Latest / LUZ musings / Dr. Will Nolan, OB/GYN Complex Benign Gynecology (MIGS), Endometriosis and Tubal Surgery

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Dr. Will Nolan, OB/GYN Complex Benign Gynecology (MIGS), Endometriosis and Tubal Surgery · LUZ musings

• riverside dr. nolan danielle j. miller' (1): A lot of times people do hysterectomies with endometriosis present and they just don't do anything about it. And so there's a good chance that a general OBG went gets trained to like see endometriosis in one or two types of forms and also not really do that much about it and I think that that's a big deal. And then there's a whole group of people who focus specifically on endometriosis. They see hundreds of cases of endometriosis. They recognize the different characteristics of endometriosis, so sometimes the lesions are very subtle. Sometimes they look like just a little fibrosis or small clear blebs. And if you don't get very close and look all over the place, you'll miss them. Okay. Hello and welcome to Lou's Musings. I'm your host, Dr. Danielle Miller. We are focusing on the people and ideas that make Lancaster County, Pennsylvania, a healthier place to live. Now back to the episode. Hello, welcome back to Lose Musings, our podcast talking about people and ideas that make Lancaster County a healthier place to be. I have a very special guest here today, Dr. William Nolan, who is a ostetrician gynecologist and specialty mix surgeon. Okay, did I say all that right? Yep, yeah, thank you very much. Yeah, so I'm a medical doctor, I'm family medicine, I am not a surgeon at all. We do a lot of women's health work at Louise in addition to bread and butter family medicine. But tell us firstly What is an OBGYN? I think a lot of people have an idea of that. What is a MiG surgeon and sort of the difference between the two? Yeah, sure. So OBGYN is a broad catch also. There's primary care, there's obstetrics, which is basically pregnancy care and deliver labor and delivery, and then there's gynecology, which is you know, care of the female reproductive tract. And again, that's very broad. So within that there's lots of different specialties and There's even multiple different surgical specialties. So minimally invasive gynecologic surgery or they're sort of rebranding down to complex benign gynecology is just basically difficult gynecologic procedures, that, you know, may be challenging to do if you have a very broad training. And so it kind of started with laparoscopy and sort of evolved a bit over time. so I'll A lot of what we do is endometriosis care. but there's all you know, difficult myomas or fibroid cases and when there's a lot of scar tissue, things like that, trying to do difficult surgical procedures, minimally invasive small incisions, better recovery, things like that. So that's kind of how the specialty started. Sort of evolving, you know, more towards advanced in Care, advanced imaging is something that's making its way into the field of it. and then just quickly the other specialties within gynecology are like there's gynecology oncology, and then there's also urogynecology, yeah, which is basically like pelvic reconstructive surgery, prolapse and things that. So cancer gynecology surgery has its own field, urine-related. public related has its own. Yeah. So benign, complex gynecologic surgery. Yeah. Okay, great. I had not heard that new Yeah it's they're trying to ha make the fellowship ACG me accredited and in doing so they had to sort of shed the MiG's name. 'Cause they didn't want the they don't want the special team named after a procedure. That's my understanding of it. That makes sense. Yeah. Okay. I I've heard MiG so many times. they were like lot of people are like, my gosh, our all of our branding is around MIGs and it's like so but Okay. Yeah. So so even within MIGs, you know, people find their niche. Mm-hmm. and a lot a lot of it is endometriosis care, but there's there's there's more than that as well. So if I'm understanding correctly, some gynecologic surgeries are very well suited to a general obstetrician gynecologist, is that right? Yeah. And can you maybe name a few of Who someone might see their general OBGYN for for surgery? What might they be looking for? Yeah, so things for I mean, at this point it's still true that some general OBGYNs are extremely good surgeons. and very high volume surgeons. as these fellowships started, there started to be more of a divide. so it can be a little tricky to parse out as a patient. You know, you think you're Going to a high volume surgeon, someone who does a lot of surgeries with low complication rate. that's not always the case. and this is a little aside from the actual question, but yeah, so that's a that's a main question you could ask someone, you know, how o how many surgeries are you doing? What sort of complications do you see? But for a what Ouija WAN who delivers your babies and things like that, most would be comfortable with the the emergency surgeries from from GYN twisted ovary or ectopic pregnancy. a lot of them we comfortable doing the cervical cancer s screening and pathway, so like leap procedures. even that like as an endometriosis specialist you know, want to be cautious because when you have a if someone were to go have a procedure like that where you think is gonna be well maybe too much. You would still want your surgeon if they have the gaming belly to sort of look everywhere and look very closely for endometriosis and endometriosis you would you need a trained eye because it's not always the classic lesions and if you c encounter them or encounter them in places where you're not comfortable operating, then you can end up with a surgery that was incomplete. So I see all the time I see operative reports there was endometriosis found near the ureter and it was left alone and so that's another question to ask a surgeon, you know, what if find endometriosis on my ureters or bowel or bladder, are you