Hi there everybody. Our next webinar is Feb 28th, on the topic of Bowel Endo. It should be a good time.
Someone asked about progesterone, and what effects it has on endo. It works in 2 ways, really. Progesterone suppresses ovulation and the normal cyclicity of the ovaries. This reduces estrogen production somewhat, and typically stops menstruation (amenorrhea is the term we use for no periods). Progesterone also is able to induce atrophy of endometriosis and endometrium, both by a direct effect on the endo cells, and by lowering estrogen levels. Typically, synthetic progestins are used rather than bioidentical progesterone, due to easier absorption and a more pronounced effect to suppress the endo cells.
There are 2 problems with progestins - they don't always work, and about 10-15% have side-effect issues. They don't always work because some women have irregular bleeding while taking them continuously, and some women just don't get any pain relief from them. The side effects can be weight gain, moodiness, depression, and the irregular bleeding stuff. This has led to alternate forms of progestins, specifically an iud containing a progestin. This eliminates the systemic side effects, and works great for women with menorrhagia (heavy periods), and has been used in women with endo with some promise.
It's hard to compare the studies of birth control pills, progestins alone, and lupron because they don't use the same outcomes. Most studies show somewhere around 85% of women having some degree of pain relief from any of the above, but how much relief is anyone's guess. They don't publish that info. The good news is that for women who get relief from progestins, they are safe to take long-term, cheap (relative to lupron or surgery), and readily available, and generally a whole lot more tolerable than Lupron and other drugs of that category.
Somebody else asked about polycystic ovaries (PCO). That's a loaded question, as there are some unanswered questions yet about the best way to treat those women. PCO is a syndrome where there's too much estrogen floating around and that messes up the feedback mechanisms so that ovulation doesn't happen. This leads to many small follicles (cysts) that never ovulate (rupture, then regress), so the ovaries get enlarged. There are several metabolic conditions associated with this syndrome - insulin resistance and increased testosterone are the main ones. The insulin resistance is sort-of a pre-diabetic condition, which is why some people advocate using metformin, a drug that reverses insulin resistance. The last I checked, the recommendations are for those not wanting to get pregnant to use OCPs to suppress the endometrium and regulate their periods, and for those trying to conceive, to use metformin along with possible clomid or other ovulation induction agents. There are those that disagree with these recommendations, and I'll leave this debate to the endocrinologists and infertility guys.
Thanks for reading, and I'll try to be a little more consistant with the blog.
Take care, and I'm still doing free record reviews.
Dr. Mos
Tuesday, February 05, 2008
Tuesday, October 09, 2007
I'm Back...
Hi There...
You probably thought I fell off the face of the earth because I haven't written in so long.
First, I went on vacation to the north end of Vancouver Island. We went fishing for a few days and caught some great fish. The one above is a 24 lb King salmon. Mmmmm.
We had a great time away, then came home and 4 days later my dog Boogie died. She was 17 and had a great life, and a quick death, so I can't complain. But it's still hard. She was a very smart dog, and almost seemed like she knew what you were thinking sometimes. Emotional rollercoaster is a cliche that in my case was a very real thing - from a super high to a pit of a low in less than a week. The amazing thing is that as humans we can bounce back from such things, or at least most of us can. Some people get stuck in the "victim" role, and whether they like the attention they get when they're ill, or whether they're addicted to pain meds, or whether they just don't know any other way to live, there are some women (and probably plenty of men, I just don't see them as patients) who continue to feel subject to the whims of their disease.
I had the great pleasure to spend a night with the Seattle Endo Group at one of their meetings last month. About 15 women, all with different stories and different variations of the same disease, came together to support each other, and to learn about the disease that was affecting them and making their lives less productive, less pleasurable, and all in all less tolerable than they should be. I was proud to be able to be a part of this, a yearning to understand and conquer endo, not continue to be victimized by it. I was also proud of them, because they were doing something, both for themselves (educating ) and for others (supporting, caring, loving). Medicine is not a one-way dictum anymore, where the patient is a supplicant at the feet of the great physician, humbly requesting healing, and the physician gives the patient his treatment plan. No questions, no options, just do this and come back in a month. No, medicine today requires a commitment by both parties. A commitment by the physician to educate the patient about their disease, give them options, and help them understand why it's important to treat the disease in one way or another. The commitment from the patient is different but just as necessary. Patients must be an active participant in their healing - they must ask questions, keep track of how they feel and what things make them better or worse, they should be willing to try certain things that have been recommended to them, and most of all they need to be motivated to get better. Some of you will read this and think "what a jerk, to think that some patients don't want to get any better." I'm not suggesting that a majority of patients fall into this category (most of our patients don't, that's why it's so gratifying to help them get better), but there are a few that do. Patients who are motivated and engaged will come in to see me with a list of questions, they'll consider things I tell them so that we can come to an agreement about the plan of attack to get them better. That's what life is all about - working together to help people understand their disease and feel that they have some control over it, rather than feeling helpless and hopeless.
Thanks for reading my ramblings - sometimes I get philosophical and I apologize if it gets to be too much. But, the emotional side of healing is an important thing to tap into, both for me, and for my patients. I want them to know that I care about them, not just to be able to whack disease out of their body (of course I like that - I'm a surgeon), but what really makes me happy is seeing them being able to return to a normal life, going back to college, starting a family, going to cooking school, pursuing their dreams. That's what keeps us going when the cases are long, when our backs get tired, and our feet are sore. That's what real medicine is all about.
Just to remind you, Dr. Redwine and I are starting a series of "Webinars" this fall. Starting on 10/25, we'll give live presentations over the internet, with time for questions and answers afterwards. You will be able to send in your questions over instant messaging type software, and we'll answer as many as we can. We'll do 3 Webinars this fall, then start up again in January. There will be a place to leave your suggestions for what we can do better, so please feel free to leave constructive comments that will help us tailor future talks to what people are interested in. Our goal is education, and we want women with endo to be knowledgeable about their disease and treatment options so they don't have to suffer through useless surgeries and miserable hormone treatments.
We're trying to help you, so we hope you'll join us. There's a link to sign up on the front page of our website.
Take care, and have a great week.
