The following articles represent an Update on CHR activities. If you want further information on any of these articles, please contact us. CHR is a comprehensive fertility center in New York, NY.
The "Surgery for Infertility?" Issue
You may be hearing all the CHR staff exhaling by the time this UPDATE appears on e-mails, fax machines and the shelves of the Center, because by then, 14 abstracts will have been submitted to the Annual ASRM Meeting. As already noted last month in these pages, April is always the big month for data analysis and abstract writing, summarizing these data. The following months are then used to turn these abstracts into full-length manuscripts.
ASRM changed submission rules this year to allow each investigator only up to six abstracts. Once the first 14 were done, we, therefore, had no more potential presenters left to list as authors, and could submit no more abstracts.
While 14 abstracts, of course, represent quite an effort for a center of CHR's size, had it not been for these new submission rules, the number of submissions this year would have been even bigger. As we start to work up the material further for publication, we, as always, will in these pages preview our findings. So, stay tuned over the next few months; some very interesting data are on the way!
Today's UPDATE is, however, dedicated to a long overdue subject that has been on our mind for quite some time:
Unwarranted Surgery Infertility Treatments
The other day, a 47-year-old new patient presented to CHR after consultations at two other fertility centers in two different boroughs of the city. One of these centers performed a hysterosalpingogram (HSG) on the patient, and determined that one of her tubes was occluded. The patient was told that, as a first step, this tube "needed to be fixed" by surgery.
At CHR, we found this recommendation astonishing, though not surprising: unnecessary surgeries for infertility appear to be on the upswing. Laparoscopies and/or hysteroscopies on most, if not all, infertility patients seem to have become routine in quite a number of centers. Indeed, some colleagues, not infrequently, even perform repeat surgeries before ultimately taking patients into in vitro fertilization (IVF).
Let us clarify what is bothering us, and what we really are talking about: We are not referring to infertility-related surgeries, where pathology is identified that could hamper treatment success with inseminations or in IVF cycles. Poorly positioned uterine myomas, polyps and, yes, even endomteriomas and/or other ovarian cysts may, at times, have to be surgically removed to improve pregnancy chances, reduce potential miscarriage risks or address other specific issues that can only surgically be resolved.
But purposeful surgery has to be differentiated from "routine" surgery, which is performed with no specific benefit in mind. For example, why would anybody perform routine hysteroscopies on everybody before taking them into IVF? To determine whether the endometrial cavity is normal, a much less invasive hysterosonogram suffices, as many studies have well demonstrated. Similarly, what is the value of routine laparoscopy if patients are already pre-determined to go into IVF? Whatever problem may be detected with laparoscopy that wasn't known before (endometriosis, for example) becomes irrelevant, once the patient is in IVF.
Coming back to the above noted patient, there is obviously no value in "fixing one tube" in a 47-year-old patient. First of all, it takes only one tube to conceive, and her second tube was allegedly normal. More importantly, how likely is a spontaneous conception in a 47 year old? Indeed, how likely is conception, even if accompanied by ovulation induction and intrauterine inseminations? Since spontaneous conception is so unlikely at such an advanced maternal age, only IVF (whether with her own eggs or donor eggs) will help her conceive. For IVF, tubal status is mostly irrelevant. Why then the laparoscopy and suggested tubal surgery?
It is always good medical practice to offer more economic treatment solutions to patients. In difficult economic times (and who remembers one more difficult than current ones?) everybody should be even more motivated to offer more economical treatment options! Just because something is "covered" by insurance does not mean it needs to be done. If so much money was not wasted on unnecessary surgeries, maybe insurance companies would look more favorably at coverage of truly effective infertility treatments. Have colleagues, who so easily resort to such spurious surgical interventions, recently bothered to review hospital bills for such procedures? If not, we suggest they do so!
The purpose of this communication is, however, not to criticize other physicians' practice patterns. What we want to highlight instead is the contrast to CHR's surgical philosophy. CHR'S Medical Director, Norbert Gleicher, MD, probably explained it best at a conference: "in over 20 years, he hasn't taken even a single patient to surgery for a diagnostic procedure, whether hysteroscopy or laparoscopy."
Both surgical procedures were initially developed as diagnostic procedures. But medicine has evolved since, and practice patterns had to be adjusted. Better, non-invasive diagnostics now allow for accurate diagnoses, making invasive surgical procedures for such a purpose obsolete. Hysteroscopies and laparoscopies, therefore, are now primarily therapeutic procedures, where the intent should be to surgically improve an already well-defined problem. Advances in medicine mandate constant adjustments in practice patterns. Therefore, when Dr. Gleicher referred to not having performed a diagnostic laparoscopy or hysteroscopy in over 20 years, it was meant that under his leadership, CHR constantly adjusts its surgical practice patterns.
