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Reproductive Surgery

What has happened to Reproductive Surgery over time?

Through the age of modern surgery, Reproductive Surgery has been a primary infertility treatment for many conditions.  Tubal adhesions, prior tubal ligation, endometriosis, fibroids, and uterine malformations are all aggressively treated with surgery.  From 1900 to 1990 these therapies were routinely included in fertility treatment.  When In Vitro Fertilization (IVF) became commonplace, surgical therapies suddenly came into question.  With IVF, all fertility problems could be addressed and the success rates were good.  Thinking as practical, logical physicians, IVF made perfect sense as the best treatment for everything.  Tubal disease was ignored and patients moved directly into IVF.  Years went by before it was realized that blocked tubes dramatically decreased pregnancy rates requiring surgery prior to IVF.  Men were not evaluated anymore, missing a large number of endocrine disorders.  They were shuttled directly into IVF with intracytoplasmic sperm injection (ICSI).  Endometriosis was completely ignored as it was felt treatment didn’t matter.  Patients with easily correctable prior tubal ligations often were not offered tubal reverse surgery, since IVF was easy and relatively successful.  From 1990 when good surgeons were everywhere, to present day where good surgeons are few and far between, surgery has gradually been downplayed.  For the last several years, at the American Society for Reproductive Medicine’s annual meeting, there has been an ongoing debate centered on whether surgery is “dead for fertility treatment.”  The tide is turning though, back toward a consideration of surgery as an important aspect of fertility treatment.  

The most important aspect that the pragmatic treatment approach of IVF only that was forgotten, was the vast majority of patients would rather get pregnant normally at home the old fashion way.  The examples described above are often amenable to surgery followed by pregnancy naturally or with minimal treatment involvement.  The problem now however is we have trained two generations of Reproductive Endocrinologists to believe surgery is insignificant, and failed to adequately train this same group in excellent successful surgical techniques.  Because Dr. Fox was trained during the height of the surgical excellence era in Reproductive Medicine, he was able to build on his training with unique innovation and was able to develop a highly successful surgical program.  These surgical skills and principles have been passed on to Dr.s Lipari and Paschall.  Through the efforts of surgery, countless couples are able to conceive naturally or with minimal treatment intervention and avoid costly IVF treatment.  These surgeries and a heavy emphasis on metabolic treatment has allowed a numerous couples avoid IVF treatments, saving money and preserving a more natural creation of life.  

Innovative surgical techniques have long characterized JCRM’s surgical program.  These innovations both involve development of instrumentation, searching for and developing unique procedures, and techniques to improve surgical outcomes.  Some examples include, radical resection of uterine adenomyosis for severe cases, outpatient affordable laparoscopic tubal reversal using extremely fine (8-0) sutures, and ovarian suspension for adhesion prevention, opening blocked tubes and use of 7-0 suture to sew the opening of the tube open, and 99% of myomectomies performed laparoscopically as outpatients with rapid return to work.  All of these cases can be performed with 5mm instrumentation, leaving minimal scarring on the surface of the abdomen and minimizing post operative pain and recovery.  

In Reproductive Endocrinology, there is debate over the benefit of surgical treatment for endometriosis prior to infertility treatment.  In other words, does endometriosis treatment improve the subsequent pregnancy rates?  The vast majority of studies supporting no benefit were done in the 1980’s and early 1990’s when most surgeons didn’t recognize all visual forms of the disease and the treatment methods used were laser or cautery destruction, both of which fail to cure the disease.  It stands to reason then that if you compare a surgical treatment group with a non-treatment group that the groups are essentially the same and will have the same outcome.  More recent studies do show a benefit, one a large multi center randomized Canadian study done with “master” surgeons, showed a near doubling of the pregnancy rate.  Our approach is to maximize the chances of pregnancy no matter what the subsequent treatment modality.  This speeds time to pregnancy and reduces overall cost of treatment due to fewer cycles needed.  This  treatment is so effective that for young patients, < 30 with pain, it is not uncommon to have them return in the first couple of months after the surgery pregnant if they are not using protection.  Their comment universally is, "I never became pregnant before and didn't think I  could; the surgery must have changed that for me."

For tubal disease, either blockage or significant scarring is another very controversial surgical treatment area.  Sure, IVF, after some treatment of tubal blockage (removal or opening) yields a higher per cycle pregnancy rate (in one cycle).  But given the chance to try for pregnancy on their own at home with a slightly lower per cycle rate, avoiding the expense of IVF, the vast majority of patients can achieve pregnancy over a slightly longer period of time on average.  We find that most couples much prefer this more natural approach.  Not all tubal situations are repairable or would yield these good results, but many do.  For those who don’t desire this route, our IVF success rates are excellent and can be easily offered.  

In summary, reproductive surgery is alive and well when indicated here at JCRM with excellent results.