going to be able to dissect it off or Am I gonna need more surgery? And yeah, before you get into surgery. Excellent. I'm also thinking obviously cesarean section, quite a general ADN and a lot of hysterectomy cases I would imagine. Yeah. certainly the C C section and then yeah, a lot of hysterectomies, especially for like benign causes which are not difficult operations, like a smaller uterus but has adenomyosis, that's like a classic one. prolapse surgeries are usually depends on the degree and how the how often the surgeon does it. Slings and things like that. Some general OBGANs are doing those things, but again, none of these things I would say every OBGYN can do. So it's just a huge variability and it it's important to ask your OBGYN those those screening questions. Yeah, absolutely. And then when I think of a MiG surgeon or a what do we call it? Benign, minimally invasive. Complex, benign gynecologic. Complex, benign gynecologic surgeon. I'm thinking endometriosis. We've mentioned that word a few times. I would love for you to maybe define endometriosis because it can be very elusive for patients who are wondering if they have it, have heard of it but don't know what it is. This is just a basic overview. Yeah. So in general, endometriosis is when cells which are like the lining of the uterus get elsewhere in the body. And the the way that they cause an issue is as they grow with the menstrual cycle and shed instead of coming out of the body with menses, it kind of causes internal bleeding or inflammatory reaction, which can cause pain, it can cause scarring over time, distortion of anatomy. And so that's That's generally what endometriosis is in a gynecologic sense. Now we're starting to learn more about endometriosis and it has kind of like some full variety effects on the nerve system over time. And so but yeah, just the narrow answer is kind of yeah, those cells are found elsewhere. Yeah. So I always show people a picture. Maybe I can do that if you hold up your fist and you have your thumb and your small finger out as tubes, the inside of this urine lining this inside of the fist that Should come out is speckled outside, right? And so if that menstrual like tissue is having a period outside of the uterus, it's not great for the surrounding structures. Yeah, yeah. A lot of inflammation and how the immune system interacts with that is I think a big part of the pathology. but yes, that certainly a lot of inflammation and spots you don't want it. Yeah. one of the most common questions we work with at my practice is if we think a Patient may have endometriosis, which the only way to truly diagnose with surgery is by certain questions. Quantum endometriosis can be pretty well diagnosed with imaging. but if imaging is negative, it's not s to say that someone doesn't have endometriosis, so that would usually have to be diagnosed with laparoscopy. In maybe with imaging that strongly suggests a classic endometriosis fission. It can't be literally rolled out without surgery. Where should I get this evaluated? And so I'd love to talk for a minute the difference between a mid or benign complex on ecologic surgeon and a general OB, because I think sometimes it can be really confusing for patients navigating that. For sure. I think this is a really important question, obviously, 'cause, you know, I did my fellowship in this. But basically, you want your surgeon to r first be able to understand and appreciate the disease in its different forms. So I'm Regular OBGYN training, some places have high volume endometriosis surgeons and residents are exposed to that. Others don't have hardly any endometriosis training. Okay. It's not it's not a minimum for ACGME to graduate residency to see X number of endometriosis. There is no requirement for minimal laparoscopies, there's minimal hysterectomies, and usually people will encounter some endometriosis. It's not required. And so some people's laparoscopies come all from tuple ligations or self-injectomies or hist a lot of times people do hysterectomies with endometriosis present and they just don't do anything about it. And so there's a good chance that a general EGYN trained. And then there's a whole group of people who focus specifically on endometriosis. See hundreds of cases of endometriosis. They recognize the different characteristics of endometriosis. So sometimes the lesions are very subtle. Sometimes they look like just a little fibrosis or small, clear blebs, and if you don't get very close and look all over the place, you'll miss them. Okay. If you're concerned about endometriosis, you would want your surgeon to basically look everywhere in a standardized fashion so that they don't miss things. and then be prepared to do something about the endometriosis that they find, preferably remove the endometriosis. and if they're not gonna do that, you would would want to know ahead of time. Like how often people don't have access to endometriosis surgeon like and they have a surgery in a certain areas. When they're not aware that that could be you possibly that's very upsetting. If they know that we're taking a look and we're trying to get a good diagnosis and then we'll get you to the right person, it's a bit less upsetting, even though it's so a patient can ask ahead of time. Do you have a standardized approach to evaluating looking for endometriosis and familiar with all the different types? And do you remove all the end endometriosis you see? Yep. and those are usually gonna be the with what resources the surgeon has at that time. And then so if they w operate frequently with cardiothoracic surgeon or colorectal surgeon and they just have them there all the time, that's less likely. The more likely is that they'd have to either come back or if if it's seen on imaging before, then it would plan with those surgeons. but yeah, that those are Great questions to ask the endometriosis surgeon. The other thing about complex benign gynecology is that some programs