Dr. Mos
Wednesday, August 22, 2007
Ovarian Remnant Syndrome
Someone asked me to write about ovarian remnant syndrome. This is actually a pretty simple thing in concept, but can be difficult to treat in some cases. What happens is that some ovaries get stuck down to the pelvic sidewall, sometimes from endo, sometimes from other things. Underneath the ovary on the sidewall (under the peritoneum) are lots of "dangerous" structures like the ureter and lots of big blood vessels and nerves that intimidate most gynecologists. Because they don't want to risk damage to these structures, some docs prefer to leave a little bit of ovarian tissue on the sidewall rather than dissect the ovary and attached peritoneum off the pelvis in order to remove the entire ovary. Sometimes this little bit of ovary has enough cells that it continues to be metabolically active enough to make hormones and form cysts. Oftentimes there are adhesions over the remnant of ovarian tissue that get stretched when the cysts form, thereby causing pain. The simple answer to this problem is to remove the remnant of ovary. The real life issues that make this a little more challenging are twofold. First, in order to diagnose a condition, one must first think of that condition. Most GYNs think that if the ovary was removed, it can't cause any more problems, so when a patient presents with right sided pelvic pain and previously had their right ovary removed, the doc starts trying to think of other things that can cause right sided pain (appendix, fibroids, gallbladder, etc). Oftentimes they're right to think of these other sources of pain. But, if the investigative workup into other causes of pain leads nowhere, then what? It's sad but true, I've seen GYNs remove the right ovary in patients with left sided pain "because the left ovary is already gone". Crazy. Ovarian remnant syndrome isn't all that common, but it certainly needs to be in the list of things thought about in patients with persistent unilateral pain after removal of that adnexa (tube and ovary). The second reason that these can be difficult problems to deal with is because some patients have incredibly dense adhesions of bowel and omentum over the top of the remnant of ovary. This can lead many surgeons to leave the abdomen before finishing the job (can you say "cut and run"?). One example of this is a patient I had in Hawaii. She had multiple surgeries by her previous GYN and a couple by me, eventually resulting in removal of both ovaries and her uterus. At the last surgery she had the worst bowel adhesions I've ever seen before or since. Imagine a kettle full of sausage, then pour Elmer's glue all over them, mix it up, and let it harden. The last thing I wanted to do was reoperate on this poor girl, but she kept having a recurrent fluid collection in her right pelvis that caused her pain. We tried everything to suppress it (OCPs), drain it via ultrasound guidance, and nothing worked. Finally before I left I agreed to go back in to remove this cystic structure. We finally did succeed in finding it, under 6 layers of bowel adhesions, and after making a couple holes in the bowel (and fixing them) guess what the path report showed? Ovarian tissue. The good news is that she finally recovered from her surgery, and now has no more pain from that cyst. The take home message is that even if you do figure out what's going on, these cases can be extremely difficult, time consuming, and risky. I knew what I would find, so the patient was prepared, but it's not always that obvious before the surgery starts. The take home message from this is that as surgeons specializing in pelvic pain, we have to be prepared for anything. We also have to be prepared to think of anything, even if it seems unlikely. Too often I see doctors try to make the operation they know how to do fit the patient. This results in removal of things that don't need to be removed, or worse, a "peek and shriek", where the scope is placed, they take a look around, and then promptly run away because they don't have the tools (skill, experience, ego small enough to ask someone with more of the first 2 than they have to help them) to do the job right. When I evaluate a patient with pain, I go through an algorithm in my head and evaluate every aspect of the pelvis. Ovaries, tubes, uterus, bladder, bowel, upper urinary tract, pelvic floor muscles, abdominal muscles, pelvic girdle/spine/orthopedic issues, upper abdominal causes, nerves, muscles, infections, masses; and on and on. When only the 1st 3 and the last 2 are considered, you miss a lot. I don't want to be like the politicians - only having scripted answers regardless of the questions. I close with the Robin Williams quote "politicians are like diapers. They should be changed often, and for the same reason."
Take care, and have a good week or 2 or 3. I'll be off for the next few weeks, but don't worry. I'll be back. Leave me all your good ideas for what to write about so I won't have to think too hard the week I come back.
Dr. Mos
Take care, and have a good week or 2 or 3. I'll be off for the next few weeks, but don't worry. I'll be back. Leave me all your good ideas for what to write about so I won't have to think too hard the week I come back.
Dr. Mos
Wednesday, August 08, 2007
Money and Medicine
OK,
I guess it's finally time to tackle the difficult issue of finances, and why we don't participate with insurance plans. One simple fact to keep in mind is that our patients come from all over the world and it would be impossible to review and sign all the contracts that various insurance plans might require, since that would be several dozen new insurance plans every few months. But that's not the real reason we don't participate with insurance plans.
First, I'll try to explain how insurance companies deal with physicians. This may not apply to all insurers, but it is how the ones I've dealt with operate. These days, most health plans are either PPOs (Preferred Provider Organizations) or HMOs (Health Maintenance Organizations).
Doctors have a choice whether or not to participate with a particular health plan.
Participating means that the doctor signs a contract agreeing to accept whatever the insurance company wants to pay the doctor without the doctor being able to bill the patient for the remainder of the fee. The upside for the doc that participates with insurance companies is that they theoretically would see more patients, so the increase in volume makes up for the decrease in reimbursement. However, this inevitably leads to the common complaint that doctors are seeing too many patients and not spending enough time with any of them.
Not participating means that the doctor doesn't accept what the insurance company wants to pay the doctor. Non-participating doctors usually see fewer patients as a rule because patients are steered toward participating doctors who have lower fees imposed on them by insurance companies, and who cost the patient less out of pocket. Unless the non-participating medical practice offers something special (like specialized surgical expertise or the new "boutique" practices guaranteeing 24 hr service and house calls), non-participating can be ruinous financially because few patients might show up at the door.
