Infertility and Contributing Technology

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Dr. Larry Demco:  “Hello, I’m Dr. Demco reporting from the Global Congress at the AAGL meeting here in Orlando, Florida.  Today, I’d like to have one of the past Presidents and a good friend of mine, Dr. Mark Surrey, give us a little insight and update on infertility and what this new technology has for us in terms of infertility.  Mark, I’ve been looking at doing diagnostic laparoscopy for several years and infertility was always one of the foremost reasons to perform a laparoscopy.  Can you give us a little past history of what’s happened with infertility and laparoscopy and then maybe we’ll move into the new techniques and the new technologies and how we can apply it?”

Dr. Mark Surrey:  “Larry, that’s an excellent point because infertility is a problem that seems to be at least increasing in our awareness as far as the public perception goes.  It’s something that we now have more tools to deal with both from a diagnostic and from a therapeutic perspective.  Our goal as physicians given a diagnosis of infertility is to try to in the least invasive and most expeditious or the quickest manner find out why the couple is infertile and then try to come upon an effective treatment course.  Unfortunately, this has been spread out and delayed, traditionally, by a lot of physicians perhaps being a little insensitive to the subject from just telling the couple to - go away, go on a cruise, relax, and come back in six months.  As you know and as many of our patients know, it’s really not considered even by a lot of the insurance companies as a disease entity, and so there doesn’t seem to be quite the urgency to treat and diagnose infertility, as there are other problems like pelvic pain.  On the other hand, if you look at statistics of treatment for infertile couples, you’ll notice that human fertility declines considerably as we age as human beings.  Therefore, if you look at the end result as being a pregnancy when a 34-year-old lady comes into you there may be an urgency because you don’t want her to be coming back at age 38 since her prognosis is going to be so much worse in a few years.  This new technology that we have from the perspective of enabling us to perform earlier diagnostic interventions in less invasive manners enables us to perform a diagnosis and to really make an accurate one much earlier in the process.  In the past, couples have started treatment for months involving fertility medications and inseminations without ever having had an endoscopy done to see what in fact their reproductive system looks like.  Many times these treatments have proved not to be effective because it turns out that the patient has a problem that an endoscopic procedure early on would have diagnosed so we now have the ability to do this and to do it early in the process.  Therefore, the net result I feel would be to shorten the time between the time the patient actually presents with a problem and we have a solution to that problem.”

Dr. Larry Demco:  “It’s well known that physicians can waste a lot of time, patient’s time, as you pointed out.  What techniques do we have now that can shorten this?  If we take it to the point that we’re taking her history and physical and we’re convinced that she needs an infertility work-up, fill us in where this new technology takes us now.”

Dr. Mark Surrey:  “Larry, there are basically three components to a woman’s fertility issues with one being the man so a semen analysis is the first thing that you want to do.  The second thing that you want to do or simultaneous with it is to test the woman’s ovarian reserve which is done early in the cycle with a hormone test involving two hormones; one from the pituitary called FSH or follicle stimulating hormone and the other is a result of that from the ovary called estrogen.  If those are okay, then the next part of the system to evaluate is the structure or the anatomy of the reproductive system, which includes the transport system or the fallopian tubes and the uterus.  Now evaluating this traditionally used to be delayed for many, many months and used to be performed by a relatively inaccurate and sometimes painful x-ray procedure called a hysterosalpingogram.  We have found by looking at the results of these procedures that this radiologic procedure has a tremendous amount of inaccuracies toward it that then will lead us down the wrong path not infrequently meaning that sometimes an abnormal x-ray is really not an abnormality and frequently a normal x-ray can be associated with an abnormality such as endometriosis, adhesions, and so forth.  So when it comes to evaluating the fallopian tubes this early intervention allows us to look either through the hysteroscope with small instruments inside the tube or perhaps in a newer manner which is behind the cervix and that’s called transvaginal hydro-laparoscopy both of which can be done in office procedures with either some local or mild intravenous sedation.  That is a quick, easy, and very accurate way to diagnose anatomical or structural problems with a woman’s reproductive system and enables us to do this very early on in the patient’s evaluation and, therefore, if in fact the patient should have fertility medications, then that’s what they should have.  If in fact the patient shouldn’t, then she should do something different like in vitro fertilization then they’re directed in that area earlier and the result of the whole process being earlier diagnosis, earlier treatment, and an earlier result.”

Dr. Larry Demco:  “One of the key points that I’ve noticed is that when patients talk about infertility it seems to be a very subjective terminology and the more that we can make it objective it seems to be easier to convince the patient which route to go that you’re explaining.  What’s your experience been in using some of this technology, either video taping this or actually chosen while they’re awake to show them their tubes and what damage there is?  What’s your idea about giving them the prospect of what their future fertility is in store for them?”

Dr. Mark Surrey:  “Clearly, the more educated the patient is the more they feel as if they are part of the process and can feel not only an active involvement but an accurate understanding of whatever their problem may be.  So the concept of being able to share with the patients either in a form of still photography or a video taping of what their problem may be is clearly in the patient’s best interest.”

Dr. Larry Demco:  “Do you usually find that it’s much easier then to, again, shorten that distance to say - I’m sorry, as you can see these tubes look quite damaged?”

Dr. Mark Surrey:  “Clearly.”

Dr. Larry Demco:  “Have you seen a shortening in that jump from either microscopic or laparoscopic repair of the tube versus IVF?”

Dr. Mark Surrey:  “Yes.  Micro-endoscopic technology whereby we can actually look inside of the tubes is really what makes that decision for us.  The fallopian tube is not just an open transport structure but rather a very complex active structure that needs to be comprised of certain elements that are almost microscopic involving certain cell types that are secretory cells.  This can only be appreciated by directly examining this area of the body and this is really what differentiates patients who ought to have surgical correction versus patients who ought to have their fallopian tubes bypassed by what’s deemed in vitro fertilization.”

Dr. Larry Demco:  “Not all gynecologists that might be viewing here have the capability of falloposcopy, the looking inside of the tube.  What tips might you have for them to look at the tube and do a laparoscopic approach to falloposcopy?”

Dr. Mark Surrey:  “Absolutely, as part of any diagnostic laparoscopy an endoscope and even a 2 mm flexible saline mediated endoscope can be inserted through an accessory trocar into the end of the fallopian tube.  These endoscopes are present in most hospitals.  Urologists use them and they’re called ureteroscopes, general surgeons use them and they’re called choledochoscopes, whatever the name of them might be, they’re fiber optic, saline mediated, small diameter, flexible endoscopes that anybody can insert through the fallopian tube to examine it.  Failing that, you can even do so with your small diameter laparoscope as long as you flood the cul-de-sac with fluid, you can get a very good idea of the access of the fimbrial ovarian hiatus, which is really the key in terms of tube ovarian pick-up.  That is the mechanism that’s essential for normal reproductive function and without that the fallopian tube can be open but it’s not likely to work normally, and exposing these patients to months and months of clomiphene citrate is probably not going to be an effective mode of therapy.  These patients might be better off if they cannot undergo a reconstructive procedure with in vitro fertilization.”

Dr. Larry Demco:  “One last question, with this shortening of the time from the onset of the doctor’s office to your full investigation, in your eyes what do you see is the optimum time a work-up should take?”

Dr. Mark Surrey:  “I think a work-up should take a month.  The evaluation of the infertile couple should not take any more than a month and that way you have blocks of therapy.  For example, if you decide after the evaluation the patient should go on clomiphene citrate and ovulation induction, it’s been clearly shown that fertility rates are the highest within the first three cycles of clomiphene citrate, and doing six, seven, and eight cycles is not productive at all.  Same thing for gonadotrophin therapy for ovulation induction and in that manner the therapeutic time, once the diagnosis has been made, also needs to be shortened.  Patients, for example, who have had major pelvic surgeries and one of the most common and most morbid procedures that we do as reproductive surgeons are myomectomies.  We have a patient that comes in and as the gynecologist he’s taking a history, the patient ovulates normally, her husband’s normal, everything else is normal but she’s had multiple myomectomies done - what do you think her problem is?  Well, it’s most likely to be post-operative adhesions.  What’s the way to diagnose that?  You’ve got to take a look so the earlier in the process that we do these things the better off the patients going to be.”

Dr. Larry Demco:  “I think the message is quite clear that the new technologies can shorten a normal 2-3 months investigation period now to within a month, and I think shortening this would have a beneficial effect for all the patients.  I’d like to thank you very much, Mark, for your important information.”

Dr. Mark Surrey:  “Thank you, Larry.”