Surgical Treatments for Infertility

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Hugo Verhoeven, MD: "Good morning, my name is Hugo Verhoeven and I'm from the Center for Reproductive Medicine in Dusseldorf, Germany. I'm on the Editorial Board for OBGYN.net, and I'm reporting from the 30th meeting of the AAGL in San Francisco, California. I'm sitting with Professor Robert Hunt, and he is an Assistant Professor at Harvard Medical School in Boston. Bob, we've known each other for many years, and you are one of the pioneers of surgical treatment in infertility in this country. I think we met at an AAGL workshop about twenty years ago. You came over to my department at the University in Dusseldorf and since that moment we have, for me, a very important friendship and I thank you for that. Since you wrote the most important atlas on infertility and microsurgery a lot has passed. We have in vitro fertilization and this technique took away a lot of indications for infertility treatment by surgical treatment. So what would now be the state of the art? What would be for you at this moment an indication for surgical treatment in the infertile patient? We're talking now just on the female."

Robert Hunt, MD: "I don't think it's changed a whole lot. I think it's true that assisted reproductive technology has certainly taken a huge percentage of the women who are infertile in the United States and prior to IVF they would have been good surgical candidates. So it's really reduced the amount of surgery we do a great deal, however, in my view the surgery should always be discussed as an option whenever it is an option and the relative values of it. So I don't think it's really changed, it's just that our percentage of patients are much smaller that we're operating on now."

Hugo Verhoeven, MD: "Good, let's say twenty years ago there was no other treatment for frozen pelvis, for endometriosis, for tubal block, or for tubal ligation so we just had reproductive surgery. There must now be some indications where you say - here I would still prefer surgery but in those cases I would now prefer to go for IVF. So tell me something about your preferences for the different indications." 

Robert Hunt, MD: "I think that endometriosis is certainly a wonderful indication for doing laparoscopic surgery, particularly of a infertile female. Of course, often pain is a part of that picture too and this deals with pain issues as well. Endometriosis, I think, is really a key indication for reparative surgery. When the pelvic adhesions are not too severe, again, they are really wonderful indications for it. We do pretty well with it and the results, and generally when it's associated pain it does help that also. The hydrosalpinges, I think, these patients are still good candidates if we know ahead of time that they have mucosal patterns present in the fallopian tubes. That can be from a hysterosalpingogram where you can see a few of those mucosal markings and the tube looks pretty well other than being blocked. Those patients are wonderful candidates for salpingostomy and it also helps IVF too by relieving the obstruction. If you have to go to IVF, I think, they have a double chance of conceiving. Our first chance is it may well work with doing the hydro salpingeal correction but it also may very well help them in their IVF efforts by making them more fertile. So those are a few of the things that come to mind that I would think would be good candidates and then we would go to anastomosis and tubal reversals."

Hugo Verhoeven, MD: "That would be my next question."

Robert Hunt, MD: "Tubal reversals are wonderful indications for surgery. There has been a big move in a few isolated centers in the United States but to do this by laparoscopic measures it's so tedious and so difficult that I think most of us still do these through a smaller, about 5-6 cm, incision and that seemed to work out well. These patients come in today, they do it, and go home generally the next day and it works well. I think the success rate in a patient, say in the mid thirties, with a no male fertility factors and a ligation lends itself to reversal, and they should run close to an 80% success rate. If you have more than one - maybe it's fine too. So I think that also is another indication and really a primary indication for surgical management."

Hugo Verhoeven, MD: "You already mentioned the possibility of doing surgery by a laparotomy or by a laparoscopy. Are there still so many indications for opening the abdomen? Don't you think that certainly in the near future there will be no more indications at all for laparotomy in infertility?"

Robert Hunt, MD: "I wouldn't say that, no, I think that as we get better with laparoscopic approaches we get better instrumentation, and we learn from the pioneers what works and what doesn't work. I think an increasing proportion of our patients are being operated on by endoscopy methods, primarily hysteroscopic and laparoscopic approaches. However, I think they'll always be at least an occasional indication for doing these by laparotomy. So laparotomy will always maintain a role but I think continue to get less and less for both because our techniques are getting better and because patients demand it. So I think those are two of the reasons that we're seeing more endoscopic surgery." 

Hugo Verhoeven, MD: "We have in Europe the problem that everybody advises what he can do himself and they do not like to refer patients to other doctors so a center for in vitro fertilization will prefer to do practically all the indications we talked about by IVF. Somebody who has a center for reproductive surgery will of course try to convince the patient to have surgery, and that is very evident so it's very good to talk to you because you have experience with both of them. Thank you very much. There is another thing I would like to talk about with you. You are the Editor-in-Chief of the most important journal of the AAGL. That journal is not that old at all, maybe six or seven years?"

Robert Hunt, MD: "The first issue came out in 1993."

Hugo Verhoeven, MD: "With what was published in your journal and with your residence in the international literature, it became a very important journal. Tell me something about your objectives and what you want to achieve with your journal and your criteria of the selection of the papers."

Robert Hunt, MD: "Of course, we want to attract the best papers that we can that have to do with mostly endoscopic techniques and the purpose of getting those papers is to determine how the techniques that we've been using have done and what we can learn from that. Also, very important and perhaps more important is newer techniques and what we can hope to expect from those so I think it's to get the best papers we can that address those issues. I'm glad to point out that 6% of our papers comes from outside the United States so it's quite an international recognized journal."

Hugo Verhoeven, MD: "Yes, do you have any idea how many people are reading or are at least having a look into the journal of the AAGL?"

Robert Hunt, MD: "I think the circulation runs somewhere around 4,000 to 5,000."

Hugo Verhoeven, MD: "That is quite, quite important. My final question is always the same - what about the future? What are your plans with the journal of the AAGL in the near future and do you have some new ideas or dreams that you want to realize?"

Robert Hunt, MD: "I wouldn't say we have any quantum leaps that we plan to do right now. We are constantly visiting this journal almost on a daily basis really and have a very active editorial board. What I basically do is send around ideas for us to vote on by e-mail and it keeps us going ahead of schedule. We plan to put our journal on the Internet soon, full volume, so people can access that. That's one of the things we're going to do soon. We have many small changes that are constantly done so I don't look at it as much as a revolution, mostly, evolution basically."

Hugo Verhoeven, MD: "I already mentioned you are the author of the most important book on female infertility surgery. I think it's now three or four editions?"

Robert Hunt, MD: "Yes, the third edition is out."

Hugo Verhoeven, MD: "It's amazing that in this time where most of the people, it's my impression, are trying to get away from infertility surgery for IVF there's still quite an interest in an atlas of infertility treatments. Any there any plans for new books?"

Robert Hunt, MD: "I don't plan to right now. I don't see enough changes in the techniques that we've gotten so far to warrant doing another book right now but it's always a possibility, you never know."

Hugo Verhoeven, MD: "Bob, it's a pleasure, thank you very much."

Robert Hunt, MD: "Thank you."

Hugo Verhoeven, MD: "I appreciate your friendship for the last twenty years."

Robert Hunt, MD: "Thank you."