Every insurance plan (even various plans offered by the same insurance company) is different in what they will pay for any given service, but they are usually somehow tied to Medicare reimbursement rates, even though not all patients are over age 65. For an office visit, they pay a certain amount and never more. For office procedures (like an endometrial biopsy or colposcopy - looking at the cervix to find precancerous areas) there are fixed payments, likewise for surgeries. Regarding surgical reimbursement, it gets more complicated because now there's an insurance payment technique called bundling. Bundling means that if you do 3 different procedures at the same time (ie excision of endo, remove an ovarian cyst, and free up a bunch of adhesions) the insurance company would only pay for one at full price, and the rest are paid at 1/2 or 1/4 of the originally agreed upon already discounted rate. Then, on top of that, there are procedures that are considered part of another procedure, so they can't be billed for at all (like looking in the bladder- cystoscopy- after doing a sling or bladder suspension). All surgeries have codes, and the payment is based on the code, not how difficult the surgery was or how long it took. What this means for us is that excision of endo has a code. When we do an excision surgery, whether it takes 30 minutes or 3 hours the insurance reimbursement is the same. Whether Dr. Redwine (who has done 3000 cases of endo) does it , or Dr. Joe Schmoe in Hickville (who might have done 30) does it, reimbursement is the same. Plus, whether it was excised (removed) or ablated by laser or electrocautery (ineffective for treating most endometriosis but much easier and faster) you guessed it - reimbursement is the same. So, insurance companies are not impressed by efficacy of therapy or the experience of those performing the surgery. They may give lipservice to "quality indicators" and track how many patients received antibiotics before surgery (even though in many cases antibiotics don't change outcomes) and other meaningless indicators, but regarding the ultimate outcome of surgery (whether or not pain relief is achieved, how many subsequent surgeries are required, how effectively the disease has been removed from the body), insurance companies could care less. They are interested only in how little they can get away with paying a surgeon for a procedure. They have learned that if they don't pay a surgeon for a procedure, then the surgeon will not schedule the surgery in the first place, so the insurance company gets to keep even more money.
There are other problems caused by this situation that affect patients just as much as physicians. HMO reimbursements are typically lower than those of PPOs, plus HMO plans are much more restrictive about what procedures can be done for patients. They may require prior authorization before approving ultrasounds, CT scans, MRIs, surgeries, and sometimes even referrals to other physicians. Docs are limited with regard to which doctors, physical therapists, etc. they can refer patients to. They are also typically rewarded on an annual basis for saving money (translation - using fewer resources). The idea of this was originally to entice docs to keep their patients healthier by keeping their blood pressure, diabetes, and other chronic illnesses under control, because healthier patients use less resources than those that are sick (out of control diabetics, strokes from uncontrolled high blood pressure). The original idea is noble, but instead it has resulted in some (not all, hopefully not even many, but some) docs doing fewer investigations into issues like pain, issues that are probably not life threatening, but definitely impact on quality of life. Some of these problems can be difficult to diagnose and manage, so if they were pursued, they would use a fair amount of resources. By ignoring them, the less than honorable primary care provider uses less resources, has less "bother", and gets a bigger rebate at the end of the year: they are paid more for withholding care.
There's another problem that's significant - the contracted reimbursement rates can be changed by the insurer, but not by the docs. There are no "cost of living" increases. When congress decides to drop medicare reimbursement rates, since many private insurers follow medicare, there's a chance that reimbursements will decrease as well. Since doctors can't or won't unionize (the ethics of this are debatable and we won't go into that now), there's no way to have "collective bargaining" and as a group negotiate a contract with the insurer that's fair for both parties. Physicians and other health care professionals are the only group that doesn't have control over what they get paid for professional services. When the law firm down the street has increases in its expenses, they raise their rates accordingly. When Matson (the big shipping line that ships most everything that gets to Hawaii) has to pay more for fuel and more for the stevedores that unload the ships, shipping rates go up. This is not surprising to anyone. What might be surprising is that from the time I arrived in Hawaii (1998) to when I left (2006), the amount we were paid by HMSA (the Hawaiian insurer that covered 80% of our patients) for certain office procedures actually went down, as did rates for some surgeries. During this time, my malpractice costs doubled, not because of any claims, but because of the national "environment" of a general increase in claims and awards. That's another story, too.
This whole situation has caused most doctors to see more patients in order to keep the same level of reimbursement, all the while enduring increases in expenses such as malpractice coverage, staff salaries, rent, utilities, and just about everything else. When reimbursements fall and expenses rise, doctors offices and usually the docs themselves take the hit. Because of this, many docs are leaving areas of high expense and low reimbursement such as Hawaii. They can move to the midwest where expenses are low and reimbursements are higher, and have a result of a net doubling of their income. I have friends who are pediatricians who are making less money than the guys with a high school education who are unloading the ships (the stevedores). Factor in the time and money it costs to go to medical school, plus making minimum wage for 3-6 years during residency, and it's no wonder that applications to med school have been down for quite a while. Applicants are less qualified than they used to be, and as a result, the brightest and best of our young people are pursuing other fields leaving the OK but not stellar to be the doctors of the future. This should be concerning to everybody who plans on living past the next 15-20 years. But I digress....
Our situation is that our surgeries sometimes take an hour, sometimes 8 hours. The surgeries that we do do not fit into the mold that insurance companies have cast. Laser vaporization or electrocoagulation may take 15 minutes to an hour to perform because they are such simple procedures. Our techniques are much more tedious, aggressive, and risky; to be done well they require specialized training and expertise that only a few surgeons in this country possess. Our techniques are worth far more than the insurance company will pay because they do what all the previous medicines and surgeries have not done: remove the disease from the body. Most of our patients have tortuously endured several years of surgeries and therapies, consuming tens or hundreds of thousands of dollars, yet our surgical fees are a fraction of what's been spent for their past therapies. We are in a unique position to judge what our talents are worth, and insurance companies are not. Insurance companies would rather pay a surgeon a small amount of money several times than a larger amount to get the job done right the first time.
I hope this serves to shed some light on the situation that doctors are in these days, and why we have the policies that we do. Our intent is to receive a reasonable fee for a specialized, difficult surgery that few surgeons can perform. It also allows us to spend as much time with each patient as they need in order to answer all their questions, explain their disease to them, fully counsel them about their upcoming surgery so that they understand all the risks, benefits, and alternatives, and sustain the real meaning of the doctor-patient relationship- trust and confidence. This is a benefit all our patients appreciate and many people wish they had with their doctors. We do bill the patient's insurance company, but since we do not participate, the insurer sends the check to the patient rather than to us. As surgery is not something one can take back, we would have no recourse (other than through the legal system) if some unscrupulous patient kept the insurance money rather than using that to pay us: this is why we require a deposit up front. Most people place this on their credit card and by the time the bill comes, they have the reimbursement from the insurance company for a portion (and in some cases the majority) of the bill. While our fees are set, if you need surgery for removal of endometriosis, we will try to work with you to come up with a solution that is mutually satisfactory.
In conclusion (finally...) I am doing record reviews without charge for the immediate future, so if you have issues with endometriosis that is impeding your ability to have a healthy happy active life, let me see if we can help you out.
Have a great week, and take care.
