SESSION II: Treatment considerations
Discussion - Scientific Symposium
Endometriosis and oocyte cryopreservation
Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 18-19, 2016
The Union Club, New York
Moderator: Any questions?
Audience Member: Hi, this question is for Dr. Singer. Working at ____ we are inner city the REI services tend to be cost prohibitive for patients. Do you know of any programs for patient that have the diagnosis of endometriosis who can get these REI services at lower costs?
Tomer Singer, MD: I do not know if any insurance companies consider endometriosis as of yet as a fertility preservation category. I will tell you that what we do with our endometriosis patients is at least we lower the price by default when they are going for surgery. The second component is the medication because egg freezing costs about $8,000, the medication can cost up to $5,000 – 6,000 in addition to that. They can apply to something called Livestrong, an organization owned by Armstrong and there is a wellspring compassion to care and with their W2s they can get actually free medication so that will lower their costs significantly so they can look at about $6,000 to $8,000 for the whole process.
Moderator: Another question?
Audience Member: My name is Dr. Sayed. I have a question for Dr. Isaacson, actually one of the questions which this young lady asked was about costs Dr. Singer is also my question. You said it was not one of the hurdles – it a very major hurdle. As soon as the patients refer to an infertility specialist you say “oh my God, $20,000” you know. Anyway, Dr. Isaacson I just have a question about adenomyosis surgery. It is like a reduction of adenomyosis in the wall but also this reduces the myometrium. I know we try to be very careful and excise it properly using least internal damage but as a surgeon struggling with adenomyosis myself many patients which I have done I find even adenomyoma extraction very difficult and it does reduce the myometrial concentration in that area and chances of future rupture and pregnancy.
Keith Isaacson, MD: That is a great question and thanks for asking it. So they are having case reports which is all there has been. The largest study out of Japan which had 121 patients they had no uterine ruptures in their patients that had delivered pregnancy and there was one case report that had a rupture in a woman who had twins. I do think that the best that you can tell now, extrapolate from this is that it is probably similar to the risk of uterine rupture following myomectomy. So we know it happens we know it increases the risk and so far, based on limited data, seems to be a small risk.
Juan Salgado-Morales, MD: I would add then you can do a double flap technique that would put the first part of the serosa and you take out that serosa and on top of that one you do the flap and you have double flap technique that would give you more strength to that myometrium.
Audience Member: Unintelligble
Juan Salgado-Morales, MD: Yes.
Keith Isaacson, MD: I do not know if that reduces the risk of rupture but it is one of the first techniques that I show to utilize.
Tamer Seckin, MD: I just want to make a comment. My experience with adenomyosis surgery has not been great ___ expectations for pregnancy. Keeping the uterus, fine, I think that you can operate on any uterus without adenomyosis if they want to keep the uterus you can diminish the uterine value. However, if the patient is contemplating pregnancy I have one patient who lost a pregnancy. She almost died. She came from Massachusetts and she had a great adenomyosis surgery. No matter what you do and I really close very well the myometrium of ___ quality I cull every single interrupted stitches, layered very nice but it is difficult to maintain the same muscle healing that you can obtain with fibroids. I had another patient with an obstetric event. She almost died after the baby was delivered for _____ severe bleeding, premature birth. So, I personally stay away from adenomyosis patients who want to get pregnant. I also just want to comment on the complication issue and I will ask Tomer a question. Endometriosis surgery is complicated surgery and is involved with complications more than general surgery. There are specific complications that come when you do multiple organ surgery with bowel, bladder, especially when you do simultaneous organ surgery with bowel repair, hysterectomy or bladder surgery. There are fistulas, there other issues with bowel so patients should know the statistics are – it varies from surgeon to surgeon – seven to 15 percent times more than, more riskier than regular surgery. My question is, Tomer, you have patients with endometrioma, bilateral endometrioma, 5 cm each, she wants to freeze her eggs do you follow with special protocols for these endometrioma patients versus non-endometrioma patients for stimulation, aspiration, what is the success rate? I am not convinced with endometriomas your success rate is very good. I am not experienced. Could you tell us, teach us this?
Tomer Singer, MD: Sure, so actually we had a couple of them, unusual patients. There is a patient now who is about to deliver, the resident will tell you, right, Dr. Silberstein’s patient who had severe bilateral endometriomas. She showed up to the ER with 8 cm and 9 cm endometriomas and she ended up doing IVF essentially because she was married. We got some eggs from one ovary then we did the laparoscopic endometriosis resection to basically, obviously reduce the bulk of the disease and then she conceived after that. The question is what is the risk of losing these ovaries and the blood supply to these ovaries? And the other question is whether or not you have access. We can do a transabdominal retrieval if you see a lot of follicles behind the endometrioma if you are doing the retrieval transvaginally you will not be able to access it. I have had cases when I had to go through an endometrioma to get some good eggs because this was the only option. I counseled the patient appropriately that we may have to go the OR right after the retrieval. So it really depends on how committed the patient is, how accessible the ovaries are, how many follicles you have, what is her age, what is her baseline criteria to go for retrieval because a lot of patients, Dr. Brill will tell you, had multiple cysts, had surgeries elsewhere and came for a second opinion. At that point you are dealing with an AMH that is undetectable with elevated FSH and they are looking at the very low chance of conception without a donor egg. So it is a cost and benefit analysis just like any other field of medicine.
Juan Salgado-Morales, MD: Any other question? Dr. Reich?
