Contemporary Clinical Delivery in Academic Practice

Transcription

1 Contemporary Clinical Delivery in Academic Practice Patrick Yeung Jr., MD, FACOG Director, SLUCare Restorative Fertility Clinic Director, SLUCare Center for Endometriosis Gynecologic Surgical Subspecialties Saint Louis University

2 Disclosures I am a certified FertilityCare Medical Consultant I have nothing relevant to disclose and will not be presenting information on non-fda approved drugs/devices during this lecture

3 Good ethics is good medicine

4 Is the Church down on sex?? It seems that the Church only offers a list of DO NOTs: Contraception Abortion Premarital sex Adultery Can a Catholic Be An Obstetrician-Gynecologist?

5 NFP-only physician? NO abortion NO sterilization NO contraception versus Fertility Care physician!!

6 Love & Live Connection Babies and Bonding Babies w/out Bonding : Bonding w/out Babies: In vitro fertilization Contraception

7 What not contraception? Lowering of morality Disregard for women s well being Coercive use of contraceptive methods by governments Treating our bodies like machines Humanae Vitae, PPVI, 1968

8 Contraception Abortion From the same roots

9 Why not hormonal birth control?

10 Some women are becoming concerned with the pill

11 FABM methods are trendy

12 FABM methods are trendy

13 Why not hormonal birth control?

14 FABM - Fertility Awareness Based Methods

15 Natural Family Planning v. Fertility Awareness Method

16 What are FAMs? Educational model - empowering Use biomarkers - prospective Either achieve or avoid pregnancy - true family planning method

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18 NaProTRACKING a Woman s Health

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20 Treatment options for infertility - ART

21 Modern Bypass the approaches marital embrace to infertility

22 The experience of ART

23 The need for alternatives to IVF Side effects of medication Multiple gestation - prematurity, low birthweight Birth defects Excess embryos Cost Bypasses the couple

24 The need for alternatives to IVF

25 Disease-based approach NPT v. ART NaProTechnology Seeks to evaluate and treat the underlying causes or deficiencies

26 Real Solutions to Real Problems

27 NPT vs. ART

28 APPROACH to INFERTILITY Male factor Are there enough motile sperm (> 20 million/cc)? Female factor Are there ovulations and are they adequate? Cooperative hormonal evaluation and treatment. Cervical factor Is there an adequate mucus score? Sexual factor Is intercourse at the right time, without inhibiting factors? Anatomical factor Are the fallopian tubes open? Is there endometriosis or adhesions?

29 Cooperative Medicine and Restorative Surgery

30 Cooperative Medicine

31 Cooperative Medicine

32 PREVALENCE - Infertility - Between 25-50% of women with infertility have endometriosis. Between 30-50% of women with endometriosis have infertility. Missmer, Am J Epidemiol 2004

33 Diagnosis of endometriosis The diagnosis of endometriosis can only be made by histology of lesions removed at surgery ACOG Practice Bulletin 310 and 51, 2004, 2010

34 How is endometriosis diagnosed? Per ASRM guidelines: Used to be standard part of workup for infertility. Now optional for patients under age 35.

35 What is endometriosis?

36 What does endometriosis look like?

37 Does hormonal treatment of endometriosis prevent progression of disease? MAYBE NOT.

38 RESULTS Patients with DIE had the following history for severe dysmenorrhea: More frequent OC pill use Longer duration of OC pill use Higher incidence of OC pill use before the age of 18 Patients with DIE had the following adolescent history: More absenteeism from school during menstruation CONCLUSIONS History, especially OC pill use history and adolescent history, can be markers for more advanced endometriosis Chapron F&S, 2011

39 Does hormonal treatment of endometriosis prevent recurrence? MAYBE NOT.

40 Recurrence rate Other published rates found 40-60% in 1-2 years after ablation. Sutton 1994 Winkel even if postoperative hormonal suppression used. Doyle 2009

41 Does hormonal treatment of endometriosis help infertility? NO. Catenacci, Clin Obs Gynecol 2009 Fertil Steril 2010

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44 GOAL is complete treatment of all disease, and depends on the ability to recognize both typical and atypical forms.

45 This data has important implications in the overall care of teenagers, regarding a management plan for pain......but potentially more important for fertility.

46 Padma Lakshmi - Host of Top Chef, supermodel, and co-founder of Endometriosis Foundation of America

47 Early diagnosis and complete excision is the best prevention. - Tamer Seckin, MD EFA

48 1072 couples in Ireland, from , had been trying for over 1 year to achieve pregnancy Average female age was 35.8 years old Mean duration of attempting to conceive was 5.6 years 33% had previously attempted to conceive with ART In life table analysis, 52.8 per 100 couples achieved pregnancy within 2 years. Younger couples and couples who had not tried ART had higher success rates Among live birth, the rate of multiples was 4.6%.

49 108 couples in Canada, of which 18% had reported 2 or more unexplained miscarriages. Average female age was 35.4 years old Mean duration of attempting to conceive was 5.6 years 22% had previously attempted to conceive with IUI, 8% with ART In life table analysis, 66 per 100 couples achieved pregnancy within 2 years. Younger couples and couples who had not tried ART had higher success rates All births were singleton births, and 78% had birth weights of 2500g or greater

50 Good ethics is good medicine Hormonal suppression is Band-Aid therapy ART is circumventive therapy Restorative Fertility Care is Disease based, and biologically sound

51 Catholic HealthCare... Is not primarily about what one cannot do. Instead, it maintains focus on Cooperative medicine and restorative surgery

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55 Good ethics is good medicine

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57 Questions? slucare.edu/fertility