Less Invasive Laser Process for Infertility
Bill and Becky Pittman wanted desperately to have a baby, but weren’t having any luck. The La Habra couple underwent all the appropriate tests and everything checked out fine. Still no luck. Be patient, Pittman’s gynecologist advised her.
Two years and an infertility specialist later, the frustrated 35-year-old administrative assistant discovered the cause of her problem: Like an estimated 4 million to 10 million American women, she was suffering from endometriosis, a benign but progressive disease that causes infertility in more than 60% of these women.
In mild cases, endometriosis, which can cause chronic, frequently debilitating pain during menstruation and sexual intercourse, often can be treated with drugs, including male and female hormones.
In the Past, Major Surgery
But for many women, such as Pittman, surgical removal of endometrial growths--uterine tissue found outside the uterus on the Fallopian tubes, the ovaries, bowel or other pelvic organs--is the best option.
In the past, that meant undergoing major abdominal surgery, a costly operation requiring a four-inch incision, a four-day hospital stay and a four- to six-week recuperation. And even then, infertility experts said, a previously infertile patient had only about a 40% chance of getting pregnant, because the disease would return or post-operative scar tissue could develop in the pelvic area that would interfere with the transport of the egg.
Today, however, there is a less extreme, less costly and, say its proponents, more effective surgical option: laser laparoscopy, in which a carbon dioxide laser is delivered through a pencil-thin optical device known as a laparoscope. The thin laser beam quickly and accurately vaporizes the diseased tissue and cuts any adhesions.
Some surgeons familiar with the technique believe this less-invasive form of surgery improves the odds of pregnancy in these women to 60% or better.
“I hate to call it a revolution in medicine, but it is a breakthrough in the treatment of infertile patients,” said Dr. Ari Babaknia, director of the California Infertility Institute in Tustin and one of the first surgeons in the state to perform the operation.
The procedure, which Pittman underwent last year, requires only two quarter-inch incisions--one below the navel for the insertion of the laparoscope and another for cleaning and suctioning out the unwanted tissue. Each incision is closed with a single stitch.
“One thing that makes this attractive--and even a breakthrough--is you’re achieving greater results with less invasive surgery: We don’t open the abdomen and the patient does not stay in the hospital four days; she goes home the same day,” he said.
The operation is performed on an outpatient basis and most patients return to work within a day or two, he said. Without the hospital stay, the cost is about half that of conventional surgery, he added.
‘I Can Do Anything’
While Babaknia and other specialists have hailed laser laparoscopy as a superior treatment method, other physicians said they will await more clinical data on the procedure’s effectiveness.
Dr. Charles March, chief of gynecology at the USC School of Medicine and president of the Pacific Coast Fertility Society, said: “There’s a tremendous amount to be said for laser surgery. There are lots of advantages, but the danger is (thinking), ‘I have a laser. I can do anything.’ ”
Dr. Sergio Stone, director of reproductive endocrinology and infertility at UC Irvine Medical Center, describes the laser as an “excellent tool” which, when used through a laparoscope, “will allow us to do a lot of things without opening a patient.”
Stone said, however, that “many patients still need to be opened, because with a laparoscope you can’t do everything. I know I have saved many patients from major surgery with a laparoscope, but with many patients you can’t do that--if there is an ovarian tumor (for example). . . . There are many conditions you can’t do.”
Babaknia agrees, saying the abdomen would have to be opened if solid tumors were present, or in cases of a blocked Fallopian tube, especially blockages adjacent to the uterus.
Lasers have been used for eye surgery and other applications for the past 20 years, but it was not until the early 1980s that the use of the abdominal laser via laparoscope began, according to Babaknia. In 1985, laser laparoscopy was accepted by the American College of Obstetricians and Gynecologists and approved by the American Medical Assn. as an effective and safe way of treatment, he said.
March believes that although efficacy of laser laparoscopy has been proven, its superiority over conventional procedures has not. Doctors who claim that laser laparoscopy results in a 60% pregnancy success rate may be treating only patients with milder stages of endometriosis, he said.
Babaknia conceded that when he began performing the procedure two years ago, it was only in mild to moderate cases of endometriosis. But the more comfortable a surgeon gets with the technique, he said, “the more advanced cases you do.”
“One of the key points about laser surgery is for the surgeon to understand the limitations of his ability or the laser’s ability and also to carefully select the cases for this procedure,” Babaknia said. “Not every case is appropriate for laser.”
Stone also questioned claims that laser laparoscopy increases the pregnancy success rate over other methods of treating endometriosis.
“Nobody has shown yet there are more pregnancies,” he said. “Where are the controlled studies showing it is better?”
In a review of the medical literature on laser treatment for endometriosis that he plans to present to the American Fertility Society, Babaknia said he has found a 58% overall pregnancy success rate among more than 1,200 cases of laser laparoscopy. Among mild cases of endometriosis, he said, there is a 58% success rate compared to 40% for conventional surgery or medical treatment; and a 52% success rate for severe cases--compared to less than 40%.
Dr. Camran Nezhat, director of the Fertility and Endocrinology Center in Atlanta and one of the nation’s pioneers in laser laparoscopy, reports an even higher success rate.
“My recent data shows that, in the hands of the experienced surgeon, the results are definitely better than anything available at the present time,” Nezhat said.
Scar Tissue Less Likely
Nezhat said previously infertile women who have the laser surgery for minimal or mild stages of endometriosis can expect an 85% pregnancy rate, the same as for the general population. For those with moderate or severe endometriosis, he said, it’s about 65% to 67%.
“The main ‘Catch 22’ is the patient must be treated by somebody who is extremely experienced, because you have to get (all the diseased tissue) out,” said Nezhat, who has performed the operation on about 2,500 patients.
Babaknia said the technique is superior to open-abdomen surgery “because you decrease the risk of the patient having post-operative scar tissue.” It’s also superior to other laparoscopic procedures in which endometriosis is either cauterized or cut with long scissors inserted through a laparoscope, he said.
“With cautery, nobody dares to touch the bowel, bladder, pelvic sidewall, Fallopian tubes or to burn endometriosis lying on top of the vital organs,” Babaknia said. “With the laser you can be more aggressive.”
Because of the high degree of heat required to cauterize tissue, cautery can damage adjoining cells, Babaknia said. The laser, however, vaporizes the cells at such a relatively low temperature (100 degrees) that it does not damage the adjacent tissue: It vaporizes an extremely thin layer of tissue--one-tenth of a millimeter compared to more than five millimeters with cautery.
Although major open-abdomen surgery is still the standard of care in treating endometriosis, Babaknia and Nezhat predict that within the next five to 10 years--as more surgeons learn the new technique--90% of surgery for endometriosis will be performed with the laser.
Becky Pittman is one of Babaknia’s success stories: By her reckoning, she became pregnant on May 20, 1986, only 18 days after undergoing laser surgery.
“I think we were very fortunate, because we didn’t expect it to happen that quickly,” said Pittman, who gave birth in January to 5-pound, 11-ounce Melinda Brooke Pittman.
“I found it was a good experience,” she said of the laser technique. “The healing process was nothing, and I didn’t have open wounds or things you have to normally contend with.”
Babaknia emphasized that there is no guarantee that endometriosis will not reappear after surgery.
“We’re not really curing the cause of it; we’re removing what’s there,” he said. “We’re hoping that before it comes back, 60% (of the patients) or more will get pregnant.”
