During this session, Dr Kristýna Frühaufová, PhD, Head Physician at GYNEM Fertility Clinic, explained the role of laparoscopy and hysteroscopy in fertility care and how these procedures may impact your chances of conception.
The event is hosted by Barbara Scott, Chair of the Association of Reproductive Reflexologists, founder of Seren Natural Fertility, and author of Reflexology for Fertility. Barbara is an internationally recognised expert in reproductive reflexology and advocates for an integrative, patient-centred approach to fertility.
Laparoscopy and hysteroscopy are well-established diagnostic and therapeutic procedures in reproductive medicine. However, many patients wonder whether these procedures are always necessary and whether they genuinely improve the chances of conception, particularly before IVF.
Dr Frühaufová began by explaining that infertility affects approximately 10–15% of couples. Traditionally, one-third of infertility cases are attributed to female factors, one-third to male factors, and the remaining third to unexplained or idiopathic infertility.
Within reproductive medicine, laparoscopy and hysteroscopy are considered invasive diagnostic and therapeutic tools. Hysteroscopy allows direct visualisation of the uterine cavity by inserting a small camera through the cervix. Laparoscopy involves inserting a camera into the abdominal cavity to assess the pelvis, ovaries, fallopian tubes, and surrounding structures.
While both procedures can improve fertility outcomes, Dr Frühaufová emphasised that this is only true in carefully selected patients. Each case must be evaluated individually, based on medical history, ultrasound findings, and sometimes MRI imaging. Routine use before IVF remains controversial.
Hysteroscopy is primarily used to diagnose and treat abnormalities within the uterine cavity.
One of the main indications is the presence of uterine polyps or intracavitary fibroids. These conditions can usually be identified during routine ultrasound examinations. Dr Frühaufová explained that both fibroids and polyps are known to reduce implantation rates. Removing them can improve the chances of both spontaneous conception and IVF success.
Operative hysteroscopy is generally a short procedure, lasting around 15–20 minutes. Recovery time is minimal, and patients can usually attempt conception or proceed with IVF in the very next menstrual cycle.
Another indication for hysteroscopy is suspected intrauterine adhesions. These may be identified through ultrasound or saline sonography. Patients at higher risk include those with a history of uterine inflammation, curettage, or repeated miscarriages.
By performing hysteroscopy, doctors can restore normal uterine anatomy, which may improve pregnancy outcomes. In patients with repeated implantation failure or recurrent pregnancy loss, diagnostic hysteroscopy may also help identify signs of chronic inflammation.
Dr Frühaufová noted that hysteroscopy allows direct biopsy of suspicious areas and further evaluation of the uterine environment, including immune factors, if indicated.
Laparoscopy can be used either diagnostically or therapeutically.
Diagnostic laparoscopy allows doctors to assess pelvic anatomy, check the ovaries and fallopian tubes, and perform tubal patency testing using chromopertubation. It also enables the detection of endometriosis lesions or pelvic adhesions that may not be visible on imaging.
Therapeutic laparoscopy is performed when treatment is required, such as removing endometriosis lesions, dividing adhesions, or treating tubal disease.
Dr Frühaufová explained that in endometriosis, symptoms do not always correlate with disease severity. Patients with severe pain may have limited disease, while others with extensive endometriosis may be asymptomatic.
In symptomatic patients with chronic pelvic pain, laparoscopy is often recommended before IVF. However, in asymptomatic patients, IVF may be attempted first, with laparoscopy reserved as a later option.
For patients seeking natural conception or IUI, laparoscopy may help restore normal pelvic anatomy. However, the benefit of adhesiolysis before IVF remains controversial, except in cases where severe adhesions prevent access to the ovaries for egg retrieval.
In patients with stage III or IV endometriosis, the decision to perform laparoscopy must consider the extent of surgery required. These procedures can be lengthy, technically demanding, and associated with longer recovery times.
Dr Frühaufová stressed the importance of weighing benefits against risks and costs. In patients without severe symptoms, IVF is often preferred over surgery.
Laparoscopy may be recommended for intramural fibroids larger than 3–4 cm, particularly when they distort the uterine cavity. Multiple fibroids may also require surgical correction to restore normal uterine anatomy.
After laparoscopic or open myomectomy, a recovery period of at least six months is necessary to allow proper healing. There is a small but real risk of uterine rupture after myomectomy, estimated at around 0.5–1%.
Dr Frühaufová highlighted hydrosalpinx as the clearest indication for therapeutic laparoscopy before IVF. Fluid in damaged fallopian tubes can significantly reduce implantation rates and increase the risk of ectopic pregnancy.
In patients with clearly diagnosed hydrosalpinx, removal of the affected tubes before IVF is recommended to improve outcomes.
While hysteroscopy is generally low risk, laparoscopy is an invasive surgical procedure. Risks include those associated with general anaesthesia, as well as potential complications such as bowel or urinary tract injury, particularly in extensive surgeries.