don't do a lot of endometriosis surgery. Okay. So they're not necessarily synonymous. No, they're not synonymous. So some places they have very heavy uret gynecology and they they need to our minimum numbers for complex benign gynecology are usually with retroperitoneal dissection and just dissecting around the ureters and different structures. There's a minimum for hysterectomies, myomectomies, taking out fibroids. But there's not necessarily like an excision of endometriosis minimum. Even in the fellowship. And that that that might change over time because I think a lot, you know, there's a lot of questions, what makes this its own specialty that a general OBGYN shouldn't be doing these procedures? And that's why it's it's not easy to meet credit because a lot of people within general OBGN think, well, we can do all those procedures. Well some of you can do them, but it's this is what it becomes a problem because it's hard for patients to tell the difference. And so I think endometriosis is gonna might end up being one of those areas where it becomes its own sort of feel. Yeah. I would ask to talk about endometriosis of the patient. That's how much endometriosis did you see? What are you gonna do if I have endometriosis? Here, here, here. Excellent. This is more complicated than I understood. And we're working with it pretty regularly trying to send patients to the right surgeon because having more than one surgery is not ever the plan or the goal you want. If you need a surgery or you think that might be the next best step for the patient or the patient believes once and done would be optimal whenever possible. Yeah, that that's always our goal that we realize that, you know, that can be difficult. Right. Whether per the location and the subspecialties, but also, sometimes y even people who are well trained, you don't see everything and you go back, they need another surgery and feature and you see a small area of endometriosis around where where we previously cut out. So yeah. But at least that the surgery be productive, useful beneficial accomplish goal you went in with. That's I think kind of the important thing. And then the sequalia, what comes next with endometriosis, that's a mixed bag. So if you do enough endometriosis surgery, you'll see patients where you removed a bunch of endometriosis from a specific area and the patient gets it back in that area. That's more rare. Yeah, but it does happen. And so it is it's just it can be a tricky ch it can be tricky. To treat. Do you think that recurrence is less likely if someone is well trained in right fall? Yeah. Yeah. So that's another encouragement that if someone is moving forward with surgery to choose the right person, to at least improve their odds. Exactly. Yeah. Okay. Has this episode gotten you thinking about an aspect of your own health or the health of someone you love? Are you interested in learning more about the approach at Lose Medicine and how we help our patients? Lose Medicine is a medical office here in Lancaster, Pennsylvania with locations both in Afrida and Manheim Township. Patients can choose which location they want to join when they become a patient at Lose Medicine. Our office has two main focuses. Firstly, we provide primary care for men, women, and children in all ages and stages of life. And secondly, we offer additional services for hormone health for those who are interested. Whether patients come to LOES for their primary care or a specific hormone focus, the tie that binds Is the same. We listen to our patients and provide exceptional medical care. Our holistic approach puts you at the center of your journey, where we are here to support you in your best health. To join our practice, check out losemedicine.com, that's luzmedicine.com, where you can learn more about our practice and sign up directly online. If you have any questions, we're here to help as well. We would love for you to be our very next patient at Lou's. We talked about imaging a little bit. I just want to clarify. What imaging are we talking about? Pelvic ultrasound, MRI, what are we likely to see? Yeah. it depend it's gonna depend regionally. we're imaging in for endometriosis is rapidly improving. which is great. Yeah. So where I trained the imaging was amazing, really cutting edge. and so that's like an endometriosis mapping ultrasound. So they can test the mobility of the uterus, they can test the mobility of the bladder in the rectum, the mobility of the ovaries, they can look for endometriosis on the on the rectum, on the uterus sacral ligaments, superficial endometriosis even sometimes can be seen with a right yeah. and so that's amazing. I that's my preference. but there are also MRI. the MRIs for endometriosis can be really good as well. but they usually use specific protocols and then you would want the radiology team to be familiar with endometriosis and looking for it. So we sometimes you'll see if you're you know, if you're doing a lot of endometriosis care, you'll see people with four or five centimeter nodules of endometriosis on their colon, which are not red on the MRI. Yeah. Yeah, the MRI will be like they have three fibroids and their uterus is this measurement and this and that. And then if you introduce yourself, you can see this big mushroom cap in the bottle. And so not all sonographers or not all, Radiologists are always looking for it too until ask that if your patient is, do you do any endometriosis mapping ultrasounds? Do you have any endometriosis protocols for MRI if I'm getting an RI? Or will the s will the radiologists are they trained to read for superficial plaques or Nodules in the bowel. And the patient is asking that question to their potential endosurgeon. Yeah. Because that person's probably ordering a specialized study. Yeah. Okay. Or if they're seeing a general OBG plan, they'll be asking those questions and then they'll get a vague a vague. They're like, well. So people that do NFK are usually very