KNOW YOUR SPE­CIAL­IST…

Re­pro­duc­tive En­docri­nol­o­gist

Wellness Update - - Esophageal Cancer -

Not be­ing able to con­ceive can be an emo­tional drain on a cou­ple. Reach­ing out to an in­fer­til­ity spe­cial­ist is an im­por­tant step in grow­ing a fam­ily. Tak­ing that step should in­clude the help of a med­i­cally trained and qual­i­fied In­fer­til­ity Spe­cial­ist.

What To Look For In An In­fer­til­ity Spe­cial­ist.

A med­i­cal spe­cial­ist who treats pa­tients with in­fer­til­ity is known pro­fes­sion­ally as a re­pro­duc­tive en­docri­nol­o­gist. Train­ing in re­pro­duc­tive en­docrinol­ogy re­quires four years of col­lege fol­lowed by four years of med­i­cal school. The physi­cian must then com­plete a four-year res­i­dency in obstetrics and gyne­col­ogy (OB/GYN), dur­ing which the physi­cian re­ceives broad train­ing in gen­eral Obstetrics and Gyne­col­ogy. The fi­nal course of train­ing is a two or three-year fel­low­ship in re­pro­duc­tive en­docrinol­ogy. Fel­low­ship train­ing fo­cuses on the di­ag­no­sis and treat­ment of in­fer­til­ity and re­lated dis­or­ders. This train­ing in­cludes ex­pe­ri­ence in mi­cro­surgery, la­paro­scopic and hys­tero­scopic surgery, in vitro fer­til­iza­tion-em­bryo trans­fer, sonog­ra­phy, and ovu­la­tion in­duc­tion. In ad­di­tion, the physi­cian spends a sig­nif­i­cant amount of time per­form­ing clin­i­cal or lab­o­ra­tory re­search.

Upon com­ple­tion of a fel­low­ship in re­pro­duc­tive en­docrinol­ogy, a spe­cial­ist seeks board cer­ti­fi­ca­tion-a multi-step process. To be­come board cer­ti­fied in re­pro­duc­tive en­docrinol­ogy, the physi­cian must first ob­tain board cer­ti­fi­ca­tion in obstetrics and gyne­col­ogy. This re­quires suc­cess­ful com­ple­tion of both a writ­ten and an oral ex­am­i­na­tion. Board cer­ti­fi­ca­tion in re­pro­duc­tive en­docrinol­ogy re­quires suc­cess­ful com­ple­tion of ad­di­tional writ­ten and oral ex­am­i­na­tions. The en­tire cer­ti­fi­ca­tion process takes sev­eral years to com­plete. Only a physi­cian who has suc­cess­fully com­pleted a fel­low­ship in re­pro­duc­tive en­docrinol­ogy and passed the ex­am­i­na­tions can be­come board cer­ti­fied as an in­fer­til­ity spe­cial­ist.

It can be dif­fi­cult for a pa­tient to de­ter­mine whether or not her physi­cian is an in­fer­til­ity spe­cial­ist. Some physi­cians have gained skills through ex­pe­ri­ence out­side fel­low­ship train­ing, and some physi­cians suc­cess­fully com­plete fel­low­ship train­ing and do not ob­tain board cer­ti­fi­ca­tion.

How­ever, board cer­ti­fi­ca­tion is the only ob­jec­tive cri­te­ria by which pa­tients can mea­sure a physi­cian's qual­i­fi­ca­tions.

Fe­male In­fer­til­ity

In cou­ples, about 50% of in­fer­til­ity is­sues are be­cause of the fe­male. Fe­male age is a very im­por­tant com­po­nent of nat­u­ral fer­til­ity. Apart from this, fe­male in­fer­til­ity can be caused by ovu­la­tory dys­func­tion (anovu­la­tion), tubal/uter­ine and peri­toneal fac­tors and other un­usual or un­ex­plained fac­tors.

Male In­fer­til­ity

About 30% of in­fer­til­ity in cou­ples may be due to the male while an­other 20 per­cent of cou­ples in­abil­ity to con­ceive may be due to com­bined male and fe­male fac­tors. A fer­til­ity doc­tor usu­ally col­lab­o­rates with urol­o­gists to en­sure fast-track eval­u­a­tion and man­age­ment of the male part­ner, which in­crease treat­ment success rates.