Dr. Mos
I guess it's finally time to tackle the difficult issue of finances, and why we don't participate with insurance plans. One simple fact to keep in mind is that our patients come from all over the world and it would be impossible to review and sign all the contracts that various insurance plans might require, since that would be several dozen new insurance plans every few months. But that's not the real reason we don't participate with insurance plans.
First, I'll try to explain how insurance companies deal with physicians. This may not apply to all insurers, but it is how the ones I've dealt with operate. These days, most health plans are either PPOs (Preferred Provider Organizations) or HMOs (Health Maintenance Organizations).
Doctors have a choice whether or not to participate with a particular health plan.
Participating means that the doctor signs a contract agreeing to accept whatever the insurance company wants to pay the doctor without the doctor being able to bill the patient for the remainder of the fee. The upside for the doc that participates with insurance companies is that they theoretically would see more patients, so the increase in volume makes up for the decrease in reimbursement. However, this inevitably leads to the common complaint that doctors are seeing too many patients and not spending enough time with any of them.
Not participating means that the doctor doesn't accept what the insurance company wants to pay the doctor. Non-participating doctors usually see fewer patients as a rule because patients are steered toward participating doctors who have lower fees imposed on them by insurance companies, and who cost the patient less out of pocket. Unless the non-participating medical practice offers something special (like specialized surgical expertise or the new "boutique" practices guaranteeing 24 hr service and house calls), non-participating can be ruinous financially because few patients might show up at the door.
Every insurance plan (even various plans offered by the same insurance company) is different in what they will pay for any given service, but they are usually somehow tied to Medicare reimbursement rates, even though not all patients are over age 65. For an office visit, they pay a certain amount and never more. For office procedures (like an endometrial biopsy or colposcopy - looking at the cervix to find precancerous areas) there are fixed payments, likewise for surgeries. Regarding surgical reimbursement, it gets more complicated because now there's an insurance payment technique called bundling. Bundling means that if you do 3 different procedures at the same time (ie excision of endo, remove an ovarian cyst, and free up a bunch of adhesions) the insurance company would only pay for one at full price, and the rest are paid at 1/2 or 1/4 of the originally agreed upon already discounted rate. Then, on top of that, there are procedures that are considered part of another procedure, so they can't be billed for at all (like looking in the bladder- cystoscopy- after doing a sling or bladder suspension). All surgeries have codes, and the payment is based on the code, not how difficult the surgery was or how long it took. What this means for us is that excision of endo has a code. When we do an excision surgery, whether it takes 30 minutes or 3 hours the insurance reimbursement is the same. Whether Dr. Redwine (who has done 3000 cases of endo) does it , or Dr. Joe Schmoe in Hickville (who might have done 30) does it, reimbursement is the same. Plus, whether it was excised (removed) or ablated by laser or electrocautery (ineffective for treating most endometriosis but much easier and faster) you guessed it - reimbursement is the same. So, insurance companies are not impressed by efficacy of therapy or the experience of those performing the surgery. They may give lipservice to "quality indicators" and track how many patients received antibiotics before surgery (even though in many cases antibiotics don't change outcomes) and other meaningless indicators, but regarding the ultimate outcome of surgery (whether or not pain relief is achieved, how many subsequent surgeries are required, how effectively the disease has been removed from the body), insurance companies could care less. They are interested only in how little they can get away with paying a surgeon for a procedure. They have learned that if they don't pay a surgeon for a procedure, then the surgeon will not schedule the surgery in the first place, so the insurance company gets to keep even more money.
There are other problems caused by this situation that affect patients just as much as physicians. HMO reimbursements are typically lower than those of PPOs, plus HMO plans are much more restrictive about what procedures can be done for patients. They may require prior authorization before approving ultrasounds, CT scans, MRIs, surgeries, and sometimes even referrals to other physicians. Docs are limited with regard to which doctors, physical therapists, etc. they can refer patients to. They are also typically rewarded on an annual basis for saving money (translation - using fewer resources). The idea of this was originally to entice docs to keep their patients healthier by keeping their blood pressure, diabetes, and other chronic illnesses under control, because healthier patients use less resources than those that are sick (out of control diabetics, strokes from uncontrolled high blood pressure). The original idea is noble, but instead it has resulted in some (not all, hopefully not even many, but some) docs doing fewer investigations into issues like pain, issues that are probably not life threatening, but definitely impact on quality of life. Some of these problems can be difficult to diagnose and manage, so if they were pursued, they would use a fair amount of resources. By ignoring them, the less than honorable primary care provider uses less resources, has less "bother", and gets a bigger rebate at the end of the year: they are paid more for withholding care.
There's another problem that's significant - the contracted reimbursement rates can be changed by the insurer, but not by the docs. There are no "cost of living" increases. When congress decides to drop medicare reimbursement rates, since many private insurers follow medicare, there's a chance that reimbursements will decrease as well. Since doctors can't or won't unionize (the ethics of this are debatable and we won't go into that now), there's no way to have "collective bargaining" and as a group negotiate a contract with the insurer that's fair for both parties. Physicians and other health care professionals are the only group that doesn't have control over what they get paid for professional services. When the law firm down the street has increases in its expenses, they raise their rates accordingly. When Matson (the big shipping line that ships most everything that gets to Hawaii) has to pay more for fuel and more for the stevedores that unload the ships, shipping rates go up. This is not surprising to anyone. What might be surprising is that from the time I arrived in Hawaii (1998) to when I left (2006), the amount we were paid by HMSA (the Hawaiian insurer that covered 80% of our patients) for certain office procedures actually went down, as did rates for some surgeries. During this time, my malpractice costs doubled, not because of any claims, but because of the national "environment" of a general increase in claims and awards. That's another story, too.
This whole situation has caused most doctors to see more patients in order to keep the same level of reimbursement, all the while enduring increases in expenses such as malpractice coverage, staff salaries, rent, utilities, and just about everything else. When reimbursements fall and expenses rise, doctors offices and usually the docs themselves take the hit. Because of this, many docs are leaving areas of high expense and low reimbursement such as Hawaii. They can move to the midwest where expenses are low and reimbursements are higher, and have a result of a net doubling of their income. I have friends who are pediatricians who are making less money than the guys with a high school education who are unloading the ships (the stevedores). Factor in the time and money it costs to go to medical school, plus making minimum wage for 3-6 years during residency, and it's no wonder that applications to med school have been down for quite a while. Applicants are less qualified than they used to be, and as a result, the brightest and best of our young people are pursuing other fields leaving the OK but not stellar to be the doctors of the future. This should be concerning to everybody who plans on living past the next 15-20 years. But I digress....