clear of what is and is not going to happen as a result of a study and how that's going to be done. That's my that's my hope. Yeah. You know, sometimes like if you have a toll Totally negative study or and the patient knows that they're wanting to do laparoscopies and remove any if there is superficial, then it's it's okay. Probably you know, you don't have to have absolutely perfect imaging in every single situation. But personally, I think if someone has no pathology, they have endometriomas, kissing ovaries, stuff like that. You should probably have some sort of advanced imaging to plan the surgery. Okay. But again None of the images are fully gonna rule out superficial fundamental. So if a patient has red iron imaging and but they still want to go looking at surgery, then it can be okay for them to not have advanced imaging, especially if the the resources are not available. But someday hopefully everyone will have an endosonographer in there. That would be amazing. I have a few more questions. I'm just wanting to make sure we're all clear. when you mention sort of Ma maybe an endosurgeon looking at these missions. Would that be something that you and your teammates are doing sometimes? If you have an MRI. ultrasound. You're looking at the report meaning what the radiologist writes about the organs, but also you're looking at the pictures. Yeah. the the report is like a primer for us. It's like they bring you your drink at the restaurant. And then and then yeah, you pull up the study and you should look through it. And that might be another thing a patient could even say, are you an endosurgeon and how do you approach this? And do you look at pictures yourself? Yeah. And that might be a nice differentiator. Yeah. Okay. And s I mean I see this yeah I see this very like ismosil is one of the things. I've seen multiple patients with secondary infertility just recently and there's no nobody ever looks at seem seemingly nobody ever looks at those on the ultrasound, but I pulled up the images and I could see it was like a uterine dehiscence basically. And it wasn't read for all the years that the patient was like going under treatment for different things. Wow. So yeah, it's important to read to look at the pictures. So you're supposed to be all media. cut where someone has the serine section that has not stayed fully closed. And so you're looking at the uterus on ultrasound and saying, Wow, there's this area that's a part. Yeah. But no one ever noticed it and wrote it down. Exactly. Yeah. Which sounds hard to miss. Well yeah, I mean and so that's the thing, like the well a lot of what this if we do an ultrasound, a lot of times they're looking at the uterus and uterus measurements for any fibroids, the ov the ovaries, if there's any cysts. And that's like, you know That's the basics which a lot of people get. And so Okay. for a lot of what we treat you wanna you wanna dig in a little bit closer. Awesome. Yeah. Very awesome. I can say at Lou's we're generally ordering a public ultrasound before we send someone to the surgeon. But I'm excited to know that some of our surgeons are looking at pictures themselves. Yeah. yeah. and I know occasionally I would say it's I don't notice commonly that somebody has an MRI after they see the endosurgeon. Would you agree that that's less common? In this region, yeah. I think so. I think they're used very frequently for mapping fibroids before a surgery. Okay. but yeah, not as much for endometriosis here. But there are areas of the country where they're doing nearly no ultrasound and they're doing mostly MRI for and they have multidisciplinary teams, meaning the surgeons meet with the radiologists monthly. Or twice monthly and do case reviews. And so those places they get very good at endometriosis identification. Wow. Okay. Which in some ways I'm not sad that we're not doing it for that. It's a very pricey study. Yeah. is the specialized because we are ordering a basic routine called with ultrasound moves for a patient that we suspect secondary due to the infertility status or maybe pelvic pain without or with infertility, either way. We're doing a routine called the ultrasound, but you're talking about these specialized endo ultrasounds. Is that the same cost and can everyone do it? I think we only know of one person that's not everyone can do it. So the sonographer has to be trained, the people who are reading the study have to be trained. I think I wanna say the cost is probably similar. Okay. but don't quote me on that. Yeah. That probably has regional. No, no, no, no, then Yeah, the but the scenographer has to have different training. That's the main Yes. Yeah. Okay. Perfect. This is exciting. Yeah, yeah. I'm hoping that this over time becomes a more of a standard like in South America, Central America, they're very good at some places in Europe. So everyone's like I get a patient from South America and they have an ultrasound report and it says all these things that we don't get here and it's like, wow, it's really cool. So that is very cool. Okay, exciting. So let's say the patient Has a high suspicion of endo either by history meaning what they tell the doctor or you know by imaging. can you talk for a minute just about distinguishing walking with your patient? Should they have surgery, should they not have surgery? Maybe it's there's some infertility, maybe there's pain. just that is just if they have if they have negative imaging, you said, or either way. Either way. Or suspecting by either what they tell us or by imaging, we're suspecting they likely have endo. Yeah. How do you help them make that choice? I know that that decision a lot of patient styles is very hard to make. Yeah. That's a great question. I think the so their goal you want to find out what their goals are. and you know, a lot of therapies for pain specifically, will cause infertility or shut down the menstrual cycle. so that autom if someone has pain and they have and they're