Surgical Options for Fertility Care

Dr. Zaraq Khan discusses his journey and passion for reproductive surgery, addressing complex fertility challenges and advocating for better surgical training and research.

Good morning, everybody. Congratulations for making it this far into the meeting. My name is Zaraq Khan, and I'm the chair of Reproductive Endocrine and Infertility at Mayo Clinic, and have a joint appointment in minimally invasive GYN surgery, and reproductive surgery is one of my passions.

When I was asked to give this talk, they told me that this would be more of a prez. Please tell me if you can, okay, you can hear me. So I was asked to give it more in a TED-style talk, and give really a story of why I'm so passionate about reproductive surgery.

We'll start by just saying what my career path was, and my personal journey and career choice of why I'm interested in reproductive surgery starts from residency and fellowship. For those of you who do reproductive surgery, or minimally invasive GYN surgery, these are not any familiar, these are pretty familiar pictures to you. So patients like these would come to our clinic, they would come in with years of pain, years of infertility, 20, 30 years old, and we would have no options for them.

I was working at the Mayo Clinic, which is the number one hospital in the US, and we would still have no options for these patients. We would tell them to go on Lupron, put a Band-Aid on it, we would say, go have surgery, send them to a GYN oncologist who sees cancer everywhere, and of course does a big debilitating, debulking surgery for fertility, debilitating for fertility, but really enhancing for their pain. So we would give patients a pain-free life, but also a child-free life.

And that is where my passion really started for reproductive surgery. Cases like these, where we had no options, absolutely no cure, no hope for these patients. I took it upon myself to really travel the world to try and get the best training that I could, and I'll explain to you why that's so important.

I start in Pakistan, which is home for me, and then went on to the Mayo Clinic to do my residency and fellowship in reproductive endocrinology and infertility, residency in OBGYN, and a master's in clinical research. I still couldn't take care of those patients with those advanced diseases. What I then did was take a sabbatical, travel around the world, and learn from experts, because we all need the appropriate training to cater to our patients well.

And from that, we started with doing and starting a complete division of reproductive surgery in our group. And when I think of the topic for today's talk, which is who do you take to diagnostic evaluation in infertility, it's a one-slide show, essentially, but I really want to take you over this journey of why this is my passion and how we can continue to help these patients. When I think about just basic approach, there's certain very significant things that a reproductive surgeon can see, and I break them by organ system.

So the ovary can have endometriomas, or endometriosis. There can be ovarian hyperthychosis, where surgery can help fertility. For the uterus and cervix and vagina, the most common one are obviously fibroids, adenomyosis, isthmus seals, polyps, Asherman's, malaria anomalies, combination of all these things that can make care exceedingly complex in otherwise physicians trained to do IVF only.

When we talk about the fallopian tubes, proximal disease, hydrosalpinges, history of tubal ligation, all of these are important things that we can help patients with with surgery to enhance their fertility. And really what we need is primarily a good history, because we're trying to see if the patient is in pain, especially in cases of endometriosis, and if that is one of the primary goals for the patient. And just start with basic imaging, just an ultrasound.

That's all we're starting with, because if we look at an ultrasound, you can catch all those list of ingredients for a reproductive surgeon that I listed. Now from there, one can move on to advanced imaging like MRI and dynamic MRIs when we talk about deeply infiltrating endometriosis, but for the purpose of screening, I think ultrasound and a history, talking to the patient about pain versus fertility is the bread and butter of a reproductive surgeon. Now as we sort of move forward, I want to describe to you sort of the various categories that I keep in my mind for reproductive surgery.

But before we even start that, I think the key ingredients for the success of any surgical field advancement are twofold. One, and most importantly, is surgical skill, training, knowledge, confidence, expertise, and knowledge of anatomy. Without that, I don't think you could be a good surgeon.

Followed by high quality multi-center research regarding surgical outcomes for pain, and of course, fertility outcomes. Those are gonna be the two most important essential ingredients for success. But when we think about reproductive surgery, in my mind, I try to make it simple and divide it into sort of four categories.

