In this video Dr. Wilshire demonstrates how we excise (resect or completely remove) painful endometriosis lesions at the time of laparoscopy.
Hello. This is Dr. Gil Wilshire at Missouri Fertility in Columbia, Missouri. Today, we are going to show you "endometriosis excision"; it is also called resection. Essentially, this is when we remove the endometriosis completely. If you will look on the screen now. This is a woman who had multiple previous surgeries but they did not excise all of her disease. You see this brown spot? This is endometriosis. This is brown, a little red, and it is also a little fibrous. There is a tiny little nodule here, and this needs to come out. Now, in this area there is the ureter, over here at the side, and the uterine arteries, so this is a somewhat tricky area to work. This is the general technique to do this. We will grab the lesion or the disease or the "boo-boo" or whatever you want to call it, and we pull it up—we pull it off to the side so we can see the nodule. You can see the nodule here—this is called tenting; we are tenting the lesion up. We are using electricity, but you can use ultrasound, you can use laser if you wish, but I prefer plain old electricity. You can see the cyst there as it popped. I like electricity as it is better at finding the blood vessels and stopping any bleeding from the blood vessels, whereas laser does not. So, we are tenting the lesion up here, cutting the membrane around it, which is called the perineum, and you can see the nodule coming out here. We are going to turn it so we can get a better approach here. We are tenting it up, and as we pull it away, it starts to separate from the underlying tissue. Here, we have a good angle on it, tenting it up, and it should be well away from the ureter and the uterine artery. And now, we should be able to get this lesion out in its entirety. We have the full nodule out, so we can cut it with these scissors…and there is the endometriosis. … Now, you can see, that is where it was. You can see the artery pulsing over here, and we have not hit it. This is no bleeding; this was completely bloodless and complete. This is an example of the excision of endometriosis. I hope that was interesting for you. This is Dr. Gil Wilshire at Missouri Fertility in Columbia, Missouri.
Hello. This is Dr. Wilshire from Missouri Fertility, Columbia, Missouri. Today, we're doing a hysteroscopy on a young woman who has been having abnormal bleeding. She also has polycystic ovarian syndrome. She happens to be from Central America and has a lot of Native American blood. You can see in her overall body shape that she has very thin thighs. She carries her weight in the mid-section, and this makes her at very high risk for growing endometrial polyps. Polyps grow in the uterus when a woman is not having regular ovulation and when she has very high sugar levels and high insulin levels that come from the typical American high-carbohydrate diet. She's been having abnormal bleeding in addition to infertility; so, on ultrasound earlier, we saw a thickened irregular lining of her uterus.
We are looking at her uterus right now with a hysteroscope, and you can see right here that she has some very large polyps, enormous polyps, in the cavity of her uterus. You can see it and we can touch it right now with the forceps. This is a polyp, and if we go past the polyp, there is---yes! Another polyp! No wonder she's been having heavy abnormal bleeding that just won't stop and a lot of cramping. Now, these polyps must come out. They have at least a 5% chance of harboring a cancer, so we are going to take them out. This is the base of this polyp. It probably has a blood vessel and a fibrous base, which means it has been around for a while. You can see how we take these out. We're going to grab the polyp and essentially tear it off the base. It may bleed a little bit, but we should be able to break it free of its connections. We'll do the same thing with the other polyp. After the polyps are removed, we are probably going to make sure her tubes are open with some wires and then she will be able to go home.
This is a very quick, safe procedure--hysteroscopy—with very, very low risk. She is under anesthesia, but it is a very light anesthesia called a laryngeal mask, so she won't even have a sore throat when she wakes up—about fifteen minutes from now. This is a hysteroscopy for endometrial polyps, and we are going to get these polyps out. It's probably going to take me a little longer than this video will allow, but you can see how we are going to break off the base and then grab it with a tenaculum. Maybe we can get this polyp out during this video. You can see the base has been broken. We're going to use a little grabber instrument called a tenaculum. Now, this polyp is pretty big, and it may not want to come out through this small opening, but let's see if we can get it for this video. I'm going to twist it, which is called "roping" it up, and let's see if it will come. It may resist. It looks like we may need to clip the base with some scissors, but you get the idea.