Our situation is that our surgeries sometimes take an hour, sometimes 8 hours. The surgeries that we do do not fit into the mold that insurance companies have cast. Laser vaporization or electrocoagulation may take 15 minutes to an hour to perform because they are such simple procedures. Our techniques are much more tedious, aggressive, and risky; to be done well they require specialized training and expertise that only a few surgeons in this country possess. Our techniques are worth far more than the insurance company will pay because they do what all the previous medicines and surgeries have not done: remove the disease from the body. Most of our patients have tortuously endured several years of surgeries and therapies, consuming tens or hundreds of thousands of dollars, yet our surgical fees are a fraction of what's been spent for their past therapies. We are in a unique position to judge what our talents are worth, and insurance companies are not. Insurance companies would rather pay a surgeon a small amount of money several times than a larger amount to get the job done right the first time.
I hope this serves to shed some light on the situation that doctors are in these days, and why we have the policies that we do. Our intent is to receive a reasonable fee for a specialized, difficult surgery that few surgeons can perform. It also allows us to spend as much time with each patient as they need in order to answer all their questions, explain their disease to them, fully counsel them about their upcoming surgery so that they understand all the risks, benefits, and alternatives, and sustain the real meaning of the doctor-patient relationship- trust and confidence. This is a benefit all our patients appreciate and many people wish they had with their doctors. We do bill the patient's insurance company, but since we do not participate, the insurer sends the check to the patient rather than to us. As surgery is not something one can take back, we would have no recourse (other than through the legal system) if some unscrupulous patient kept the insurance money rather than using that to pay us: this is why we require a deposit up front. Most people place this on their credit card and by the time the bill comes, they have the reimbursement from the insurance company for a portion (and in some cases the majority) of the bill. While our fees are set, if you need surgery for removal of endometriosis, we will try to work with you to come up with a solution that is mutually satisfactory.
In conclusion (finally...) I am doing record reviews without charge for the immediate future, so if you have issues with endometriosis that is impeding your ability to have a healthy happy active life, let me see if we can help you out.
Have a great week, and take care.
Dr. Mos
Monday, July 30, 2007
Randomized controlled trials - God's gift to medicine???
Hi there.
I saw that there was a link to a letter to the editor of Fertility and Sterility from 2005 by a Dr. Clark in England posted in one of the chat rooms frequented by women with endometriosis. The letter referred to excision of endometriosis and the lack of randomised controlled trials of excision, concluding that unless and until it is proven by these randomised trials to be superior to other therapies, then it should not be recommended as a treatment. There are several issues raised in this letter that I disagree with, and I will try to explain them as simply as possible, although some of the concepts are difficult even for some doctors to understand. But here we go...
First, Dr. Clark is of the mindset that prospective randomised controlled trials (RCTs) are the only way to document effectiveness of a treatment. To understand why he is wrong takes a little background into medical research and the different types of studies. When patients are enrolled prior to treatment and randomly allocated to one of 2 or 3 groups that will undergo different treatments for the same disease, then followed to assess results, this is called a prospective (done in real time) randomized (randomly assigned) controlled (the control group is one group that either has no treatment or a well established treatment) trial. Placebo controlled trials are typically done to see if a given drug has more effectiveness than the placebo effect, which is where people think they're getting therapy so they feel better. Placebo effects are well documented for both surgery and medical treatment, and about 30% of people typically respond to placebo for a limited amount of time. Once a drug has been on the market for a while and we know it works (for example cholesterol lowering drugs), it would be unethical to have a treatment group that gets no therapy (placebo), so one drug is compared with another drug (ie Lipitor vs Vytorin) in a randomized fashion to see which drug lowers total cholesterol and LDL the most. RCTs are typically felt to be the best quality evidence available because of the lack of bias (imposing the author's own perspective on the results). However, RCTs are rarely done to study surgery, and their quality depends on how they were set up. The Women's Health Initiative (WHI) is a perfect example of a huge (15,000 pts) study that was a randomized, blinded, placebo controlled waste of money (your money as it was funded by the NIH). This was the study publicized by CNN and all the network news programs about 4-5 yrs ago where all the TV people said "stop your prempro!" because it causes heart attacks and breast cancer. The goal of the study was to see if hormone replacement therapy actually protects women from heart disease as we thought for many years based on cohort studies (see below). Unfortunately, the study design was flawed and instead of studying women who were going through menopause around age 50, they chose women with an average age of 64 who were in most cases 10 years or more past the menopausal symptoms and off HRT for that long. Then, they started the treatment group women on hormones (prempro), and tabulated the incidence of breast cancer, heart attacks, strokes, and in a sub-analysis, mental function. I don't have time to go into all the details, but suffice it to say they were shocked at the findings, and actually stopped the study early. The women in the treatment group had a higher incidence of heart attacks and dementia, contrary to what had previously been thought. After further review and several more studies designed to look at hormone replacement in women who need it (around age 50 and within 1 year of starting menopause), guess what? The women on estrogen DID have a lower risk of heart attacks AND had better mental function. The multi-million dollar RCT was wrong, and it was all because of a faulty design. Just like the Titanic (well, sorta).
The next type of study we'll examine is called a cohort study. These can be done either prospectively or retrospectively, and involve groups (cohorts) of patients that undergo a particular treatment and subsequent followup. These are the type of studies that are most often done to assess surgical outcomes. Typically, a specific type of patient is selected (ie stage IV endometriosis with no previous surgery) and a specific type of procedure is done to them (ie excision of rectovaginal endometriosis via laparoscopy) and certain outcome measures are followed over a period of time. The more specific the outcomes (quality of life questionnaires, rectal pain, lack of tenderness on exam, etc) and the longer that patients are followed without losses (ie if 100 pts had surgery and 90 are followed for 5 years then 10% are lost to follow-up) then the better the quality of information. Most of the data regarding the surgical treatment of endometriosis is in this class of studies, and most of the studies on excision clearly state the outcomes measured, and also the numbers lost to follow-up. When multiple studies done on different continents by different surgeons all agree with nearly the same results, it is probably the best quality evidence that could possibly exist. This is the case with the excision literature. One study is based on laparotomies (open surgery) with excision done on all stages of endo (Wheeler and Malinak, 1987). Redwine in 1991 wrote about a cohort of women who underwent conservative excision (without hysterectomy or oophorectomy) via laparoscopy, followed for 7 yrs. Redwine and Wright in 2001 studied women with complete obliteration of the culdesac who underwent excision, then followed them for on average 5 years. Abbott and Hawe in 2003 studied women who underwent excision in England and Australia with a 2-5 yr follow-up period. ALL of these studies had nearly identical results - a 20% likelihood of persistent endometriosis over a long follow-up period. To me, this is much better evidence that excision works than any randomized controlled study could ever be.
