Melanie Cole (Host): Traditionally, infertility caused by tubal diseases or endometriosis has been treated surgically but is that still the case and is it competition or collaboration that’s going on today? My guest today is Dr. William Ziegler. He’s a specialist in reproductive endocrinology and infertility, and the Medical Director of the Reproductive Science Center of New Jersey. Welcome to the show, Dr. Ziegler. What’s typically been done for women in regards to reproductive surgery? What has been the past history?

Dr. William Ziegler (Guest): The prior history with patients who have had pelvic pathology as a cause for their infertility was to proceed with surgery. We do specific screening tests, we do hysterosalpingograms, we do sonohysterograms, we do saline tubal flow studies. So, there are different tests that we can do to assess if there is pelvic pathology, as well as include their history. Over the last two decades, we have moved from doing these procedures open, or something referred to as a laparotomy, to doing laparoscopic surgery. And now, most of our reproductive surgeries are done laparoscopically. From that point in time, then in vitro fertilization has come on to the playing field, and has moved the area of reproductive or reconstructive pelvic surgery to the wayside. There’s now been more babies born through in vitro fertilization than we really have ever seen before. There’s going to over 155,000 cycles done which basically--the number of babies born through IVF now is 1.5% of the 3.9 million births within the United States. But, over the last, I would have to say the last year and a half to two years, pelvic surgery or reproductive surgery is now coming back into the forefront. Instead of it competing with in vitro fertilization to help these couples get pregnant, it’s now collaborating with in vitro fertilization patients to help improve outcomes.

Melanie: So, in the modern treatment of tubal infertility, how has technology changed that? We hear so much about different types of surgery and robotic surgeries, and laparoscopic and minimally invasive--and people don’t understand how technology has come into this place.

Dr. Ziegler: Well, technology in the aspect of reproductive surgery, it’s now become less traumatic, the complication rates are lower. In the past, we didn’t have treatments to help minimize adhesion formation from our surgeries. So, therefore, in the past, doing reconstructive surgery or reconstructive pelvic surgery actually could hinder fertility. Now, with all of the advances we have with regard to even the robotic surgery where we can do very specific suturing laparoscopically where we can actually look and find which tissue should be removed, what’s normal, what’s abnormal, has really turned our surgical technique into more a precise one.

Melanie: So, what would be some indications of primary management for women, and how do you decide who is a candidate for certain assisted reproductive surgeries versus another type.

Dr. Ziegler: We have to take a look at the patient then as a whole. We have to look at their age because pelvic reconstructive surgery is really not indicative for those that have diminished ovarian reserve, those who are older, so we have to take into account the entire picture. We also have to take into account the screening tests which have been performed, whether a patient has tubal disease, meaning they have an obstructive fallopian tube close to the uterus; far from the uterus is the tube what’s called the “hydrosalpinx”; does the patient has a history of having a prior pelvic infection like chlamydia or gonorrhea--all those play a role in determining whether we go to surgery or whether we go directly to in vitro fertilization. Also, at the time of surgery, we can define how do these tubes look and determine from that standpoint is it beneficial to proceed with more conservative treatment such as inseminations, or whether these tubes--the fallopian tubes, do they look like they may not be functioning. And, therefore, they would benefit from in vitro fertilization.

Melanie: So, are you also looking at--besides the health of the patient, what about patient preference itself or religious beliefs or cost or insurance reimbursement, do any of those come into play when you’re looking at this?

Dr. Ziegler: Definitely. A lot of patients do not have coverage for in vitro fertilization within our state. Within the state of New Jersey, we do have the mandate which basically, probably affects around 80% of all women in New Jersey, which means 20% are self-pay. In that standpoint, our surgery that we’re looking in taking care of pelvic adhesions or even treating pelvic pain, is covered under major medical. So, for those that do not have coverage for in vitro fertilization, surgery is their best option into establishing normal anatomy and to help them get pregnant quickly.

Melanie: And, what have you seen are some of the outcomes and results in live birth rates and women being able to maintain pregnancies--is there a difference that you’ve seen?

Dr. Ziegler: Yes, there have been multiple--in the past we had retrospective studies to look on. But now there’s been a lot of prospective trials. From those patients that have had hysterosalpingograms and both their tubes were blocked close to the uterus or something we refer to as proximally, around 80% of those patients, their tubes will actually be open if you repeat the HSG six months later. That’s because of tubal spasm. Those are patients that could get pregnant naturally or with inseminations, and they don’t need in vitro fertilization. For those patients that have distal disease or fallopian tube disease towards the end of the tube, and it’s just some filmy adhesions, we can actually take those down. There was a study out that showed within two years, 60% of those patients were actually pregnant and the ectopic rate was 5% which is very close to the general population rate. So, these surgeries that we do can actually help improve a couple’s chances in conceiving without going to in vitro fertilization. Now, if you take a look at how our surgery can actually complement in vitro fertilization, it really comes down to those patients that have, what are called, hydrosalpinges, which is fluid in the fallopian tube. The fluid in the fallopian tube is like a stagnant pool of water. It should always be moving, but when it’s blocked the tube becomes enlarged and this fluid sits within the tube and can actually make its way back down to the uterine cavity, contaminate the uterine cavity, and it has been shown to decrease implantation rate, and increase miscarriage rate. So, in that situation, proceeding to surgery and actually removing the fallopian tube without compromising ovarian function, has actually increased the success rates of in vitro fertilization, and it has decreased the risk of miscarriage. At the time of surgery, as I mentioned before, we can look at a tube and the tube looks open, but if it does not look healthy, if it’s very hard, it’s very fibrotic, those tubes are not going to work, and those patients would do better going directly to in vitro fertilization, and not waste any money, if they’re self-pay, going through something that’s not going to get them to the endpoint they want to which is a healthy pregnancy and a healthy baby.

Melanie: Absolutely fascinating, Dr, Ziegler. So, wrap it up for us on the role of reproductive surgery in this era of assisted reproductive technologies, and what you’re seeing as the future, and really what patients can look forward to exciting in this field.

Dr. Ziegler: Well, I think, reproductive surgery has moved from a primary treatment for infertility to actually being a modality to help enhance the success rates of in vitro fertilization. It also gives the opportunity for patients to make a decision of whether or not they want to proceed with less aggressive treatments like intrauterine insemination or do they actually need in vitro fertilization. So, I think, reproductive surgery can, basically, enhance a couple’s treatment options, and to help define what would be their next step so they are not wasting time, they’re not getting frustrated, that we’re moving them at a pace and in a direction which will get them to their ultimate goal which is to have a family.

Melanie: Thank you so much for being with us today, Dr. Ziegler. You’re listening to Fertility Talk with The Reproductive Science Center of New Jersey. And, for more information, you can go to www.fertilitynjcom. That’s www.fertilitynj.com. This is Melanie Cole. Thanks so much for listening.