Costs and recovery time also vary between countries, and insurance coverage differs across Europe. Importantly, neither diagnostic hysteroscopy nor laparoscopy should be considered first-line treatment for unexplained infertility.
Dr Frühaufová made it clear that laparoscopy and hysteroscopy are not part of routine screening before IVF. In patients with clearly identified intrauterine pathology, hysteroscopy can improve pregnancy chances. Laparoscopy offers benefits mainly in selected cases, such as tubal disease or fibroids distorting the uterine cavity.
There is no clear evidence that asymptomatic endometriosis should be surgically treated before IVF.
Modern fertility treatment often allows IVF to bypass the need for surgery altogether. In many cases, IVF may be the preferred first step, with surgery reserved for specific indications.
Dr Frühaufová concluded by emphasising that fertility treatment must always be individualised. Decisions should be based on medical history, imaging results, age, symptoms, and reproductive goals.
While laparoscopy and hysteroscopy can improve outcomes in selected cases, they should never be used as routine screening tools. Targeted, evidence-based use ensures that patients receive the most appropriate treatment without unnecessary intervention.
For many couples, IVF itself may provide the most effective path to pregnancy, without the need for surgery.
If MRI does not provide clear answers, then diagnostic hysteroscopy and laparoscopy may be a reasonable option. Another important step is to ask for a second reading of the MRI by a different radiologist. General radiologists may not always be highly specialised in female pelvic anatomy. A radiologist with specific expertise in this area may be able to provide clearer answers without the need for invasive procedures. I would recommend starting with a second expert review of the MRI before proceeding to surgery.
There is no single general rule, as this is highly individualised. However, diagnostic hysteroscopy is used more often than diagnostic laparoscopy. In general, when a patient has experienced three or more failed transfers of good-quality euploid embryos, it is time to start further investigations. At that point, we look more closely at the uterine and immunological environment. In most cases, hysteroscopy would be the first step.
Yes. In many clinics, including ours, purely diagnostic hysteroscopy can often be performed without anaesthesia. We use very thin instruments that pass through the cervix, sometimes with the help of numbing gel. If the patient has not had previous cervical surgery, most can tolerate the procedure well. Even biopsies can be taken during this type of hysteroscopy. It is often a very good starting point for gathering useful diagnostic information.
There is no clear evidence that all patients should undergo hysteroscopy before fertility treatment. With IVF, cumulative pregnancy rates can reach up to 80% after 3 embryo transfers, meaning many patients do not need intervention at all. However, it is crucial to perform high-quality ultrasound examinations and take a thorough medical history. Any history of inflammation or previous uterine interventions may indicate pathology within the uterine cavity. Listening carefully to the patient is essential.
Yes, this depends on patient preference, age, ovarian reserve, and male factor fertility. Up to the age of 35, there is often time to allow for natural conception if semen parameters are good. In younger patients, we may allow six to twelve months for natural conception. This is particularly relevant after laparoscopic surgery for endometriosis. Patients should be advised to return earlier if symptoms recur, as endometriosis can return relatively quickly.
Patients can usually proceed in the very next cycle. No recovery time is needed once the polyp has been removed. Polyps are hormonally dependent and may recur, so starting treatment sooner is generally better. The same applies to fibroid resection performed hysteroscopically. In some cases, a second hysteroscopy is needed if part of the fibroid extends into the myometrium and emerges later.
Yes, that is usually what we advise. Proceeding quickly allows patients to take advantage of the optimal window before any recurrence of pathology.
When removing polyps or fibroids from the uterine cavity, the risk of adhesion formation is almost negligible. Adhesions may recur if adhesiolysis is performed, and repeated procedures may sometimes be required. With laparoscopy, the risk depends on the extent of surgery. Fibroid removal requiring sutures on the uterus carries some risk of adhesions. However, studies show that adhesions after laparoscopy are usually mild and rarely require further intervention. Endometriosis and fibroid surgery can be associated with adhesion formation, but the overall risk is relatively low.
Laparoscopy remains the gold standard, but high-quality imaging can identify many cases. Skilled and well-trained sonographers using advanced equipment can detect even small lesions of peritoneal endometriosis. MRI, especially when performed with protocols focused on endometriosis, can also identify deep infiltrating lesions. Imaging is far less invasive and often sufficient, depending on the quality of the equipment and the expertise of the specialist interpreting the results.
This occurs in a small percentage of patients, particularly those preparing for frozen embryo transfer with oestrogen therapy. The fluid may come from the fallopian tubes, as in cases of hydrosalpinx, or from mucus produced in the cervix due to high oestrogen levels. If hysteroscopy is normal, the fluid often drains spontaneously. It is important to confirm that the tubes are not the source. In some cases, fluid is evacuated shortly before embryo transfer, typically one to two days beforehand. Sometimes the fluid resolves on its own once progesterone treatment begins.
Yes. If fluid enters the uterine cavity, it can flush out the embryo and increase the risk of ectopic pregnancy. Even if the fluid comes and goes, it is safer to remove it before embryo transfer.