Another note on the RCT. I don't believe it's ethical to randomize women with pain into a surgical treatment arm vs a surgical placebo arm (making the incisions and not removing the disease). The only ethical way to do a RCT of surgical treatment of endo would be to compare excision and ablation of early stage disease. We shouldn't do it for stage IV disease, because ablation of deep disease doesn't work, as proven by cohort studies. This study of excision vs ablation for mild disease was actually done in 2004, but with only 12 pts in each group followed for 6 months. Not surprisingly, there were no differences in outcomes. Again, it seems that the better quality data comes not from the esteemed RCT, but from the consistency of results in cohort studies which have remained the same over time and continents.
Dr. Clark's second error is that he confuses chronic pelvic pain (CPP) with endometriosis. While it is true that endometriosis is one of the conditions that comprises CPP, it is the only one that is amenable to surgical excision. Several factors need consideration in order to understand the dilemma at hand. The main symptom of endometriosis is pain, but there are many other things that can cause similar pelvic pain. One of the problems we have in studying endo and responses to treatment is that we can't re-operate on everyone to assess whether or not they had resolution of their endometriosis after excision. We re-operate on the patients who have recurrence of their pain, and in general we find that about 60% of them do Not have endometriosis, ie, they're cured. Ironically, it's the patients with the deep disease (typically stage IV, some stage IIs) that have the best chance of pain relief after excision. Why is this? Most people think it's because deep endo almost always causes pain, and superficial disease may be asymptomatic. When a patient with pelvic pain from another cause (such as interstitial cystitis or IBS) undergoes a laparoscopy and is found to have stage I endo and treated for it, the initial assumption is that the pain was from the endo. But maybe the pain was actually from the IC, and the endo was a red herring. You see the problem, I think. This is why it is troubling to follow patients by symptomatology, yet we can't reoperate on every patient 5 years after their initial surgery just to see if the endo is gone, especially if they are asymptomatic.
Without a doubt there is room for more research to be done in order to direct clinicians towards the best way to treat their patients with endometriosis. This doesn't mean, however, that we "throw the baby out with the bathwater" just because we don't have the type of evidence some people want. We have to practice evidence-based medicine, yet there is always the need for common sense in order to interpret what we read.
I hope this is understandable to you all. One thing I've been impressed with since I've been here in Bend is how great an understanding of medicine many of our endo patients have. It's refreshing to have patients who truly understand treatment options, risks, benefits, and alternatives; not just not and say "Yes, doctor".
Anyway, have a great week, and let me know if you have any more questions.
Dr. Mos
ps - for those of you that wrote, next week we'll discuss the finances of medicine.
I saw that there was a link to a letter to the editor of Fertility and Sterility from 2005 by a Dr. Clark in England posted in one of the chat rooms frequented by women with endometriosis. The letter referred to excision of endometriosis and the lack of randomised controlled trials of excision, concluding that unless and until it is proven by these randomised trials to be superior to other therapies, then it should not be recommended as a treatment. There are several issues raised in this letter that I disagree with, and I will try to explain them as simply as possible, although some of the concepts are difficult even for some doctors to understand. But here we go...
First, Dr. Clark is of the mindset that prospective randomised controlled trials (RCTs) are the only way to document effectiveness of a treatment. To understand why he is wrong takes a little background into medical research and the different types of studies. When patients are enrolled prior to treatment and randomly allocated to one of 2 or 3 groups that will undergo different treatments for the same disease, then followed to assess results, this is called a prospective (done in real time) randomized (randomly assigned) controlled (the control group is one group that either has no treatment or a well established treatment) trial. Placebo controlled trials are typically done to see if a given drug has more effectiveness than the placebo effect, which is where people think they're getting therapy so they feel better. Placebo effects are well documented for both surgery and medical treatment, and about 30% of people typically respond to placebo for a limited amount of time. Once a drug has been on the market for a while and we know it works (for example cholesterol lowering drugs), it would be unethical to have a treatment group that gets no therapy (placebo), so one drug is compared with another drug (ie Lipitor vs Vytorin) in a randomized fashion to see which drug lowers total cholesterol and LDL the most. RCTs are typically felt to be the best quality evidence available because of the lack of bias (imposing the author's own perspective on the results). However, RCTs are rarely done to study surgery, and their quality depends on how they were set up. The Women's Health Initiative (WHI) is a perfect example of a huge (15,000 pts) study that was a randomized, blinded, placebo controlled waste of money (your money as it was funded by the NIH). This was the study publicized by CNN and all the network news programs about 4-5 yrs ago where all the TV people said "stop your prempro!" because it causes heart attacks and breast cancer. The goal of the study was to see if hormone replacement therapy actually protects women from heart disease as we thought for many years based on cohort studies (see below). Unfortunately, the study design was flawed and instead of studying women who were going through menopause around age 50, they chose women with an average age of 64 who were in most cases 10 years or more past the menopausal symptoms and off HRT for that long. Then, they started the treatment group women on hormones (prempro), and tabulated the incidence of breast cancer, heart attacks, strokes, and in a sub-analysis, mental function. I don't have time to go into all the details, but suffice it to say they were shocked at the findings, and actually stopped the study early. The women in the treatment group had a higher incidence of heart attacks and dementia, contrary to what had previously been thought. After further review and several more studies designed to look at hormone replacement in women who need it (around age 50 and within 1 year of starting menopause), guess what? The women on estrogen DID have a lower risk of heart attacks AND had better mental function. The multi-million dollar RCT was wrong, and it was all because of a faulty design. Just like the Titanic (well, sorta).
