David Redwine, MD

:  “I’m Togas Tulandi and I’m the Professor for Obstetrics       and Gynecology at McGill University in

Montreal, Quebec, Canada.  Beside       me is Dr. David Redwine who is the Director of the Endometriosis Institute       of Oregon.  David, you and I       have been interested in endometriosis for a long time, what’s the       current management of endometriosis in women with infertility?”

:  “Of course, that depends on who you talk to.        There’s a variety of opinions out there ranging from the old       reproductive endocrinology opinion that you shouldn’t do anything       surgically to endometriosis because you will induce adhesions that can       sterilize the patient to medical management, although there is no FDA       approved medicine for treatment of infertility associated endometriosis,       to extensive surgical removal of all endometriosis by surgeons that are       capable of doing that.  Those       three main prongs of management are continuing to this day.”

:  “I think there is enough evidence showing that surgical       treatment is better for infertile patients because there is no delay in       fertility, after surgery they get pregnant.        Let me ask you, what technique is the best to remove this       endometriosis at laparoscopy?”

:  “I think if a surgeon believes that endometriosis is       causing a symptom, whether it’s infertility or pain, the surgery that       results in the most complete removal of the disease should be the best       surgery.  In my hands, I found       that excision is the thing that works the best.        In the early years of my practice, I remember treating two patients       with electrocoagulation and I re-laparoscoped those patients two or three       months later and their disease was still present.        It was at that point early in my career that I decided for me the       only way that I could treat this disease comfortably was to remove it and       make sure it’s all gone.  So       I believe that excision is the best way to treat the disease whether       it’s superficial or deep.”

:  “Actually, I would agree with you; I have stopped doing       coagulation.  I found the same       thing like you, at second-look laparoscopy we find endometriosis again,       and the risk of adhesions after excision is very small.        Coagulation causes thermal damage as well and might cause       adhesions, and I have done many second-look laparoscopies after excision       and there are very little adhesions.        In fact, on one we operated on, we stripped the whole peritoneum       and I found very little adhesions.”

:  “I think it depends in part on where you operate, if you       operate on or around the ovary, I think that that patient is more prone to       develop some adhesions than if you do endometrial surgery at the bottom of       the pelvis where fortunately the endometriosis is most commonly located       anyway.”

:  “Now I think you’re still using unipolar scissors?”

:  “Have you used other techniques – laser or others?”

:  “I have never fired the laser out of the human female       pelvis.  I’m probably one of       the only gynecologists that might be able to say that at this point.        The only other technique that I’ve used laparoscopically is the       two early cases about twenty-one years ago of LF coagulation, which I       mentioned.  I formerly used       the scissors just in a cold cutting technique but I found that       electrosurgical excision is just much easier, faster, and it makes surgery       pleasant for me again.”

:  “I’ve used laser and I’ve used electrocoagulation, now       I’m using scissors.  I think       that the results are the same, and there are several studies showing that       the results are the same.  Now       how about pelvic pain, David, is your approach the same?”

:  “Pelvic pain is the most common and most specific symptom       of endometriosis, and I think that once again if the doctor believes that       endometriosis is the cause of pain, the surgery that removes the disease       most completely is the best surgery.        So I treat endometriosis the same for any symptom of any age       patient, it’s always excision and it’s always aggressive excision.        Now you have to remember though that I’ve operated on over 2,200       patients with endometriosis at this point in my career so I’m quite       comfortable doing this.  Excision       isn’t something that every surgeon should just jump in and start to do       because everybody agrees that it is technically more difficult than laser       vaporization or electrocoagulation, but it’s also by the same token much       more effective.”

:  “Maybe I should mention that there is a study in Canada       looking at infertility in women       with mild or minimal endometriosis and treatment could be with       laser, electrocoagulation, or excision.        It seems like the results with any technique is better for       infertility than no treatment.  But       that’s only for minimal and mild endometriosis, we don’t know about       more extensive disease.  Let       me ask you about post-op medical treatment.”

:  “I don’t, most of the patients who come to see me have       had multiple rounds of previous medical therapy and multiple rounds of       surgery.  I could not convince       my patients to take medical treatment after surgery even if I wanted to or       even if I believed in medical treatment, which I don’t.  I also don’t like the patients to use medical therapy after       surgery because then that obscures the true effect of surgery.        One of the things that people may not notice when they read a       follow-up study that I might produce is that the results that they’re       seeing are primarily the results of surgery and not combined surgery       followed by medical therapy which frequently can be something that you see       with other surgical…”

:  “How about medical therapy before surgery?”

:  “I don’t like to use it before surgery either because Johann       Evers showed, I think back in 1988, that if you have somebody on a       GnRH agonist that not all the endometriosis is visible at the time of       surgery.  If you stop the agonist and wait three months, more       endometriosis is visible so that’s one of the things that worries me       about the GnRH agonists and doctors thinking that it makes surgery easy.  Does it make it easy because they see less of the disease and       so the surgery is more incomplete?  I       think that may be what’s going on so I like to see the disease       full-blown and stimulated as much by estrogen as possible so that I have       every possibility of finding it and removing it.”

:  “I would agree actually.        I don’t use LHRH analogues before surgery; it doesn’t make the       surgery easier.  I also       don’t use it for a myoma before myomectomy; in fact, it makes the       surgery more difficult.  Sometimes       there is no surgical plane       and there’s more bleeding so I       don’t use LHRH.  I might use       LHRH analogue post-op for pelvic pain but as you said, it might obscure       the result of your surgery.  Let       me just close this interview by saying that for some women who are       interested in endometriosis there is an Endometriosis Association.  I think they have their own website which they can visit as       well.  I’d like to thank Dr.       Redwine; David, thank you very much.”

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