trying to become pregnant, you know, it narrows down some of the treatment options. there's still a lot of options, but so that's one thing. pain, you know, we really try to see how well it correlates with, you know, certain events, ovulation or the period. What I tend to find is if someone has constant pain all through the month, there's a good chance that along with endometriosis they may have some centralized central sensitivity to pain basically. And so in those cases, maybe theoretically they might not get as much relief as we're saying, well, people have pain that's very well correlated to the menstrual cycle. We might have a little bit higher hopes for good pain relief. Both in the studies have shown both groups get some pain relief. so it's not that the people have pain all the time don't get any pain relief. But some of those pains that are don't seem very tightly correlated with the cycle, So that that's one thing. A lot of the studies show on average when you remove endometriosis, the pain goes up on average of seven in the cohort down to about a three. Okay. So that's not nothing. No. Yeah. What I try to impart to the patients is that if you have surgery, you're going from usually like you're missing work, missing school, laying in bed to back to what your friends might experience where they could like take a motrin and have a regular day. Okay. So that's kind of like the goal, but it usually full elimination of pain is not something that we see. Okay. and then with fertility, that also depends on the goals, but we know that the removal of endometriosis should improve fertility. Mm-hmm. and so it's in in my opinion, it's a very worthwhile box to check. you know, as doing restorative reproductive medicine is a little bit different than what the maybe the REI colleagues would be recommending to people. So you know, we recommend looking at that as a possible contributor to fertility, infertility, subfertility, and addressing it to optimize fertility. whereas that may be skipped over i in favor of assisted reproductive technologies when talking to a reproductive endocrinologist. Okay. So the there could be endo present and the two approaches that the patient and their medical team can choose from would be ART or IBF or IUI related procedures to help them conceive pregnancy in the U.S. one manner versus reducing, removing, improving other underlying pathology, underlying problems with the body and helping them get pregnant the old fashioned way, if you will. Yeah, that's the binary look at it. There is this group in the middle where there are a lot of reproductive endocrinologists who do take endometriosis seriously and, don't try to fully bypass it. We know if you remove endometriosis, it improves success rates of things like ART. Yeah. So, it's not really like a one or the other per se. but just in clinical practice we tend to see that where there's like There's large fertility groups who are just like do things the same way every time and endometriosis doesn't even seem to be on the radar. Yeah. That's at least my what I see in clinical practice. Yeah. I remember reading a review article, a number five ten years ago, in JAMA talking about best practices within fertility. And out the gate early in the article, it said endometriosis has a high likelihood to reduce fertility and the treatments offer ART IV. which is confusing because endometrios endometriosis removal is of often cheaper and might improve quality of life versus this high cost procedure that may not necessarily improve quality of life. Yeah, it's just like, you know, one one treatment isn't actually addressing the actual it's very focused on getting the patient. Which is a is what a lot of people want. So not to ignore that. But there are a l large group of patients who want to feel better and have the opportunity to conceive without ART. Yeah. Interesting. And I appreciate I agree it's not just binary, right? And there's a lot of grey and I find patients they feel sometimes they're walking on a tightrope. They don't know what to do. They feel like they have to make this decision. Yeah. I think in that scenario. I find out my role is to just educate the patient on their options and you know, allow them to make a decision that works best for them. I think the most the The thing where doctors start fighting with each other is when you know the doctor just telling the patient that you can only do this, only do this without any consideration. Yeah, yeah. Right. So I think there's multiple reasons or multiple reasonable approaches to these things that the with the right information the patient can have optimity and choose what works best. Yes, the patient can choose. I love that. that's exciting. Talk to us a little bit more, Dr. Nolan, about I know you have additional expertise in and around complex ovarian pathology surgery and also tubal. and that's we find for our patients who are perhaps trying to recover and remove any pathology, any problems with the body. They are not interested perhaps in IBF or ART or I. Sometimes tubal and ovarian pathology come up and not many doctors have that experience. Yeah, so basically, you know, working del working delicately with these structures and trying to, prevent any sort of harm from them or the the ovary you know you can lose eggs when you're operating on the ovary and overall decrease fertility in the tube, you know, once a tube is damaged, it can be very difficult to fix. and so, you know, I have a particular interest, especially in tuple surgery. There's when ART grew, they're the interest in tubal surgery decreased. So a lot of people, you know, didn't didn't do tubal surgeries, don't know about tubal surgery. so I was able fortunate to be able to write a book chapter for a mixed textbook recently about tubal surgery. And there are good well done studies. They're old now because people aren't doing this so much anymore. So just because a study is was done a while ago doesn't mean it