Harry Reich, MD: This is a funny question. This is for Dr. Shin. It is almost like she was talking another language. Most of us like you said but she said that the study was showing what is going on and what people in Italy and we know Mark Possover does it and he is in Switzerland now and Ciccarone and they have foundations even. Ciccarone teaches anatomy and Possover teaches nerves. So my question really is why, and we are in a group discussing endometriosis, why is none of this transporting to the United States? Why are we not doing some of this stuff? Why are not these researchers – I thought maybe the answer was they are not interested in anatomy and surgery. But obviously they are and in the rest of the world but congratulations on the talk and possibly what we should be doing is trying to figure out a way to simplify all these nerves when everything is booked hypogastric, no one knows what hypogastric – you know, they do not know which is the parasympathetic branches and the sympathetic branches. We learned the anatomy many, many years ago but I think it is time. And somebody like yourself should start even working with some of these other people to try to really simplify it for the American audience.
Juan Salgado-Morales, MD: Thank you, any other questions?
Tamer Seckin, MD: There was a cancellation of a speaker so we have time, right?
Juan Salgado-Morales, MD: Yes, we do, we have five more minutes.
Tamer Seckin, MD: I disagree with the platform of I think the speakers are excellent. My comment on the painful orgasm.
Audience Member: Wait, wait, wait – we have to hear her comments to Harry.
Ja Hyun Shin, MD: That is fine! I think it is several faults why we are not having studies coming out of the States here because the truth is gyn-oncologists are performing these pretty intense radical hysterectomies, right? But they do not publish papers on the topic. I think maybe just the training that is entailed in minimally invasive gynecological surgery in these areas in Europe may be a bit broader and maybe that is why there is for example more bowel resections in this level of surgery. It could just be a difference in training at that level. But also I am pretty sure that the IRB process also has something to do with it as well. There is very little known about the surgery and it is a dangerous surgery. If you do not do it right this patient may have severe, severe problems, lifelong problems. Maybe there is kind of an administrative reason also for the lack of studies from here. As I reviewed these three basic studies I think it is yet to be established really how beneficial it is. I do not think there is a decision on that yet. Going through these lengths, even though it took them the same time or even shorter to perform the surgery, for us lay people in this country I do not know how quickly it can be adapted. That might be a reason but it was fun preparing for this talk I felt like I was back in medical school, learning my neuroanatomy.
Harry Reich, MD: This is a really important point and it is very important to continue to educate us about it. I think it is embarrassing (unintelligible) see the operations and you are going up there. There are doing operations where the colon is affected, which it is in… rectovaginal…
Ja Hyun Shin, MD: It is 15 percent.
Harry Reich, MD: So what are we doing here? Nobody is doing it. (unintelligible) knows nothing about it. (unintelliglbe) Somewhere along the line we have to change…
Tamer Seckin, MD: But Harry, eventually, no matter what, there is no escape. If you are doing endometriosis surgery you are going to have to deal with the hypogastric nerve. My residents know that. We do see hypogastric nerve and we spare it if the endometriosis spares it. Many times when endometriosis presacral area extends closer to the sacrum it is very difficult. I know some patients and I see them again at this conference I remember their cases and I presented them. Endometriosis may not spare the hypogastric nerve and you cannot identify at all due to deep fibrosis in that area. I was not able in certain cases. It is difficult so it is important not to do bilateral deep resection at the presacral area when you go for pudendal or sacrospinous pelvic floor.
Harry Reich, MD: Some of the answer is that the way I operated and the way Tamer and the way Melanie operates I think we go for the disease and we try to remove it. We excise it well. In Europe, no matter what, they start at the top of the pelvis and they dissect out the ureters and they dissect out the nerves from the top of the pelvis all the way down into the deep pelvis almost before they start working on the endometriosis. Totally different approach.
Tamer Seckin, MD: Eventually one will learn to standardize their procedures to cut complication. We have to really have a step-by-step and do the same thing the same way. We start from above. We start from above mobilizing the bowel, find the ureter and presacral area on each side. Come all the way down like that. Even in minimal endometriosis. Eventually it has to be done so people will discover when they have atonias and things like that.
Juan Salgado-Morales, MD: Time for one more question.
Keith Isaacson, MD: Melanie, can I ask you a question? You brought up the fact that if you were to practice like before surgery that it would enhance your skills. Do you do that?
Melanie Marin, MD: No, I do not.
Keith Isaacson, MD: Do any of your residents or fellows do that?
Melanie Marin, MD: The residents and fellows actually do use the trainers. I do not think immediately prior to surgery. What is interesting is some of the studies show that it actually is helpful. As somebody who has been doing this for a really long time I have used the simulators because they had all of the experienced surgeons use them also to, I am not sure exactly where we are getting the validation, to see if they are showing an improvement. I found the trainers confusing and difficult because the haptic feedback is not there the same way that you are getting it during surgery. I think it is going to be very interesting to find out if that is something that is helpful and when that is going to happen because we are already not compensated for so much of what we do.
Keith Isaacson, MD: (Unintelligible) No one is doing a warm up prior to surgery.
Melanie Marin, MD: So it is interesting that this study showed that it was helpful and yet we are not doing it. Now having said that the studies also show that the mental preparation of reviewing the surgery in your head actually does some of the similar things to the actual physical practice. I find it interesting and it is just such a different way than anyone who is finished more than ten years ago, 15 years ago practices because we, I learned on live patients who were bleeding. That is not what happens anymore and rightly so.
Juan Salgado-Morales, MD: I want to thank everybody.
Harry Reich, MD: …cases. These are not short cases for the difficult endometriosis. They are long cases. How much practice do you want? You get a lot of practice over those next four hours.
Juan Salgado-Morales, MD: We need to finish the morning session. We are going to have lunch now.