We are going to get this polyp out, and look at it under the microscope in the pathology department, and if it is cancer, we'll need to see what kind it is and treat her appropriately. Clearly, we need to get these polyps out, because that should stop her excessive bleeding. We will then manage her with carbohydrate restriction, weight loss, and medicines of the progesterone type, and this will get her back to normal, fix her bleeding, and restore her fertility.
This is Dr. Wilshire of Missouri Fertility in Columbia, Missouri. I hope that was interesting for you. Thank you very much.
In this video Dr. Wilshire discusses the repair of blocked fallopian tubes with Tubal Cannulation surgery.
Hello. This is Dr. Wilshire of Missouri Fertility in Columbia, Missouri. Today, we're doing something called a tubal cannulation. Our patient today was told she had blocked fallopian tubes. [She had normal-looking tubes with no history of infection or of severe endometriosis.] She had a laparoscopy a number of months ago, and they were unable to get dye out through the tubes. Today, we're going to see if that is really true. What we are doing is, we are starting out with something called a hysteroscopy. We are looking in her uterus, and we've opened up her uterus with salt water under pressure. We've cleaned out some polyps and some other abnormalities, and now we are able to see the inside of the uterus and the opening of the fallopian tubes. This is the inside of the uterus, called the endometrial cavity, and you can see the openings of both fallopian tubes. There's the left tube, which is on our right, and the right tube, which is on our left. So, now, we are going to take this wire, which is called a urologic Glidewire® (guidewire). We borrowed this wire from the urologists; they use this to remove kidney stones. We are going to put this wire up into this tubal opening that is called the ostium, and…look at that! It passed through a slight obstruction, and you can see the wire going up the tube. I bet you that tube is nicely open now, so we are going to slide the wire out. Fantastic. The right tube is probably open now. And now, we will go over to the left side and perform a similar procedure. There's the opening of the tube, the ostium. We are now going to advance the wire. We've encountered a little obstruction here, so we are going to see if we can get it through, and it does…fantastic! That wire also slides up, so I bet you the left tube is open as well. I'm going to take a picture while I'm here. So, there you have it—that's called a tubal cannulation. Both tubes are now open in this nice woman, and I suspect she will be able to have babies with very little difficulty at this point. Thank you very much. This is Dr. Wilshire of Missouri Fertility in Columbia, Missouri.
Dr. Wilshire discusses surgery for pelvic pain after an ectopic pregnancy.
Hello. This is Dr. Wilshire of Missouri Fertility in Columbia, Missouri. Today is obviously a Surgery Day. We have a very interesting case today. Our patient is a young woman who, several months ago, had an ectopic pregnancy. It appears to have been on the right side. Ectopic pregnancies are pregnancies that occur in the body, but outside of the uterus. These can be life-threatening. They are deadly. Nowadays, we can treat them with medicine rather than with surgery most of the time. So, she had her ectopic pregnancy about six months ago. It was treated medically, and she recovered from the pregnancy. Her pregnancy hormone levels are now zero—but now she has pain in her pelvis, and this strongly suggests that she has scar tissue from where this pregnancy used to be. Now, 97% of ectopic pregnancies are in the tube, and almost all of them are around the tube, so we can expect a lot of scar tissue around this tube. We need to evaluate the tube and get her out of pain; these are both very important goals. and we should be able to accomplish both. Of course, some very difficult decision making will need to be made, however—do we save this right tube, can we open it, can we free it of scar tissue, and can we get rid of the issues that might be causing her pain? That's the situation, and that's why we need to go inside. Hopefully, the left tube is open and looks really good. The right tube, however, will almost certainly have scar tissue around it. Now, if we take the right tube out, then she will be forced to use only the one remaining tube to become pregnant. If we leave it in and it is open, then she is at higher risk for having another ectopic pregnancy in this tube. The risk is at least 6% and probably closer to a 25% chance of having another ectopic in that tube. She is aware of this and so is her family. This is a good example of how we can improve anatomy, but we can't make everything perfect again. So, we're going to do the surgery, hopefully help her out, and hopefully not have to make too many difficult decisions. This is Dr. Wilshire of Missouri Fertility. Have a nice day.
Ever wonder what to expect before surgery? Dr. Wilshire and nurse Kim discuss what to expect in a pre-op visit before surgery.
