of natural conception.

Diagnostic Laparoscopy in Infertility

Diagnostic laparoscopy is a minimally invasive surgical procedure performed under general anesthesia. It involves inserting a laparoscope—a thin tube with a camera—into the abdominal cavity through a small incision, usually near the umbilicus.

Purpose in Infertility

To visualize the uterus, fallopian tubes, and ovaries directly.

To detect pelvic adhesions, endometriosis, or pelvic inflammatory disease.

To confirm or rule out anatomical causes of infertility such as blocked tubes, fibroids, or ovarian cysts.

To provide a platform for immediate therapeutic interventions.

Procedure Steps

Pneumoperitoneum is created using carbon dioxide gas.

The laparoscope is introduced through the umbilical port.

Accessory ports are inserted for manipulation of pelvic structures.

The surgeon systematically inspects the uterus, tubes, ovaries, and pelvic cavity.

Tubal Patency Test

The patency of fallopian tubes is one of the most important aspects of female fertility. Blocked tubes prevent sperm from meeting the egg and hinder fertilization. Laparoscopy allows direct testing of tubal patency using chromopertubation.

Method of Chromopertubation

A cannula (Rubin’s cannula or Leech–Wilkinson cannula) is inserted into the cervix.

A colored dye (commonly methylene blue or indigo carmine) is introduced into the uterine cavity.

The surgeon observes laparoscopically whether the dye passes through the fallopian tubes into the peritoneal cavity.

Interpretation

Free spill of dye bilaterally: Tubes are patent.

Unilateral spill: One tube is blocked.

No spill: Bilateral tubal block, requiring further intervention.

Advantages of Laparoscopic Tubal Testing

Direct visualization, making it more accurate than hysterosalpingography (HSG).

Ability to detect peritubal adhesions or pelvic pathology simultaneously.

Opportunity for immediate surgical correction if minor adhesions are present.

Ovarian Drilling

Ovarian drilling is a laparoscopic procedure used to induce ovulation in women with polycystic ovarian syndrome (PCOS) who are resistant to medical treatment such as clomiphene citrate. PCOS is characterized by irregular ovulation, hormonal imbalance, and multiple small cysts in the ovaries.

Indications

Infertility due to anovulation in PCOS patients.

Failure of ovulation induction with medications.

Elevated LH levels and androgen excess.

Procedure

After diagnostic laparoscopy and tubal testing, the ovaries are visualized.

A monopolar electrocautery or laser is used to puncture each ovary at multiple sites (usually 4–10 punctures).

The depth of puncture is kept shallow (3–4 mm) to prevent ovarian damage.

The procedure reduces the ovarian stroma, thereby lowering androgen production and restoring ovulation.

Mechanism of Action

Destruction of androgen-producing tissue in the ovary.

Reduction in luteinizing hormone (LH) levels.

Improved follicular maturation and spontaneous ovulation.

Advantages of Ovarian Drilling

Can restore natural ovulation in many women.

Reduces dependency on long-term medications.

Avoids the risks of multiple pregnancies associated with ovulation induction drugs.

Possible Risks

Adhesion formation on the ovarian surface.

Premature ovarian failure if excessive drilling is done.

Postoperative pain or infection (rare with proper technique).

Combined Benefit of the Three Procedures

Performing diagnostic laparoscopy, tubal patency testing, and ovarian drilling together has several benefits:

Comprehensive Evaluation – Structural and functional aspects of infertility are assessed in one sitting.

Dual Role – Both diagnostic and therapeutic interventions are possible during the same procedure.

Improved Fertility Outcomes – If tubes are patent and ovarian function improves after drilling, natural conception rates increase significantly.

Patient Convenience – Only one anesthesia and one surgical session is required, reducing physical and financial burden.

Postoperative Care and Follow-Up

Most patients are discharged within 24 hours.

Analgesics and antibiotics may be prescribed.

Normal activities can usually be resumed within a few days.

Ovulation and menstrual cycles are monitored in the following months.

If spontaneous conception does not occur, assisted reproductive techniques like intrauterine insemination (IUI) may be considered.

Conclusion

Diagnostic laparoscopy, tubal patency testing, and ovarian drilling represent an integrated approach to managing female infertility. Laparoscopy provides direct visualization and diagnosis, chromopertubation accurately assesses tubal function, and ovarian drilling offers a therapeutic solution for PCOS-related infertility. Together, these procedures maximize the chances of natural conception while minimizing repeated interventions.