I had surgery two years ago to remove endometriosis and one ovary and fallopian tube. I still have been unable to conceive, and my gynecologist suggested another laparoscopy, D&C and a tubal insufflation. What is tubal insufflation? How much does it improve chances of pregnancy?

L.M.

After such a surgery there are many considerations. Is there an age-related fertility factor, and is the day three FSH level normal? (Age-related declines in fertility may be seen earlier in women with one ovary.) Were the other tube and ovary involved at the time of the first surgery? How likely is it that more endometriosis is present? Do you have painful menses or painful intercourse? Does the remaining ovary seem to be mobile on transvaginal ultrasound, or is it stuck down by adhesions? Is your partner's semen analysis normal? If your physician feels scarring is likely or there is a sperm problem, IVF may be far more cost-effective and successful than surgical management of infertility.

Tubal insufflation involves passing a blue-colored dye through the cervix, uterus and fallopian tubes at the time of laparoscopy to see if the tubes are open. It is similar to HSG X-ray procedure, but it is performed while you are asleep for laparoscopy.

I cannot be sure whether surgery will improve your odds of conception. If there is scar tissue, the laparoscopy may help. But even if that is the case, pregnancy rates will often be higher with IVF than with surgery.