Twitter Linked-in Infertility Youtube Pinterest Google Plus

Reproductive Surgery History

Within Reproductive Endocrinology, Reproductive (fertility) surgery has been downplayed now for many years, with most fellowship programs offering very little training.  Peritoneal excision for endometriosis, for example, is not taught primarily to any fellows in Reproductive Endocrinology.  Most practicing Reproductive Endocrinologists including those who train fellows, perform very little surgery.  Our specialty has evolved into an In Vitro Fertilization (IVF) weighted specialty characterized by practices offering and recommending IVF as a first treatment to the majority of patients presenting for therapy.  This allows streamlining of practices and is much more  convenient and beneficial for the physicians.  For the most part, surgery has been minimized and relegated to getting patients ready for IVF.  In contrast to the widespread IVF oriented approach, careful meticulous surgeries to open or repair tubes, and or rid women of endometriosis are very successful in many cases.  Successful tubal surgery allows patients to achieve pregnancy without IVF.   For patients with a prior tubal ligation, tubal reversal surgery is extremely effective, yet the vast majority of practices push these patients directly into IVF and fail to offer this highly effective surgery.  It is our clear impression from years of practice that patients want to become pregnant utilizing the least technical means possible. At JCRM, we are committed to providing you with surgical approaches that allow for spontaneous pregnancy and are proud of our extensive success utilizing long established conservative fertility treatments including surgery. Likewise, our IVF program has been extremely successful for patients that eventually need this more advanced therapy. We will work diligently as a team to provide you with the most appropriate cost effective treatments in your particular situation.  

Surgery and getting the correct surgery is a big deal – you only want one surgery, one that will tackle all of your problems completely.  It is amazing the wide range of surgical abilities and approaches, a fact only known by those of us in the subspecialty world by reading thousands of operative reports through the years.   It is difficult for patients to choose a reproductive or gynecologic surgeon.  In our current system it is common for example with endometriosis, to have a general OB/GYN perform laparoscopy and partially treat endometriosis or just note the severity and send the patient on to a more skilled surgeon who can completely treat the disease, vs in many cases, not referring and just treating with birth control pills or Lupron.  In general, a better approach is to start surgery with a surgeon who for example, in the case of endometriosis, can treat any stage of a disease and if other problems are discovered such as tubal occlusion or fibroids where a fine microsurgical tubal repair or myomectomy could be performed at the same time removing the need for a second surgery.

Another such example is Tubal Reversal.  The same claims of outpatient benefit with the robot to avoid a large incision are made – true.  Traditional laparoscopy however, offers multiple advantages with smaller incisions, the ability to be performed in a more comfortable outpatient setting and at a much lower cost.  Our experience locally with tubal anastamosis also involves differences in suture utilized for the closure.  The smaller the better.  In traditional open surgery 8-0 // 9-0 non absorbable (smaller the number: larger the suture)  suture smaller than human hair was utilized which provides by far the best outcomes.  When we migrated to microlaparoscopy 5 years ago, we did so only when we felt the instruments would allow us to continue to use this suture so the outcomes would be the same.  Other pre-robotic laparoscopists had long since been compromising and using 4-0 to 6-0 suture with poorer results for pregnancy.  Now as we read op notes from area robotic surgeons, these larger suture choices are being made compromising the outcome and we are seeing patients with non-patent tubes (blocked) after this surgery.  The JCRM patency rate is nearly 100%.  So not only did the surgery not work, but the abdominal incisions are larger and more visible.  Again, these nuances are extremely difficult for patients to ferret out on the internet or anywhere else.  Our commitment is to you the patient and to the outcomes you desire.  

Pelvic Pain and Endometriosis are some of the most confusing and poorly managed areas in medicine.  It is frustrating that the majority of gynecologists don’t understand the nuances of this disease continuum and it’s management (by virtue of gynecological training).  Laparascopic laser vs cautery “spot treatment,” or medical therapy with lupron, are used by 99% of the gynecology world to treat endometriosis.  Surgery is the only effective treatment, but to cure the disease it must be completely excised laparoscopically to achieve the desired outcome.  There are fewer than 20 practices in the US that offer comprehensive excisional surgery for all stages of endometriosis.  In a patient without prior disease, there is no consistent way to predict the severity of the disease before surgery, since symptoms and the amount or nature of disease are poorly correlated.  For example, most infertility patients with endometriosis have very little if any pain.  At JCRM, all causes of pelvic pain are considered and often at surgery we are addressing 3 or more different sources of pain.  Without such a comprehensive approach, patients are left with residual endometriosis and often continue with pain since other common causes of pain are not addressed.  Read more on our Pain and endometriosis pages.