Hello. I'm Dr. Gil Wilshire of Missouri Fertility. And I'm Kimberly Ritter, RN, BSN, Surgical Coördinator. G: Today, we're going to be discussing your preoperative preparation. At this point, you've probably had a chat with us about having surgery, we've probably discussed the risks, benefits, and alternatives, and we have all decided that surgery is a good idea for you. Most of our surgeries will be laparoscopic or minimally invasive, so your recovery should be very rapid. Some of you may be having a larger incision and a larger surgery, and obviously your recovery will take a little bit longer, but our standard instructions go something like this—you're going to need a bowel prep. How do you like those bowel preps done, Kim? K: Approximately two days prior to your surgery, we would like for you to get a laxative--magnesium citrate, and drink that the morning of the two days prior to the surgery date. G: So, two days before the surgery, in the morning, you are going to drink this bottle of magnesium citrate. I've heard if you pour it over some ice, it's all right. Maybe a little juice. K: Right. You can put it in the refrigerator, just chill it a little bit, and it's ready to go. This is about an 8 to 10 ounce bottle, sold over the counter at any pharmacy. Just ask the pharmacist and they can help you with that. G: Yes. This bowel prep is not like a bowel prep you would have for a colonoscopy. This is essentially just to get your bowels basically empty. We want you to have a large bowel movement the day before the surgery, so you can come into surgery basically empty, and then you won't have to go to the bathroom for a day or two afterwards either. K: True. Perfectly. And after you consume the magnesium citrate, you can eat lightly that day. G: Yes. Just eat lightly. You don't have to be N.P.O. (which means "nothing by mouth"), but eat lightly the two days before the surgery. Now, the night before the surgery at midnight, what happens, Kim? K: I'd like for you to not eat or drink anything after midnight the night before the surgery. G: Nothing. K: And do not eat or drink anything the morning of your surgery date. G: That's right. You can brush your teeth, but make sure you spit the water out. We want to make sure that you have an empty stomach. Now, the one exception is for medications, I believe. K: If you should have any questions or any concerns, you will be seeing the anesthesiologist and the nurse prior to your surgery, They will call you two days prior to your surgery. G: That's right. They will be telling you what medications you might take the morning of the surgery with a small sip of water; that's okay, and they will be talking to you about that. You might need a blood pressure medicine or a thyroid medicine. There are a few medications they might want you to take, but most of your medications you probably will not take the morning of the surgery. Also, the morning of the surgery, Please take a shower. We want you clean, okay. You don't have to put on fancy make-up or perfume or anything, just come in clean with your teeth brushed. After the surgery, generally what happens, Kim? K: Recovery time after surgery, you can expect four to five days, We will see you back in the office for a post operative visit approximately seven to ten days after your surgery date. G: That's right. After the surgery, we will have what I call a Debriefing Visit. We'll talk about what we found, and we'll talk about future plans, depending on what we found and what we accomplished. Most of our surgeries are minimally invasive, and recovery is generally very rapid, but we generally like for you to take it easy for at least two or three days after the surgery. Many women are able to go back to their normal activities in four to five days, but—as they say--your results may vary. There you go. So, Kim, thank you for your insights. It's wonderful working with you, and I look forward to doing another wonderful surgery, here at Missouri Fertility.
Hello. I'm Dr. Gil Wilshire of Missouri Fertility in Columbia, Missouri. Today, we are going to be discussing fertility treatment and its effect on long-term health. I get this question all the time. Women are concerned, "I was treated for fertility over these years. I had some IVF babies, and now I have these health issues coming up. Did my treatments affect my health?". These are very good questions, so let's discuss this issue. One aspect of fertility treatment is, we frequently give medications to produce more eggs. It's a common misperception that if we produce more eggs each month that we are running down, that we are "using up" the eggs in the "pool" that every woman has. The answer to this is "No". When we give women medications such as injectable medications to make lots of eggs for in vitro fertilization, for example, we are not getting more eggs to grow, we are taking the eggs that are already waking up and getting ready to grow and we are promoting growth for all of them. Kind of like "a rising tide raises all ships". We are not depleting the number of eggs, even though it seems like we may be doing that. So, are we bringing on early menopause with treatment? Probably not.