Fer­til­ity Pro­mot­ing Surgery

Many of the fer­til­ity pro­mot­ing surg­eries per­formed by In­fer­til­ity Spe­cial­ists are min­i­mally in­va­sive surgery tech­niques al­low­ing the dis­charge of pa­tients on the same day with­out re­quir­ing an overnight hospi­tal stay. Th­ese tech­niques in­clude la­paroscopy, hys­teroscopy and mini-la­paro­tomy. Some surg­eries, such as mul­ti­ple my­omec­tomies, are per­formed through a larger ab­dom­i­nal in­ci­sion re­quire a 24 to 48 hour hospi­tal ad­mis­sion to al­low the physi­cian an op­por­tu­nity to ob­serve and sup­port ini­tial re­cov­ery

La­paroscopy:

La­paroscopy has be­come one of the most com­mon pro­ce­dures per­formed by sur­gi­cal spe­cial­ists. Physi­cians use la­paroscopy for re­moval of ec­topic preg­nan­cies, treat­ment of en­dometrio­sis, as­sess­ment and re­moval of ab­nor­mal ovar­ian masses, ovar­ian drilling to in­duce ovu­la­tion in clomiphene re­sis­tant pa­tients with poly­cys­tic ovary syn­drome, eval­u­a­tion and treat­ment of tubal dis­eases, treat­ment of scars, re­moval of small uter­ine my­omas and more. It in­volves cre­ation of pneu­moperi­toneum with CO2 gas to dis­tend the ab­dom­i­nal cav­ity to ease ex­plo­ration and place­ment of a spe­cific tele­scope (a lens and a light sys­tem) con­nected to a video cam­era into the ab­domen, mostly through the belly but­ton. This site usu­ally re­quires 5-12 mm in­ci­sion. The sur­geon may need one to three 5 mm in­ci­sion sites in the lower ab­domen to in­tro­duce la­paro­scopic in­stru­ments to ex­plore or to per­form rel­e­vant sur­gi­cal pro­ce­dures.

Hys­teroscopy:

This is a min­i­mally in­va­sive pro­ce­dure for eval­u­at­ing uter­ine cav­ity and treat­ing var­i­ous ab­nor­mal­i­ties. It in­volves a specu­lum place­ment to ex­pose the cervix for tran­scer­vi­cal place­ment of tele­scope (a light and a lens sys­tem) at­tached to a video cam­era sys­tem into the uterus. Hys­teroscopy is an ex­cel­lent di­ag­nos­tic tech­nique for po­ten­tial ab­nor­mal­i­ties de­tected in screen­ing tests like sa­line in­fu­sion sonog­ra­phy or hys­teros­alp­in­gog­ra­phy. In ad­di­tion to its di­ag­nos­tic value, it serves as an ef­fec­tive min­i­mally in­va­sive treat­ment for ab­nor­mal uter­ine bleed­ing, en­dome­trial polyps and fi­broids, prox­i­mal tubal oc­clu­sion, some uter­ine ab­nor­mal­i­ties like uter­ine sep­tum and in­tra-uter­ine scars.

Tubal Re­ver­sal:

To see the walls of the en­dome­trial cav­ity and its cov­er­ing cel­lu­lar tis­sue (en­dometrium), a dis­ten­tion me­dia, mostly nor­mal sa­line, is used. Although there are hys­tero­scopic sys­tems, which can be used at an of­fice set­ting, many op­er­a­tive hys­tero­scopies may re­quire am­bu­la­tory surgery cen­ter fa­cil­i­ties. Tubal re­ver­sals are per­formed as an out­pa­tient pro­ce­dure. The pro­ce­dure is done through a mini bikini in­ci­sion un­der loop mag­ni­fi­ca­tion uti­liz­ing mi­cro­sur­gi­cal tech­niques. The pa­tient may start try­ing to con­ceive within 2-3 weeks of surgery fol­low­ing the pa­tient’s com­plete sur­gi­cal re­cover. If the cou­ple can­not be­come preg­nant in 4-6 months, a hys­teros­alp­in­gog­ra­phy (HSG) may be nec­es­sary. Af­ter a suc­cess­ful tubal re­ver­sal, cu­mu­la­tive preg­nancy rates in the year fol­low­ing tubal re­ver­sal pro­ce­dure are in the 50-80 per­cent range. Sev­eral clin­i­cal char­ac­ter­is­tics are as­so­ci­ated with the high success rates for tubal re­ver­sal: • Pa­tient un­der 40 years of age • Tubal length af­ter tubal re­ver­sal greater than 4 cm • Pre­vi­ous ster­il­iza­tion by Fal­lope ring, clip or Pomeroy type

(most post­par­tum tubal ster­il­iza­tions) tubal ster­il­iza­tion • Ab­sence of as­so­ci­ated pelvic pathol­ogy such

as en­dometrio­sis, se­vere pelvic scar­ring • Ab­sence of male fac­tor in­fer­til­ity • Ab­sence of other fac­tors like anovu­la­tion

My­omec­tomy:

Fer­til­ity may be com­pro­mised by the pres­ence of my­omas (fi­broids) dis­tort­ing or press­ing or grow­ing into, the uter­ine cav­ity. Th­ese mostly be­nign tu­mors may need to be re­sected while min­i­miz­ing ad­di­tional harm to the uterus by la­paroscopy or hys­teroscopy or via an open ab­dom­i­nal in­ci­sion.

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