CHR's Surgical Philosophy
Also constantly driven home by Dr. Gleicher is the message that "there is no small surgery" or, as he often formulates this paradigm, "small surgery is always only the surgery performed on somebody else." Even when statistical risks of complications are small, for the one person experiencing a complication, it is always 100 percent!
Besides exorbitant costs, surgery always carries risks, which go beyond anesthesia accidents or surgical complications, which initially come to mind. Hospitals nowadays are dangerous breeding grounds for antibiotic-resistant infections, where most SARS is picked up.
CHR's surgical philosophy is, therefore, conservatively simple and straightforward:
- Avoid surgery unless it is unavoidable;
- Clearly define surgical benefits and measure them against surgical risks;
- Always choose the least invasive surgical approach with lowest risks;
- Unaffected by insurance coverage, always select the most cost-effective approach.
Noting above a rather "conservative" approach towards surgery at CHR, it is important to note that surgery may, at times, hamper conception. Two examples come to mind:
Surgery for fibroids (myomas) is often considered necessary but rarely proven necessary. Indeed, a review of the medical literature of this subject would only reveal how little is known about when surgery should be performed for fibroids, and when it better be avoided.
Only too often do we see women, who after myomectomies return with badly distorted uterine cavities, often partially or completely obliterated. This can happen even to the best surgeons because healing always results in scar tissue, and scaring constricts tissues (though, of course, there are better and poorer surgeons).
What we want to point out is that, at times, leaving fibroids untouched may be the lesser of two evils, even though a correct decision can be excruciating difficult to make.
Surgery for endometriomas ("chocolate cysts") is another extremely complicated subject. Endometriomas are ovarian cysts filled with endometriosis. There can be no argument that in a woman who has completed childbearing, endometriomas above minimal size should be excised.
Yet, in women who are still trying to conceive, the issue can become very complex: In most such women, the endometriosis has already significantly "eaten away" on healthy ovarian tissues, and, therefore, ovarian reserve (OR). Every time an endometrioma is surgically resected, more ovarian tissue is removed, even by the best of all surgeons (once again, a better surgeon will lose less additional tissue).
Whatever a patient's OR was before surgery, it, likely, would be even lower after surgery. Amongst infertility patients it is not uncommon to hear that "FSH levels suddenly increased" after resection of ovarian endometriosis or that menses ceased. In other words, in such patients, it is not uncommon that surgery puts them into premature menopause!
At CHR, we, therefore, practically uniformly, recommend against surgery, even with quite large endometriomas if patients are still planning on pregnancy. There are risks with such an approach because endometriomas can leak or even rupture, but once a woman is in menopause, there is no way back. Just as there is risk to the endometrial cavity or even for loss of the whole uterus with uterine myomectomies, so is there risk of reproductive function whenever endometriomas are operated on, especially if surgery is done bilaterally.
Many CHR patients with large endometriomas today are mothers because we did not recommend them to have surgery. Indeed, some have had more than one pregnancy with quite large endometriomas.
Surgery, therefore, does not always help with female fertility; and at times, surgery can make things clearly worse.
Surgery in the Male
Fortunately, there is much less surgery going on in male infertility, but in one area CHR practice differs here, too. Many major fertility centers still send all males, diagnosed with so-called varicoceles to surgery. Varicoceles are excessively dilated veins in close proximity to the testes. They are believed to excessively radiate heat to the testicular tissue, thus disturbing sperm maturation, resulting in abnormal semen analyses. By ligating these veins, many of our urology colleagues believe, they improve fertility.
Unfortunately, objective data in support of such an approach are sparse. Indeed, a recently published review by urologists reemphasized this point. At CHR we believe that this surgery is only very rarely indicated because, even if semen parameters may slightly improve after surgery, the surgery practically never turns an infertile male into a spontaneously fertile male. What then is the purpose of a slightly improved semen analysis if the male still needs IVF and ICSI to establish a genetic pregnancy with his partner?
We assume that by now it will be quite obvious that the topic of surgery in infertility has been gnawing on us for quite some time. We hope that this brief summary has offered, once more, a very good example of what differentiates CHR as an infertility center. We are here, first and foremost, to serve the wellbeing of our patients!
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Last Updated: October 18, 2011