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
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
Good ethics is good medicine
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?
NFP-only physician? NO abortion NO sterilization NO contraception versus Fertility Care physician!!
Love & Live Connection Babies and Bonding Babies w/out Bonding : Bonding w/out Babies: In vitro fertilization Contraception
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
Contraception Abortion From the same roots
Why not hormonal birth control?
Some women are becoming concerned with the pill www.sweeteningthepill.com
FABM methods are trendy www.cnn.com
FABM methods are trendy www.kindara.com
Why not hormonal birth control?
FABM - Fertility Awareness Based Methods
Natural Family Planning v. Fertility Awareness Method
What are FAMs? Educational model - empowering Use biomarkers - prospective Either achieve or avoid pregnancy - true family planning method
NaProTRACKING a Woman s Health www.naprotechnology.com
Treatment options for infertility - ART
Modern Bypass the approaches marital embrace to infertility
The experience of ART
The need for alternatives to IVF Side effects of medication Multiple gestation - prematurity, low birthweight Birth defects Excess embryos Cost Bypasses the couple
The need for alternatives to IVF
Disease-based approach NPT v. ART NaProTechnology Seeks to evaluate and treat the underlying causes or deficiencies www.naprotechnology.com
Real Solutions to Real Problems
NPT vs. ART
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?
Cooperative Medicine and Restorative Surgery
Cooperative Medicine www.fertilitycare.org
Cooperative Medicine www.fertilitycare.org
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
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
How is endometriosis diagnosed? Per ASRM guidelines: Used to be standard part of workup for infertility. Now optional for patients under age 35.
What is endometriosis?
What does endometriosis look like?
Does hormonal treatment of endometriosis prevent progression of disease? MAYBE NOT.
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
Does hormonal treatment of endometriosis prevent recurrence? MAYBE NOT.
Recurrence rate Other published rates found 40-60% in 1-2 years after ablation. Sutton 1994 Winkel 2003...even if postoperative hormonal suppression used. Doyle 2009
Does hormonal treatment of endometriosis help infertility? NO. Catenacci, Clin Obs Gynecol 2009 Fertil Steril 2010
GOAL is complete treatment of all disease, and depends on the ability to recognize both typical and atypical forms.
This data has important implications in the overall care of teenagers, regarding a management plan for pain......but potentially more important for fertility.
Padma Lakshmi - Host of Top Chef, supermodel, and co-founder of Endometriosis Foundation of America
Early diagnosis and complete excision is the best prevention. - Tamer Seckin, MD EFA
1072 couples in Ireland, from 1998-2002, 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%.
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
Good ethics is good medicine Hormonal suppression is Band-Aid therapy ART is circumventive therapy Restorative Fertility Care is Disease based, and biologically sound
Catholic HealthCare... Is not primarily about what one cannot do. Instead, it maintains focus on Cooperative medicine and restorative surgery
Good ethics is good medicine
Questions? slucare.edu/fertility