The next type of study we'll examine is called a cohort study. These can be done either prospectively or retrospectively, and involve groups (cohorts) of patients that undergo a particular treatment and subsequent followup. These are the type of studies that are most often done to assess surgical outcomes. Typically, a specific type of patient is selected (ie stage IV endometriosis with no previous surgery) and a specific type of procedure is done to them (ie excision of rectovaginal endometriosis via laparoscopy) and certain outcome measures are followed over a period of time. The more specific the outcomes (quality of life questionnaires, rectal pain, lack of tenderness on exam, etc) and the longer that patients are followed without losses (ie if 100 pts had surgery and 90 are followed for 5 years then 10% are lost to follow-up) then the better the quality of information. Most of the data regarding the surgical treatment of endometriosis is in this class of studies, and most of the studies on excision clearly state the outcomes measured, and also the numbers lost to follow-up. When multiple studies done on different continents by different surgeons all agree with nearly the same results, it is probably the best quality evidence that could possibly exist. This is the case with the excision literature. One study is based on laparotomies (open surgery) with excision done on all stages of endo (Wheeler and Malinak, 1987). Redwine in 1991 wrote about a cohort of women who underwent conservative excision (without hysterectomy or oophorectomy) via laparoscopy, followed for 7 yrs. Redwine and Wright in 2001 studied women with complete obliteration of the culdesac who underwent excision, then followed them for on average 5 years. Abbott and Hawe in 2003 studied women who underwent excision in England and Australia with a 2-5 yr follow-up period. ALL of these studies had nearly identical results - a 20% likelihood of persistent endometriosis over a long follow-up period. To me, this is much better evidence that excision works than any randomized controlled study could ever be.
Another note on the RCT. I don't believe it's ethical to randomize women with pain into a surgical treatment arm vs a surgical placebo arm (making the incisions and not removing the disease). The only ethical way to do a RCT of surgical treatment of endo would be to compare excision and ablation of early stage disease. We shouldn't do it for stage IV disease, because ablation of deep disease doesn't work, as proven by cohort studies. This study of excision vs ablation for mild disease was actually done in 2004, but with only 12 pts in each group followed for 6 months. Not surprisingly, there were no differences in outcomes. Again, it seems that the better quality data comes not from the esteemed RCT, but from the consistency of results in cohort studies which have remained the same over time and continents.
Dr. Clark's second error is that he confuses chronic pelvic pain (CPP) with endometriosis. While it is true that endometriosis is one of the conditions that comprises CPP, it is the only one that is amenable to surgical excision. Several factors need consideration in order to understand the dilemma at hand. The main symptom of endometriosis is pain, but there are many other things that can cause similar pelvic pain. One of the problems we have in studying endo and responses to treatment is that we can't re-operate on everyone to assess whether or not they had resolution of their endometriosis after excision. We re-operate on the patients who have recurrence of their pain, and in general we find that about 60% of them do Not have endometriosis, ie, they're cured. Ironically, it's the patients with the deep disease (typically stage IV, some stage IIs) that have the best chance of pain relief after excision. Why is this? Most people think it's because deep endo almost always causes pain, and superficial disease may be asymptomatic. When a patient with pelvic pain from another cause (such as interstitial cystitis or IBS) undergoes a laparoscopy and is found to have stage I endo and treated for it, the initial assumption is that the pain was from the endo. But maybe the pain was actually from the IC, and the endo was a red herring. You see the problem, I think. This is why it is troubling to follow patients by symptomatology, yet we can't reoperate on every patient 5 years after their initial surgery just to see if the endo is gone, especially if they are asymptomatic.
Without a doubt there is room for more research to be done in order to direct clinicians towards the best way to treat their patients with endometriosis. This doesn't mean, however, that we "throw the baby out with the bathwater" just because we don't have the type of evidence some people want. We have to practice evidence-based medicine, yet there is always the need for common sense in order to interpret what we read.
I hope this is understandable to you all. One thing I've been impressed with since I've been here in Bend is how great an understanding of medicine many of our endo patients have. It's refreshing to have patients who truly understand treatment options, risks, benefits, and alternatives; not just not and say "Yes, doctor".
Anyway, have a great week, and let me know if you have any more questions.
Dr. Mos
ps - for those of you that wrote, next week we'll discuss the finances of medicine.
Thursday, July 26, 2007
Almost a year
Hi everybody, hope you're having a great summer.
I realized the other day that it's been almost a year since I left Hawaii on my quest to become the next endometriosis specialist. I've truly learned a lot, more than I could ever put into words, and I've been lucky to have a phenomenal teacher in Dr. Redwine. He's taught me surgical techniques, anatomy, clinical diagnostic pearls, persistence, and the ever important quality of trusting your gut. Working with David has made me realize what a great man he is - he's not just an excellent technical surgeon, but he has that thing that's hard to quantify that makes someone special - the ability to relate to people where they are, to understand their situation, and be able to reach out and help them transform their lives. I am humbled every day, and at the same time I strive to be worthy to follow in his footsteps. I'm growing in my surgical abilities - what once was moderately difficult is now easy, and what seemed nearly impossible when I got here is challenging, but doable. You all know that I've been moved by your stories of frustration over multiple failed surgeries, and that knowing what you've been through both before and after trips to Bend continues to motivate me to "fight the good fight", enlightening the medical community and patients alike about the benefits of surgical excision, the shortcomings of Lupron, and the need to realize that endometriosis can be cured. Last week we read an article by a bunch of PhD microbiologists on the genetics of experimental endometriosis induced in rats ( who don't naturally get endo) and in multiple places in the article they said endometriosis was incurable. I'm realizing that it's now my job to publicly correct these old outdated incorrect opinions thrown around as facts.
So, hang in there, and remember I'm here for you. Any questions you want answered let me know and I'll do my best.
Dr. Mos
I realized the other day that it's been almost a year since I left Hawaii on my quest to become the next endometriosis specialist. I've truly learned a lot, more than I could ever put into words, and I've been lucky to have a phenomenal teacher in Dr. Redwine. He's taught me surgical techniques, anatomy, clinical diagnostic pearls, persistence, and the ever important quality of trusting your gut. Working with David has made me realize what a great man he is - he's not just an excellent technical surgeon, but he has that thing that's hard to quantify that makes someone special - the ability to relate to people where they are, to understand their situation, and be able to reach out and help them transform their lives. I am humbled every day, and at the same time I strive to be worthy to follow in his footsteps. I'm growing in my surgical abilities - what once was moderately difficult is now easy, and what seemed nearly impossible when I got here is challenging, but doable. You all know that I've been moved by your stories of frustration over multiple failed surgeries, and that knowing what you've been through both before and after trips to Bend continues to motivate me to "fight the good fight", enlightening the medical community and patients alike about the benefits of surgical excision, the shortcomings of Lupron, and the need to realize that endometriosis can be cured. Last week we read an article by a bunch of PhD microbiologists on the genetics of experimental endometriosis induced in rats ( who don't naturally get endo) and in multiple places in the article they said endometriosis was incurable. I'm realizing that it's now my job to publicly correct these old outdated incorrect opinions thrown around as facts.