wasn't well conducted, but you know, studies showing that certain tubal scar tissue or a hydrocell pinx can actually be relieved in a lot of cases. And so being able to offer that to people who, you know, would like to to have that as an option. whereas most of the time these patients are told, well the tube needs to be removed and you have to do ART and if if that's not an option for them, you mean you know that's only option you're presenting to someone who isn't going to do that, well that's not re optional. So being able to do those surgeries but also kinda make other people aware of them. And I've done some surgical videos training other surgeons how to do them. I worked with like a surgeon in Alaska. the patients didn't have access to ART there, but they wanted to try something and so sent her the like the instructional videos and discuss, you know, how to do these and Yeah, that's a big a passion of mine. Something that want people to have access to. this one patient from Fellowship who bilateral control type. Remove them and do ART while they were fixed and she got pregnant and she can have however many children she wants to have. Right. Just like we're ordinarily unable to and not have to do all the rounds and embryos and the putbacks and you know. So because I think too when people are First encountering an infertility journey, it's always they've always thought, well, if I can't get pregnant, I can do IVF and have a baby, but they don't realize how intense IVF is and that it doesn't always lead to a baby. So but can be a lot and it's nice if they have a sim a relatively simple pathology that can be managed otherwise. There are there are cases where the tubes are very damaged. And they can't be fixed. I don't want it to sound like every tube can be matched. Sometimes the tube is too damaged to really fix well. And the topic pregnancy rate and pregnancy rate start to match each other, which is not a good not a great spot to be in for a patient. Right. So if a tube can be fixed back to health, that is an option. Sometimes I guess hearing that it may not be able to be fixed and then the patient. Yeah. blocked tubes, you mentioned retinalization surgery meaning rotor rooter opening the tubes, if you will. tetrosalpinx I know what that means, but can you just define that? So hydrosalpinx is when the end of the tube, which is near the ovary and is kinda supposed to pull the egg in, it gets scarred down and then the there's n natural fluid that's made within the uterus and the tube it fills up. So it's like a w water fluid filled tube because of the scar tissue. So basically you release the scar tissue and then you fold the end back open with the permanent suture and it can allow the To to function again. Awesome. Yeah. opening it and stitching it down like a flower almost. That's very cool. I never heard that described that way. Very cool. So instead of having a water filled tube, then your tube is patent or open again. Exactly. And so the there was a study that came out that said basically if someone has a black tube, it decreases the success of the I think that's because of fluid that's stuck in tube is toxic to the embryo and it affects implantation. So theoretically if you fix the tube. it won't have that toxic fluid anymore. And so patients like let's say they already had embryos or something, like it would if single food could improve sick test essentially with IBS. That hasn't been well studied. but And after it's repaired, the patient should still get to benefit whether or not they choose to try to conceive naturally or with ART. Awesome. Yeah, I was just talking to an REI doc recently about exactly that and her seeing some success for the rare surgeon in her area who does reduce hydrosalpinx. Yeah. That it's increasing odds in patients. awesome. Talk to can you mention we talked about blocked tubes and the hydrosalpinx, water filled tubes. Is there any other Yeah, I think in restorative reproductive medicine there's probably just a bit or also in infertility surgery for RIS anyone who's trained for fertility surgery specifically, there's a big focus on adhesion prevention. So adhesion prevention is very important. Adhesion prevention is also very difficult to study. So basically in order to adhere scar tissue. Scar tissue, yeah. So to prevent scar tissue on surgery, you want to do that so that the anatomy is preserved and the patient expenses. Function properly. to know if someone forms scar tissue, technically you'd have to look back. with surgery. And so to get a study approved to look for adhesions is unlikely to happen because with a review board and it just for the patient. Or over time there has been some but there's not a whole lot. And then adhesions themselves is not really the outcome. That you're interested in you're really more interested in either persistent pain or fertility. Yeah. Pain and fertility are both multifactorial. They can be due to multiple different things. So studying that endpoint, getting enough patients and and then trying to say, well, it's due to adhesions or not is very difficult. Yeah. So well what do we do then? Well, we wanna the first the best thing for adhesion prevention is surgical technique. So you want to have minimal blood, frequently, making sure you have hemostasis 'cause the blood we know can cause adhesions. Minimal char, same thing. You wanna delicately handle the structure so you wanna rip or pull things. and then afterwards, you know, there's thought of maybe using adhesion barriers. and There's different techniques like suspending the ovary if there's operations aside. Well, and on the ovary sometimes you put a dissolvable suture in the ovary to keep it away from that area for the first couple of weeks while the tissues are healing. Interesting. There's some people who are starting to be interested in using PRP for adhesion prevention. plasma rich platelets, right? That you draw the patient's own blood, spin it down, and then reinject