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IVF treatment after inadequate surgery

The Independent of may 16th wrote “IVF clinics accused of putting money before safety” Infertility treatment in addition is complicated by another even bigger problem which causes avoidable costs and physical suffering for women seeking infertility treatment. As explained in 2004 when receiving the “Distinguished surgeon award” of the ASRM the introduction of laparoscopic surgery had a fundamental impact upon fertility surgery - Fertility surgery used to be done by microsurgery and thus remained centralized. With the introduction of laparoscopic surgery in the early 90-ies fertility surgery became mainstream and the quality went down. Simultaneously the number of IVF cycles went up. - Today infertility units with excellent surgery have become rare. Most of the infertility centers have become IVF centers.  When attending meetings as ASRM or ESHRE this discrepancy between emphasis on surgery and IVF is obvious. - We should moreover realize that in surgery there is no quality control of the individual intervention. For this reasons I wrote that video-registration should become mandatory especially in infertility surgery which should maintain and restore function Being aware of the underlying problems I therefore made in 2004 Philadelphia the following recommendations First infertility treatment needs a quality control. Since surgery is the first line of treatment, video-registration of the entire intervention and quality control should be mandatory. IVF should be organized as service centers but should not make the decision to start IVF treatment;  the choice of treatment should be made by somebody else (this is similar to radiologic exams that have to be prescribed by others)  Otherwise the judgement of IVF centers could become biased with the actual end...

Robotic surgery in gynaecology and endometriosis

The discussion on robotic assisted surgery is continuing . Following our opinion statement on www.endometriosis.org John F Dulemba posted in World Endometriosis Research Foundation 7 January 07:43 PEOPLE. THE ROBOT IS JUST LAPAROSCOPY!!!!!!!!!!!!! PLEASE WATCH THIS MINUTE VIDEO….TO THE VERY END. YOU WILL SEE HOW PRECISE THE INSTRUMENTS CAN BE, AND I DO NOT THINK ANY STANDARD LAPAROSCOPISTS CAN BE AS PRECISE AS THE DOCTOR IN THIS VIDE!!!!!! When I wrote the comment below, the video has been withdrawn Nice video but misleading - obviously for specific movements a robot is superior to the human. Therefore I do expect that a robotic tubal reanastomosis will be superior to standard laparoscopy and come close to classic microsurgery. Unfortunately however , to the best of my knowledge, this superiority has never been demonstrated. No attemps were made even to demonstrate this in animal models. So doubt persists whether there is some uncertainty about outcome of such a trial. Failure indeed would killing a major indication - except tubal reanastomosis I doubt that superiority can be proven for any other gynaecological intervention (since it probably does not exist) - in addition robotic surgery can be potentially dangerous when performed by surgeons without sufficient training in laparoscopic surgery. (see blog http://www.gynsurgery.org/hysterectomy-myomectomy/robotic-surgery-is-not-superior-and-potentially-dangerous/) - finally, in this period of economic crisis, it is unclear who is willing to carry the associated huge cost : the surgeon ? the hospital ? (for marketing reasons) the patient ? (I doubt any patient is willing to pay today if correctly informed) I anyway want to stress my interest in robotic surgery as can be found in de development...

endometriosis risk and dietary fat consumption

Endometriosis risk and dietary fat consumption Risks factors for developing “endometriosis” are discussed since 30 years while this is a frequent topic at meetings and factors as heredity, age, menstrual flow etc seem to be common knowledge if judged from the literature and from endometriosis websites. We even suggested 30 years ago that typical endometriosis might not be the cause but the consequence of the Luteinised Unruptured Follicle(LUF) syndrome, and thus not a cause but a consequence of infertility. The debate however is flawed by the fact that specific end-points are rarely/given. Indeed that risks for developing subtle, typical, cystic and deep lesions might be different. The 4 types of lesions anyway are very different in prevalences varying from 80 to 1% respectively, while pain ranges from no pain to very severe pain in most women. To the best of our knowledge only heredity is a clearly defined risk factor, which seems to be bigger for severe lesions, thus for cystic ovarian endometriosis, and possibly also deep endometriosis. Also the discussion on the association between endometriosis and cancer is an example of this bias in the literature as is the recent article in human reproductio on dietary fat consumption and the risk for endometriosis (Missmer SA et al A prospective study of dietary fat consumption and endometriosis risk. Hum Reprod 2010;00:1–8.). For this reason we wrote a letter to the editor in order to address this problem. Click for the full text . In brief we were concerned that the abstract may induce readers conclude that fish oil consumption might be beneficial in preventing endometriosis. Indeed we only know...

