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Good News for Patients! IVFs are Routine, Successful Procedures

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a blog by David Kreiner, M.D., F.A.C.O.G., East Coast Fertility, June 2, 2010

My son is starting his second year residency in obstetrics and gynecology. Like I was 30 years ago, he’s turned on by reproductive medicine and enjoys performing gynecologic surgery. When I decided then to specialize in reproductive endocrinology and infertility (REI), I was looking forward to being on the frontier of fertility medicine. The details of reproductive physiology were being unraveled in real time and IVF had just reported its first successful pregnancies. In those days, microsurgery of the fallopian tubes was commonly performed by REIs, as well as endometriosis and fibroid surgery.

During my fellowship, surgery was a huge part of my training. I trained with one of the world’s experts in laser laparoscopy. Each week, I practiced tubal microsurgery on anesthetized rats in a plastic surgical lab and assisted on several cases of reproductive surgery every week throughout my fellowship.

Along with my other fellows, I researched basic reproductive physiology questions that had yet to be worked out. My specific interest was polycystic ovarian disease (PCOS) and its relationship to weight gain. I studied male hormone production in the ovary and the adrenal gland before and after significant weight loss. I discovered that there was an inverse relationship between weight loss and male hormone production which was mediated through insulin. If only we had metformin back then, I would have proven that in addition to weight loss, we could decrease insulin levels and, therefore, male hormone levels with it.

Today, discoveries in reproductive physiology are much more esoteric than they were when I was a fellow. Reproductive surgery, in particular tubal microsurgery and laser laparoscopy for endometriosis and adhesions, is usually replaced with in vitro fertilization (IVF) which has become so much more successful and less invasive, it’s the preferable option. Most causes of infertility, if they are not successfully treated with ovulation induction and intrauterine insemination (IUI) can be overcome with IVF.

Today, we get excited about advances in preembryo genetic screening and diagnosis and contemplate the current and future potential of eliminating hereditary medical disorders. This involves highly trained laboratory personnel who perform the latest technologic advances. In 2010, the REI, in general, no longer has hands on involvement with the frontiers of reproductive medicine. Instead, he works like a film producer gathering his team of lab personnel, nurses, etc., directing them as to how to approach his patients’ fertility problems. It used to be that he used the microscope and laser laparoscope to perform the tubal and endometriosis surgery. Today, IVF retrieval and transfer are routine cases an REI performs daily.

My son looks at the REI of today as a doctor who starts his day with a couple hours of ultrasound that is part of the daily ovulation monitoring for IUI and IVF. Many REIs no longer perform surgery other than hysteroscopy and occasional laparoscopy or myomectomy in addition to their retrievals, all considered routine procedures now.

The current frontier in infertility is limited pretty much to the laboratory. Though many of us consider ourselves expert in stimulations, retrievals and transfers, our work does not appear or feel as glamorous as it once did.

Perhaps, my son will decide, as I did, that the pleasure in helping women build their families is sufficient reward. Or perhaps, this Nintendo generation, will seek a more apparently exciting lifestyle. Robotic surgery, anyone?

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