the patient with part of their own blood to decrease the pollination. So there's no human studies on this. Yeah. so it's all it's experimental. and then some people use different fibrin products, which again the studies there's not great studies on any of this stuff. So it's a little bit like the Wild West, the main thing is So if you're having if you're in fertility, you probably want to ask your surgeon, what are your how do you, you know, prevent adhesions? And then they should at least be able to talk intelligibly about those things. Yeah. That you that you want to have the sense when talking to your surgeon that they've thought about this. Yes. And that they're gonna you know, try hard to prevent adhesions. Excellent. if someone has had Obviously their tubes removed, which is the new tube ligation is removing tubes, that's gonna reduce their natural fertility. But if they had an old fashioned tuple ligation, can tubes be repaired in that way? Yeah, they can. It depends on a bit on how the tube was ligated and so that would be like if it was excessively burned through the whole tube, success rates are lower. Uh-huh. If they cut out a huge portion and there's not enough to repair, sometimes you don't really know that until you get into the surgery. but if it had pretty much like a roll of the mill where they tie the tubes and then they cut part of it out, those oftentimes can be repaired with pretty good success. You see the success of that decrease with age, which makes sense. It's just a age related job of fertility. But for young patients who've had pregnancies before and have no other causes of infertility, it's a more cost effective option than doing ART. If you are a business owner, leader, or HR teammate at your organization, we should talk. Lose Medicine partners with several businesses of all sizes to serve your employees in their health. For a reasonable monthly fee per patient, your teammates have access to the full array of services at Lose Medicine, where we provide primary care, urgent care, and low cost ancillary services such as lab testing. Small businesses, mid sized businesses, self funded businesses, and those offering commercial insurance are all benefiting from direct primary care to their employees in Lancaster County and beyond. Direct primary care as a Benefit to your team helps create stickiness with your employees, keeps them healthy with less time out of work sick, and may help save your organization money. If you've been trying to figure out how to improve benefits for your team, offer something at all in the healthcare space, or show your teammates you truly care for their well-being, direct primary care may be the solution. Contact us today to learn more. Go to losemedicine, that's luzmedicine.com and reach out to us directly. We look forward to learning about your organization and seeing if we can be the partner to serve your teammates in their best health. And is there any other tubal pathology you can think of that you might be working with patients on? Yeah, well one thing is endometriosis. So people say But I I notice that patients never ask what are you gonna do if you find endometriosis on a tube? Well tube is tricky to treat because you don't want to use too much energy there because it can damage a tube. Meaning you don't want to use like coagulation or anything. But the tube's also somewhat vascular. So you if you start cutting things out without energy, you can bleed have bleeding. Interesting. So you don't want to start, but you don't want to let it bleed. Yeah. And so you wanna get a sense for if you find endometriosis on my tube, do you have a skill set or knowledge to fix it or will you just remove the tube? And surgeon will yeah, they should they they should tell you the truth. Okay. I guess I haven't thought too much about endo with the tube. Yeah, so oftentimes people will just take the tube out and then they'll say there's too much endo there. And it it's true that you want the endo gone because that's a pain driver and fertility driver, but do you really want the endo gone if it's means you're gonna lose the tube or if both tubes have endo. So we'd love to hear that they have some sort of strategy for removing it without damaging the tube. Interesting. Any Anything else around anything on the Yeah, this the other things for tubes would just be like any scar tissue on the tube. And then yeah, the proximal tubal occlusion. those are kind of like the main things we see. with the ovaries, maybe talk a little bit about pathology you're working with there. I think of endometriomas or cysts, but yeah, like the main things we'll see are endometriomas, dermoid cysts, different type of ovarian cysts. And endometriomas are endometriosis tissue on the ovary. Yeah. And so those if you're having surgery you'll usually want them removed or for like smaller endometriomas, there's two different therapies that work pretty well, which are not like classic excision. There's a argon beam where they basically coagulate it, the endometrioma. It's effective at keeping the endometrioma away, but it's probably better as far as not losing extra eggs because it has a very low depth of penetration. So you drain out the cyst and then you coagulate. You basically might burn destroy yeah, you destroy the cyst wall. But it doesn't go deeper then. Yeah, it doesn't go deep and kill the eggs, yeah. We know if you kinda really try to pull out these small endometriomas, you end up damaging other parts of the ovary. Interesting. and so yeah, that So that's one option. Then there's one where they put a concentrated alcohol into the endometrioma and it can do the same sort of thing. Wow. Yeah. Yeah. Yeah. So those are options that you may hear not a ton of people are doing those. a lot of that's in Europe, where those studies came from. But they're those are also good options. Okay. And then for things like dermoid, teratomas, things like that, it's mainly just you want Energy