When we look at the first one, these are, in my opinion, technically easy surgeries, and there's good evidence for enhancement of fertility after these surgeries. Now here, you can see the first example, for example, is a patient with submucosal fibroids. There are two, they're fairly large.

Good data for excision of these fibroids. All the patients I'm showing you today are actually pregnant, so I specifically picked those patients to show you today. This one had a hysteroscopic myomectomy.

Within six weeks, she was pregnant. Did not require any fertility treatment. Had 15 years of infertility.

This patient came in with bilateral hydrosalpinges. No problems, no issues otherwise. 12 years of jostling around from practice to practice.

Just needed a salpingectomy, followed by IVF. And this is where that knowledge of surgery and fertility really comes to play together. There are other cases that are technically, I think, easier, but there's minimal evidence to support that they're fertility-enhancing.

An example here is a uterine isthmus seal, classic uterine isthmus seal. There's some gray literature, though in our world, we usually do repair these for otherwise unexplained secondary infertility. And of course, the famous endometrial polyps that become a bread and butter for most fertility practices.

If we really look at the literature and the evidence behind that, it's gray at best. But because these are technically easy procedures, we tend to get into these, but then we make the same argument and say a stage four pelvis does not need surgery, it needs Lupron and IVF. That's where the issue lies.

I think we need to think about both things together. The next, things are technically difficult, but there's really good evidence to support that they will be fertility-enhancing. So an example here is a patient that had about 50 submucosal fibroids and her entire myometrium was studded with myomas.

So there's possibly no way of doing a safe open myomectomy because you're gonna leave this patient with a completely obliterated scarred cavity. Now that knowledge and approach of utilizing your fertility knowledge base, as well as all the tools that you have in the surgical toolbox helps patients like this. So this patient, for example, we approached with a submucosal myomectomy, followed by UAE, followed by another submucosal myomectomy to get the cavity cleared, and she is pregnant and actually delivered a couple of days ago.

So there are some nuances that you can use. This is another patient that was referred to me by one of my mentors. And this patient was told in all major medical institutes around this country that there was nothing they could do for her.

And I don't blame them. I mean, look at this pelvis. You cannot see the uterus.

And I'll show you some pictures, but it took us three hours just to get to the uterus in this case. And so moving on, we also, another one is where we have good evidence but these are technically difficult surgeries to do are something like Asherman's, when we see a completely obliterated cavity as shown here with an ultrasound, a 3D ultrasound, a sauna histogram, and then finally a diagnostic office hysteroscopy and the ultimate postoperative image that we achieved after surgery. Again, these are some of very, very tough cases, but they are good evidence to show that surgical correction really enhances fertility.

And then comes this whole bucket of what I call technically very difficult surgeries with minimal evidence. An example for here is an adenomyoma, a localized adenomyoma in the posterior wall of the uterus. These are primarily patients where we talk about pain and fertility and balancing that act.

And you can see here excision of these adenomyomas are fairly aggressive, but work well. Similarly here, you can see ureteric disease and bilateral anastomosis of the endometriosis. And finally, some bowel disease that are really aggressive, but help patients with their pain.

And in my opinion, also gives them a bump up in their fertility. Now, why a reproductive surgeon? We can deal with complex fibroid cases, adenexal cases and keep the age and ovarian reserve and IVF before or after surgery in mind. And we can take care of their post-op care as well as bridge to their fertility.

And we can counsel them for third party and gestational carriers, egg donors, when appropriate. Now, this is what I wanted to show you, the before and after advanced training or additional training is that same patient where it took us about eight hours. We did an LAR, bilateral salpingectomy, an adenomyomectomy, ileocecectomy, and actually a bladder excision for a nodule.

And this patient is pregnant post-IVF. Again, in the interest of time, I'm gonna zoom real quick to my last slide. And I want to take some take home points.

Reproductive surgery has a big role in fertility treatments. They let your symptoms and basic imaging be your guide. When we talk about more training, I'm really excited to announce that the SRS has started the surgical tracking for fellows.

So I think there's gonna be a lot of bridging of that gap of lack of surgical training. And then we're making a call for collaborative multi-center research because as you know, the two important ingredients for success is surgical skill and multi-center research. So I'd like to thank everyone for their time.