So, hang in there, and remember I'm here for you. Any questions you want answered let me know and I'll do my best.
Dr. Mos
Thursday, July 12, 2007
First of all, thanks to all you ladies who wrote back about your relationships. I was especially touched by the last comment, and it's so true that endo affects more than just the spousal relationship, but also the ones with your kids, your parents, your friends. Seeing the pain our patients go through before getting any relief is what drives me to excellence, because it's only by my ability to do what Dr. Redwine does that I'll be able to carry on his legacy of helping patients who find no help elsewhere. It's gratifying to know that David thinks I'm almost there - I can successfully excise all endo in about 95% of our patients, and it's only the really really tough cases (who most other endometriosis surgeons have failed) where I need his help. I'm pretty excited about that. But I digress.....
I was asked to write about endo and infertility by Nancy Peterson. I guess she's had a lot of questions about this and thought I might shed some light on this. I told Dr. Redwine about my quest, and he said "it's a black hole"....
So, what can be said about infertility within the context of endometriosis?
First, endo patients typically are slightly less fertile than women without endo. That being said, there are many different etiologies for sub-fertility, and many may be at play in any one couple. Plenty of women with endo conceive and carry perfectly normal pregnancies, so why is it that some can't? There are the obvious reasons such as those with tubal adhesions where the tubes are stuck to the back of the uterus, or to the colon, or anything else, really. But those people are few and far between. Why does mild endo affect fertility? I pulled a couple of articles yesterday that pertain a little to this. For women with mild-minimal endo, the conception rates and delivery rates after IVF were much better in those women who underwent surgical excision of the endo prior to IVF. This suggests that even when bypassing the tubes via IVF, the endo living in the pelvis has a negative impact on fertility. Probably this is mediated by some local inflammation, but the exact reason hasn't been elucidated yet. Treatment with any medicine, whether birth control, lupron, or aromatase inhibitors only decreases fertility, and has never been proven to enhance fertility in patients with endo.
Finally, conservative surgical excision (what we do - remove the disease, not uninvolved innocent organs) has a beneficial effect on fertility. Dr. Redwine wrote a paper about conservative excision for obliteration of the culdesac (stage IV endo), and 40% of the women who wanted to conceive after surgery did. That's pretty good, considering that most of those women hurt too much beforehand to even think of getting pregnant. Surgery is the only treatment for endometriosis that improves fertility, although it is not a guarantee of fertility. The only time fertility is challenged by surgery is when the patients have large bilateral endometriomas, and after removing the cysts, at times there is not a lot of normal ovary left in place, so the number of follicles (potential eggs) is greatly decreased after surgery. Unfortunately, there's no other way of treating endometriomas that works without risk of recurrence, so pretty much that's what we have to do to get pain relief. Luckily, this is a rare situation and occurs mostly in women in their late 30s and 40s. Stimulating ovaries such as with clomid or pergonal (used with IVF cycles) is contraindicated in women with large cystic ovaries, so there's really no other alternative to ovarian cystectomy in patients with large endometriomas.
So, to summarize this rambling stream of consciousness blog, surgery preferably with excision of endometriosis lesions is the best first-line treatment for women with endo and infertility. If pregnancy is not achieved spontaneously after surgery, then success rates with IVF will still be better after surgery than before.
For those of you with endo who haven't tried to get pregnant - don't give up. Plenty of women with endo get pregnant spontaneously, the old fashioned way, without any help. For those of you with pain, excision is the most effective way to permanently get rid of the endo and preserve fertility, as well as natural hormone production.
Take care, and have a great week.
Dr. Mos
I was asked to write about endo and infertility by Nancy Peterson. I guess she's had a lot of questions about this and thought I might shed some light on this. I told Dr. Redwine about my quest, and he said "it's a black hole"....
So, what can be said about infertility within the context of endometriosis?
First, endo patients typically are slightly less fertile than women without endo. That being said, there are many different etiologies for sub-fertility, and many may be at play in any one couple. Plenty of women with endo conceive and carry perfectly normal pregnancies, so why is it that some can't? There are the obvious reasons such as those with tubal adhesions where the tubes are stuck to the back of the uterus, or to the colon, or anything else, really. But those people are few and far between. Why does mild endo affect fertility? I pulled a couple of articles yesterday that pertain a little to this. For women with mild-minimal endo, the conception rates and delivery rates after IVF were much better in those women who underwent surgical excision of the endo prior to IVF. This suggests that even when bypassing the tubes via IVF, the endo living in the pelvis has a negative impact on fertility. Probably this is mediated by some local inflammation, but the exact reason hasn't been elucidated yet. Treatment with any medicine, whether birth control, lupron, or aromatase inhibitors only decreases fertility, and has never been proven to enhance fertility in patients with endo.
Finally, conservative surgical excision (what we do - remove the disease, not uninvolved innocent organs) has a beneficial effect on fertility. Dr. Redwine wrote a paper about conservative excision for obliteration of the culdesac (stage IV endo), and 40% of the women who wanted to conceive after surgery did. That's pretty good, considering that most of those women hurt too much beforehand to even think of getting pregnant. Surgery is the only treatment for endometriosis that improves fertility, although it is not a guarantee of fertility. The only time fertility is challenged by surgery is when the patients have large bilateral endometriomas, and after removing the cysts, at times there is not a lot of normal ovary left in place, so the number of follicles (potential eggs) is greatly decreased after surgery. Unfortunately, there's no other way of treating endometriomas that works without risk of recurrence, so pretty much that's what we have to do to get pain relief. Luckily, this is a rare situation and occurs mostly in women in their late 30s and 40s. Stimulating ovaries such as with clomid or pergonal (used with IVF cycles) is contraindicated in women with large cystic ovaries, so there's really no other alternative to ovarian cystectomy in patients with large endometriomas.
So, to summarize this rambling stream of consciousness blog, surgery preferably with excision of endometriosis lesions is the best first-line treatment for women with endo and infertility. If pregnancy is not achieved spontaneously after surgery, then success rates with IVF will still be better after surgery than before.
For those of you with endo who haven't tried to get pregnant - don't give up. Plenty of women with endo get pregnant spontaneously, the old fashioned way, without any help. For those of you with pain, excision is the most effective way to permanently get rid of the endo and preserve fertility, as well as natural hormone production.
Take care, and have a great week.
Dr. Mos
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