in the ovary. You want to gently remove the pathology from the ovary. Yeah. And then there's some debate about closing the ovary. Over you want I prefer to fold the capsule in a tiny bit so that there's not raw bleeding edges. Yeah. And that can help prevent it from sticking either to the tube or the sidewall. Yeah, and deremoin teratoma just a benign invariance. They can be pretty large, but they're not dangerous, not cancerous, they're just in the way. Yeah. Which we think can impact fertility because it's taking up space and impact of the Apart from each other. Yeah. interesting. There's paratubal cysts are another thing. They're very common. and there was one study that showed that there was sort of increase in people who had unexplained infertility and that when they were treated or removed the the pregnancy rates were improved. It's a small study that hasn't been like rigorous rigorously studied, but probably the tubal distortion or pulling the fimbria away from the ovary. So those can be treated at surgery. So parents will only Near the tube cyst, which is just a fluid filled sac, right? And I am not aware you can't see those ultrasound, right? Or can you see Sometimes you can't pass things. Yeah, sometimes they'll look just like a follicle and well trained sinographer, they can push on the ovary. And if the cyst slides separate from the ovary, they can tell it's a peritual cyst. Well, so we need those specialized ultrasonographers. Yeah. But getting those getting those out during surgery as well. Yeah. That would be part of a comprehensive approach. Yeah. Awesome. Anything else Yeah, off the top of my head, just the main thing is just you want to be very gentle with those tissues. As pristine as possible, it's kind of like the biggest thing with that. I was always spot I again. No surgical training. But even just pressure onto the lesions, pushing, pulling, pressing, you know, all those things create like a super glue effect, right? Yeah. Which is not the goal. Yeah. I wouldn't use as scary of a word, but yeah, no. Yeah. You you don't want to destroy the cells basically and then have that inflammation there. This certainly can lead to the adhesion. So yeah. Awesome. Well, I'm super excited. I appreciate your time so much. This is so helpful. Yeah, this is fun. And I know some about this, but again as a non surgeon, I don't know a ton, so I feel like I learned a lot today. Cool. Anything else that you want to tell on because you know the theme I should ask the theme of the podcast is the people and ideas making Lancaster County healthier. So anything to say about health in regards to benign gyalogic disease, endometriosis, words of encouragement for our audience. Yeah. I think one thing that I would want people to know is like it's as a patient, it's very important to advocate for yourself. it can be very intimidating to be talking to someone who's gone to school for a long time and you think they might be wrong about something to speak up. and I had a s just a little tangent if I can, but when I was a teenager I broke my wrist playing lacrosse and in the next basketball season it fell the same way and injured my hand and they didn't take the picture of the bone, the skateboard bone the second time and I asked the ER physician, How come you didn't take the skateboard view? And he's like, You want to know why? Because it's not broken. Just like just that to me. And I was like, Yeah. And so I played the rest of my basketball season with my wrist taped and everyone's like, your shooting's off, you need to take the tape off the wrist, all this stuff. And I was at the end of the season it still hurt. So before la crosse I got another I got a C T and they sh it was broken the whole time. And you didn't know. Yeah. And so so h you know, him putting me down like that really like I I was afraid to advocate for myself. So I recently had a patient who I I was reading their pathology report and I like, well, I didn't think there was endometriosis there. And they're like, Can you take another look? Because when the second path you know. And so I was like, sure, I looked it up and I like, Yeah, you're right. Had and so had she not had the guts to say something to me, I would have thought maybe she had less disease than she did. And so with pelvic pain or you think something's wrong, listen to your body, you know, like you patients know what's going on. And if they really think something needs to be investigated and they understand the risks of investigating it, they they should advocate for themselves. So amazing. I love that. So we're all just people, right? Doctors may make mistakes, doctors might need to be reminded or asked a question. That's not bad. No, there's we used to get these charts, there's so many tabs and there's so many pieces of information that we could potentially miss. So if you think your doctor's missing something, just say, Hey, did you d I happen to see this in my chart and usually, you know, hopefully the doctor is has humility and they say, no, and then they go look and they're like, okay. Well that changed. So I forgot to ask you for this because of that. So Amazing. Yeah. I am so grateful. Dr. Nolan, thank you for your time. Yeah, thank you, Pat. Thank you for everything. We appreciate you and we'll see you again, guys. Thank you so much for spending time with us today. We are grateful for you and hope this episode got you thinking. It's important to remember that the content provided in Lou's Musings is not considered medical advice and no doctor-patient relationship is ever formed by listening. Additionally, the ideas and opinions represented on the show and its guests are not endorsed by Lou's Medicine exclusively, and we welcome thinkers of all kinds to engage with us and our audience so that we can all learn together. Once more, thank you so much for joining Lou's Musings. Feel free to share with a friend and until next time we are wishing you the best in health always.