Surgical mistakes and surgical quality

Surgical mistakes and surgical quality. Recently, surgical mistakes have been highlighted in the Belgian press because of surgical instruments left behind in the abdomen of patients. Fortunately this occurs very rarely. However, it has been said that more people die every year because of surgical mistakes than by car accidents Google ‘surgical mistakes’ and the problem and the stakeholders become clear. This however is only the tip of the iceberg. The most frequent problem indeed in surgery is patients providing “informed consent” based upon incomplete information and lack of information concerning surgical quality (ie. the surgeon’s experience and complication rates). For most patients it is not very clear which quality of surgical care will be given, and this care varies from the best available to the minimum practice, which is the medico legal standard. This can be highlighted by the observation that it takes between 10 and 20 years or longer before innovation is introduced; the slow introduction of laparoscopic surgery is an example of this – it is only today, 30 years after its introduction, that laparoscopy is more or less accepted as the standard of care when performing a hysterectomy, removing fibroids, and treating endometriosis This website principal aim therefore is providing information for the patient which is considered essential for obtaining informed consent . Surgical quality often is suboptimal There is no official/formal quality control for individual surgical intervention . National statistics only reveal complications. But without evidence of the entire surgical procedure it is very hard to demonstrate the underlying mistake, which may have caused the complication. For this reason we published in 2009 the...

Tubal sterilisation Reversal

Message: I need a tubal reversal procedure  called tubouterine implantation to remove coils : do you do that surgery? Answer Tubouterine implantation to remove coils can be done,  but the success rates depend upon the depth the coils were inserted - for an istmo-isthmic reanastomosis :  over 80% - for a isthmo-cornual reanastomosis : 50% - for a deep intramural reimplantaion < 20%  (and thus IVF becomes preferable) One of the problems with tubal sterilisation is informed consent which cannot be given by the patient , without the following information (to be given by the surgeon.)  The surgeon indeed should mention all alternative techniques and not only the one he performs. 1. Yoon Ring and Hulka clip sterilisation are normally “reversible” with an isthmo-isthmic tubal reanastomosis either by microsurgery either by laparoscopy. If the sterilisation is not performed mid-isthmic, -as should be done- success rates of isthmo-ampullary or isthmo-cornual reanastomosis are much lower. 2. Ring or clip sterilisations can be done under local anaesthesia with an hospitalisation of 3 hours. 3. Extensive coagulation, ampullectomy (Pomeroy) or hysteroscopic coils are considered non-reversible types of sterilisation. This is important since nobody knows what the future will bring. The issue of reversibility remains debated since a tubal sterilisation should be considered definitive, thus requiring extensive counseling. Reversibility however can be compared to a live insurance which is not taken with the intention to die. Anyway, the risk of regretting a sterilisation, is well known to increase when the patient is younger or has no children. Professor P.R. ...

Endometriosis – bisphenol – dioxin – pollution

Recently the Italian press has been debating bisfenol as a cause of endometriosis. This needs some comments 1. The relationship between endometriosis and endocrine disrupters as dioxin started in 1994 with the article of Koninckx-Kennedy-Barlow soon followed by the primate article of Rier. Since then numerous articles have been published but the relationship remains unclear. The logic hypothesis that breastfeeding could cause endometriosis since dioxin is excreted in breast milk, fortunately has been proven not to be true - the opposite is true. This is a nice example how careful we have to be when interpreting scientific data , and not to jump at conclusions. Anyway there is no reason today to become really worried. 2. Also the story of bisfenol - another endocrine disruptor with estrogen like activity - goes back some time. It starts with a nice article of Tsutsumi. followed by an article of Newbold et al, 2005 . As demonstrated 30 years ago for stilbestrol , high doses of estrogens during neonatal live can cause congenital anomalies of internal genital organs . The first article linking bisfenol to endometriosis dates from 2009 and demonstrates that the concentrations of bisfenol in adult women with endometriosis is increased. They concluded that it is unclear whether the small doses found could cause any effect. 3. Recently Signorile, 2009 described ‘endometriosis-like lesions’ in mice in utero.  Since we disagreed that these lesions could be considered endometriosis we (Ronald E. Batt,  New York, USA ,Lone Hummelshoj,  London, England,Charles Chapron, Paris, France ,Dan C. Martin,  Memphis, USA, Glenna C. Bett,  New York, USA, John Yeh,  New York, USA, Philippe R. Koninckx,...

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