A second problem or difficulty with this whole field of inquiry is that it will be almost impossible to prove a connection between fertility treatments and adverse outcomes in the long term. Let me explain a little better. To prove something in medicine, you need to do something to one group and NOT do it to another group, then follow them over years and see what happens. You can see in practical terms, that will never happen with fertility treatments. We are not going to give placebos or sham treatment to half of the patients who come to us. We are going to treat everybody. So, when you see in studies that maybe there is a link between a problem and a fertility treatment, what you are looking at is an association, part of a process called epidemiology, where you give some women a questionnaire, and you go back and see how often did the women experience this, or this, or eat this, or was treated with this, and you look for associations, or their increased risk of an outcome that is associated with a particular medication or a particular treatment. These may show small-percentage changes, but the problem with epidemiology is, unless you see a HUGE change in outcome—a three- or four-fold increase in something—then, the associations are weak and usually meaningless; this is what I call pseudoscience. There is no science that shows causality, and associations are NOT causality. One of my favorite examples of an association not showing causality is a fire. Say, your house is on fire. You go home, and you are going to see the fire department. You're going to see their trucks. You are going to see the firemen. So, you might say, "Aha! Firemen cause fires!" Well, they do not. They are associated with fires, but obviously, they are not causing them. So, that's the conflict you see between causality and association.
A third issue you need to understand is that chronic diseases and health conditions are associated with increased infertility or subfertility. Chronic diseases—such as autoimmune diseases, not just lupus but rheumatoid arthritis and psoriasis of the joints—these things can be associated with a lower fertility rate. Underweight, overweight, chronic pain, all kinds of chronic medical conditions will lower a woman's and a man's fertility potential. So, you can see that we are dealing with a pool of people who are more likely to have some chronic diseases, and this is the same pool of people who are more likely to have chronic diseases later on in life. Once again, it is an association, not a causality. One other thing—since I mentioned autoimmune diseases— some of these diseases actually get better in pregnancy. Pregnancy will make some of these conditions better, and some women with these conditions generally feel best when they are pregnant. Pregnancy does decrease the risk of some cancers and nursing, particularly longer than a year, may decrease the risk of breast cancer as well—so, there are benefits of pregnancy. It is very difficult to weigh risks and benefits and extrapolate them over the long term. Very difficult. So, if you are having health problems and you underwent fertility treatment, the natural question is, "Did my fertility treatment cause my problems?", and the answer is, "Probably not". Now, obviously, there may be some things going on that we don't understand yet. Future studies may show associations that actually do demonstrate causality, but at this point, there is NO evidence of long-term health damage due to fertility treatments. Fertility treatments—while you are doing them—can result in ovarian hyperstimulation and hormone issues and, obviously, treatment may have some risks, but as far as long-term health effects, there is no good evidence that fertility treatment affects future health or has any long-term damage to the body. So, I hope that answers your questions. This is Dr. Wilshire of Missouri Fertility.
Hello, everyone. My name is Heather, and I work at Missouri Fertility with Dr. Wilshire. I have a little girl I had at 20 years old. Her name is Genevieve. After having Genevieve, I was told by my ob physician that it was going to be super easy to have another child, but at that time I was not ready, so I had the Mirena IUD placed in my uterus. A few years later, my husband and I discussed that we would like to make our family a little bigger. So, in 2015 I had my IUD removed and we began trying to have a baby; however, we were unsuccessful for a while. The job here at Missouri Fertility came to my doorstep, and I gladly accepted it in 2016. Once I began working here, I began to see other patients' journeys, and it made me realize that something was wrong. I discussed this with Dr. Wilshire and he suggested some options that might help my husband and I, but he said that it is not a good idea to wait, and we should get the answers we need, then decide what we want to do from there. I am glad that I received the answers we needed, and we are super excited to be able to choose the route we wanted to take from there. So, if you want to get the answers for your journey, then come to our Infertility Awareness Conference. It will be held on April 27th here in Columbia, at the Country Club. We will also be having lunch, and it is free to come. So come to our conference to get your answers for your specific problem. We look forward to seeing you. Of course, we are always ready to help you in our office. Just call and make an appointment to see Dr. Wilshire. You will always be thankful you did.
Dr. Wilshire recently got together with Cosmo from Y107 to discuss infertility and what Missouri Fertility does to help build families in the midwest region: