Programs Presented at the First Congress on Controversies in Obstetrics, Gynecology & Infertility

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Dr. Howard Carp: "My name is Howard Carp and I'm from the University of Tel Aviv. I'm sitting this evening with Bruno Lunenfeld, a noted professor at Bar-Ilan University just outside of Tel Aviv, Togas Tulandi, who's Professor of Obstetrics and Gynecology at McGill University in Montreal, and Alan DeCherney, Professor of Obstetrics and Gynecology at the University of California, Los Angeles. They've been discussing some of the sessions, which have gone on here today. Professors Tulandi and DeCherney, I understand that you were speaking about some of the controversies surrounding ectopic pregnancy. Could you please tell us some of the controversies which came up for discussion and the things which were discussed at the meeting?"

Professor Alan DeCherney: "We talked about which surgical approach was better, salpingoscopy or salpingectomy, and I think that we concluded that salpingoscopy in most incidences in a first ectopic pregnancy was better. We also discussed whether a laparotomy or a laparoscopic approach was better, and we came up with the conclusion that a laparoscopic approach was preferable if the patient was stable. And last, we talked about chemotherapy and the discussion there centered around whether a local injection or a systemic injection was preferable. It seems that since they both have the same outcome, the systemic treatment is better because it doesn't really require any skill, and it doesn't have to be injected into the ectopic. So we came up in the end with a continuum-the best way to treat a patient fulfilling criteria of small size was first methotrexate, then a laparoscopic approach, and last a laparotomy."

Dr. Howard Carp: "Do you feel that the surgical management was adequately discussed in this session?"

Professor Alan DeCherney: "Yes I do. Actually, the last three sessions today did cover surgical aspects, but basically they were the sessions only looking at real surgical aspects. So I think that if this was to cover the whole field, perhaps a shortage was not enough coverage of some of the surgical controversies. But perhaps that will be covered in another meeting."

Dr. Howard Carp: "Now Professor Tulandi, I know that you've also been discussing surgical aspects this afternoon, but also surgical aspects of a different nature-hysterectomy and the alternatives to hysterectomy. Could you tell us a little about what was discussed this afternoon, please?"

Professor Togas Tulandi: "Yes. We discussed the treatment of abnormal uterine bleeding, by hysterectomy or other methods, and we came up with the conclusion that an alternative to hysterectomy such as endometrial ablation has a place in the treatment of abnormal uterine bleeding. Those talking about subtotal or total hysterectomy were also represented, and I think we agree that there is a place for subtotal hysterectomy, as well for benign gynecological conditions."

Dr. Howard Carp: "When you were speaking about endometrial ablation, were you only speaking about the hysteroscopic forms of ablation under direct vision, or also possibly some of the catheter techniques, such as using heat to ablate, and so on?"

Professor Togas Tulandi: "We talked about both hysteroscopic techniques and non-hysteroscopic techniques. The non-hysteroscopic techniques are microwave, balloon, thermal balloon, and VestaBlate, which is with electrodes. It seems like the results are often similar."

Dr. Howard Carp: "Were there any conclusions reached as to which may be an optimal method of ablation, or does that still remain controversial?"

Professor Togas Tulandi: "The hysteroscopic technique certainly works very well. It has high efficacy, and several endometrial studies have shown that the newer methods are as effective."

Dr. Howard Carp: "Thank you. Professor Lunenfeld, I understand that you touched on a very important subject this afternoon when you talked about a cancer risk in patients who have had ovulation inducing agents. Could you please elaborate on the points which were discussed?"

Professor Bruno Lunenfeld: "You probably remember that after the Witmore paper in 1992, there was a big problem and people were afraid that using drugs may increase their risk of ovarian cancer. This was increased even further by the Austin paper, which showed that patients who receive more than twelve treatment cycles with clomiphene citrate had an accelerated risk of ovarian cancer. We are now able to look at other studies, concentrated and modulated by Professor Mundon, in which we collected some 130,000 women in Israel with a mean age of patients of 52. We demonstrated very, very clearly that there is no increased risk of ovarian cancer. Furthermore, we were able to obtain the data from the California study, which is around 65,000 patients from 15 IVF centers and 40 physicians, and their study is only preliminary for the time being, also. But the data on ovarian cancer is already there. They observed no increased risk of ovarian cancer when the patients were treated or were not treated. I think this is an important result, although the author said at the end of the study that he still would like to wait another ten years to see the patients after the age of sixty. I think we can be quite comfortable today. I think this data, at least for me, is sufficient reason not to be afraid anymore of the relation in using drugs. We did not discuss assisted productive techniques because the time interval between ART and ovarian cancer is too short, for the time being. Although we were told that in approximately three to four weeks a paper will appear in the Lancet in which the Australians will claim there is an increased risk of breast cancer about one year after treatment, and after ten years this risk equalizes to the non-treated patients. So today we believe-and Dr. Carson agrees with me fully-that this first increase after one year that comes after ART, or after stopping contraception, may just be a group of patients who had already harbored a tumor and where the treatment actually stimulated this harboring tumor and brought this tumor about. Of course, when we look after ten years, we'll disseminate this out. This is what we believe is probably the reason, and I'd like to ask Alan if this sounds reasonable to you?"

Professor Alan DeCherney: "Yes. Reasonable, I agree with that. It's very much like endometrial cancer, where the high estrogen levels are exaggerated, but it's already present."

Dr. Howard Carp: "Professor Lunenfeld, this is taking the whole group of ovulation inducing agents as a whole. Was there any difference between various sub groups, possibly women who had had urinary menotropins, possible menotropins based on FSH alone, or the most classical ones which also included LH in the preparation? Was there any difference seen or was that not looked at?"

Professor Bruno Lunenfeld: "Don't forget this was a study where the patients are now 52 years old. This was a study that was performed between 1961 and 1984, where there was no other preparation other than the old H&G preparations. We do not have any data yet on the newer preparations."

Dr. Howard Carp: "Thank you. I understand that another subject which you spoke about was the so-called andropause, or partial androgen deficiency. Could you elaborate on some of the points that came up in that discussion please?"

Professor Bruno Lunenfeld: "Yes, I think we all agreed today that in men there is a gradual decline of the Leydig cell function and adrenal cell function related to dehydroepiandrosterone, not cortisol. There is a decrease in cortisol hormone, there is an increase in melatonin, and there is a decrease in IGF-1. That means that today, with the prolonged life span of men, they will live about one-third of their lives in partial endocrine deficiency. Now, if we have endocrine deficiency which is expressed by clinical signs and proven by laboratory tests, then I believe only in these cases should we start using replacement therapy. It has been shown quite well today that testosterone is probably not a risk factor for cardiovascular disease. I believe the our study team demonstrated quite elegantly that you can reduce cardiovascular risk because you reduce visceral effect, and that it seems quite likely that testosterone does not induce prostatic cancer, but it may stimulate existing prostatic cancer. Therefore, the guidelines of today suggest that, before initiating testosterone therapy, we should have a digital examination and a PSA (prostatic specific antigen), and if there's anything suspicious, a transrectal ultrasonography. And we should repeat this three months after the testosterone therapy because this could create a very early diagnosis of cancer, should the PSA go up within three months. So I think guidelines are being developed. We are in the very, very beginning-we are where we were with HRT about thirty years ago."

Dr. Howard Carp: "Professors Lunenfeld, Tulandi, and DeCherney, thank you very much."