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Fertility treatment and management with regard to endometriosis
Dr Guy Gudex MD,
interviewed by Deborah Bush QSM Deborah
Bush QSM: Hello, my name is Deborah Bush, and I am Chief Executive of
the New Zealand Endometriosis Foundation. I
am also on the Advisory Board for EndometriosisZone. We are at the 9th National Women’s Hospital Minimal Access
Surgery Course and it is being held at the Hilton Hotel in downtown Auckland.
I have with me this afternoon, Dr Guy Gudex, who is the Clinical Director of
FertilityPlus at National Women’s Hospital in Auckland.
Guy, there is a lot of interest around surgery and fertility outcomes,
particularly in regard to patients with endometriosis.
Can you tell us a little bit about your work at National Women’s
InfertilityPlus? Dr Guy Gudex MD: Yes, FertilityPlus primarily is involved with assisting
infertile couples, investigating them, which will obviously include
investigating the tubes, the pelvis, we often make the diagnosis of
endometriosis as part of that, and we are also involved with fertility
treatment. Although many people
will associate that with in vitro fertilization (IVF) intra-uterine insemination
(IUI), surgery clearly also has a role to play for those couples with
endometriosis where endometriosis is a factor.
And do not forget that you can really only diagnose endometriosis through
surgery anyway. Deborah
Bush QSM: I was listening yesterday to some of the presentations that
were made and I guess met with some differences of opinion in some measures,
particularly with regard to whether to treat a patient who has endometriosis for
the endometriosis or whether to treat fertility first.
What is your view on that aspect? Dr Guy Gudex MD:
I think clearly that if the surgery is available, then surgery should be
done first, and what I mean by that is that for advanced endometriosis, some of
the surgery is very difficult and not all gynecologists have the skills to do
that. Not all cities in the world
will necessarily have surgeons with those skills and I am really talking about
the advanced stage IV endometriosis where there is disease involving the bottom
of the pelvis, the bowel, really the pelvis is obliterated.
So, equally, a lot of endometriosis that we see is not that severe.
It may involve the ovaries, it may be in what we call the peritoneum,
which is like the internal “glad wrap,” and often that is reasonably
amenable to surgery. It is often
reasonably straightforward and most centers would now offer that.
I think that even if you go back to some of the research that was done as
long ago as fifty or sixty years, before laparoscopic surgery was introduced so
these were open operations, there is pretty good evidence that for severe
endometriosis, where it is very likely that that is the cause of the
infertility, pregnancy rates of around 50% in the year after surgery were seen,
and that is going back forty or fifty years.
So I think it has been known for quite a long time that if you try and
restore the anatomy so that the structures are back to as normal as possible a
position, then pregnancy may well result. Deborah
Bush QSM: With some very encouraging outcomes from some of the work I
have read that you have done at National Women’s.
What are those statistics, Guy, that you can tell us about?
What are the outcomes of your work, the practice on women who are pretty
desperate in achieving a pregnancy? Dr Guy Gudex MD: Well, in terms of mild endometriosis, and this is, as I said,
diagnosed at laparoscopy, we know from pretty big studies done particularly in
Canada but repeated elsewhere, that if women have mild to perhaps moderate
endometriosis, treating that surgically, and the most common method now is to
actually cut it out, rather than to vaporise or burn it, that will approximately
double the chances of that woman getting pregnant over the next nine to twelve
months. Now, if the woman is older, approaching late 30s, early 40s, it can be a
dilemma waiting that time, so they may have their surgery and then if they are
not pregnant within three or four months, not feel that they can wait any
longer. But for people who are younger and time is on their side a
little bit, often waiting that twelve months after surgery can result in a
pregnancy, and it means that they have avoided the stress and the financial
strains of having to do treatment such as IVF.
We know from experience that the simpler technique of intra-uterine
insemination, where the husband’s sperm is simply squirted up into the womb,
that that only works approximately half as often if there is some endometriosis
present or if there has been endometriosis present.
So we are now reserving that primarily for people with what we call
completely unexplained infertility. And if a woman has IVF and has not got
pregnant after surgery, we would tend to recommend IVF rather than any other
simpler form of treatment. The information about IVF outcomes is a little bit conflicting.
There are some quite big studies suggesting that endometriosis does not
make the outcome of IVF worse. My
feeling is that, in most people with severe endometriosis, particularly if it
affects the ovaries and so if they have had a history of chocolate cysts in the
ovary, I think that if the disease has not been removed surgically, then the
outcome from IVF is not quite as good. Now
that is not to say that IVF cannot work; of course, it does in many cases, but we have certainly seen
people where the embryo quality is not as good, the egg quality is not as good,
and we think it is quite likely that that may be attributable to the
endometriosis. So, instead of
persisting with IVF, and instead surgically treating the endometriosis, it may
either result in just a spontaneous pregnancy on its own or may improve the
chances of IVF working. But again, I come back to the point that the dilemma is if you have got very
severe endometriosis and you do not have access to surgeons locally who can
actually treat that safely surgically, many people cannot afford to have private
treatment and their local public hospital, government-funded service, may not
necessarily provide the service that they need.
Having said that, those services are developing and most cities,
certainly in the western developed nations now, would have a pretty
well-resourced endometriosis service. Deborah
Bush QSM: I think one of the things I have been particularly encouraged
about this week is looking at what has been developed at National Women’s
Hospital. So, you have
FertilityPlus working on site, as well as having developed the relatively new
multi-disciplinary holistic approach to treating the disease and I think that,
as more time develops, that service, indeed, will grow and certainly is the gold
standard now for what we can hope for with patients with endometriosis. Dr Guy Gudex MD: Yes, I agree, and again, certainly working in both fertility
and also surgery, I find it hugely helpful to have both of those hats.
Clearly not all women with endometriosis have fertility issues.
They may have completed their family or they may have chosen not to have
a family. But I find it hugely
helpful being able to operate and treat the endometriosis of women who also have
a fertility problem. I think it
just helps me with my fertility hat, as well, to think a little bit more about
preserving tubes and their function, trying not to damage ovaries when we are
doing surgery, thinking ahead to whether this woman may not may not need IVF,
and it is really nice to be able to continue to look after people through that
whole spectrum of both surgery and then also IVF if they need it. The problem again is that as the surgery becomes more
specialised and more developed, it is becoming more common that fertility
specialists do not necessarily do both, but certainly in my own practice I find
it hugely helpful to be able to continue to look after people. Deborah
Bush QSM: And there are very few specialists wearing both hats, as you
were saying, in developing alongside each other, so we are very fortunate in
having you at National Women’s, the largest hospital in New Zealand. Dr Guy Gudex MD: Yes, we find the fertility service works really well being
alongside the surgery service, alongside the recurrent miscarriage service.
We are shifting in October to a new unit on the site and right next door
to us is what is going to be called the Regional Clinical Genetics Service and
we are really excited about that because IVF, recurrent miscarriage, genetics
have huge overlaps and we will see stronger links increasingly with that
service, as well. Deborah
Bush QSM: Even in discussion with other consultants and specialists
from different parts of the world, almost looking quite enviably upon the
services that are being developed here and I
congratulate you on what has happened at National Women’s.
We hope that there are some really good outcomes for the future of the
treatment of women with endometriosis and also associated fertility problems. Dr Guy Gudex MD: Thanks. Deborah Bush QSM: Thanks very much, Guy.
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