The Group for Women has been presented the Silver Award for The Best of the Best – Health and Beauty – Family – Ob/Gyn

Thanks to all of our patients for their votes!!

by Barbara L. Kersey, Ph.D

The emotional stress associated with infertility evaluation and treatment has been likened to the experience of the death of a child or the stress experienced by families who have a loved one missing in action. Those who experience infertility may be surprised at the toll that the experience is taking on them (and on their marriages). Even the healthiest partnerships may be stretched to their limits with the experience of having difficulty conceiving a much wanted child.

Initially, couples who experience infertility feel shock that conception is not happening according to their plans. Often, these are mature, wise, responsible people who have taken care to plan marriage and family at a time in their lives when they are equipped to handle the responsibility of children. With the realization that there is a problem with conception, a couple begins to experience the emotional roller coaster ride of infertility. With each month there is a cycle of hope followed by devastation. The longer the attempts at conception, the more intense the emotional process becomes. Long-term infertility patients experience a variety of emotions: despair, anger, jealousy (of those who have children), depression, difficulty mustering energy for other life tasks, and a profound alienation form others – feeling different, with difficulty fitting into a world that expects couples to have children. It is not uncommon for clinical depression to result.

Of course, men and women handle their emotions very differently. SHE needs to talk about her experiences.  HE will often feel frustrated by talking, as it may seem futile to him. It is important that the couple understand these differences and for the woman in particular to find a safe and helpful support system.  Marriages are stressed additionally by the immense decisions that can be a part of infertility treatment.  Some of these are: “How much money can we spend?” “What level of technology are we willing to use to achieve our goal?” “Will we openly share with others the fact that we are involved in treatment?” Couples rarely agree on their answers to these questions without some time (and perhaps help) to process the myriad of feelings and issues involved.

Couples are often hurt and disappointed by the good intentions of people who care about them. Statements that illicit hurt, as well as anger, include: “Just relax and you’ll get pregnant,” or “Take a vacation and you will conceive.” While each of these statements may be an attempt to be supportive, they are really said in ignorance of the intense emotional process that infertile couples face.

The most convincing evidence for the importance of emotional support for infertility patients is this:  research shows that those who get support have pregnancy rates that are higher than their counterparts who have no support network. Whether or not support helps with conception, it is a necessary part of treatment for many couples.

by Tina D. Fries

Abnormal bleeding. Uterine Fibroids. Pelvic pain disorder. Endometriosis. These are some of the most common reasons more than 600,000 total abdominal hysterectomies are performed on women each year in the United States, making hysterectomy one of the most commonly performed surgical procedures.

By age 60, one in three women will have undergone the procedure, with 65% of them having both uterus and cervix removed, with or without ovaries or fallopian tubes, in the most invasive way: through a 4-8 inch abdominal incision requiring an extended hospital stay and a 4-6 week recovery time.

But there are alternatives to total abdominal hysterectomy. Vaginal hysterectomy — with or without the assistance of a laparoscope — is performed by removing the uterus through an incision in the vagina, requiring a 2-day hospital stay and 4-week recovery period.

Since 2001, Surgeons Jon L. Crockford, M.D., and C. Dwight Groves, M.D. of The Group For Women, a Division of Mid-Atlantic Women’s Care, PLC, have been teaming up to bring a third, minimally invasive alternative called laparoscopic supracervical hysterectomy (LSH) to women in Hampton Roads. Laparoscopic supracervical hysterectomy is performed by making three half-inch long incisions in the patient’s abdomen through which the upper two thirds of the uterus is removed. The bottom third of the uterus — the cervix — is left in place and therefore no incision is made in the vagina.

While not an appropriate option for women with malignancies, LSH offers a number of benefits for the patient with benign disease including a short, one night or less hospital stay, significantly shorter recovery time of 7-14 days, less scarring, less risk of injury to surrounding organs, fewer post-surgicalncomplications such as infection, better long-term support of the top of the vagina and maintenance of sexual health, including earlier resumption of sexual activity. “With this procedure, we’re not seeing the GI complications or the infection complications,” said Dr. Groves. “We don’t have the wound problems we had before. For obese patients this may actually be better than the other options.”

Equipment Advances Increase Safety

LSH uses specialized equipment including a laparoscope, a thin lighted endoscope connected to a camera that allows the surgeon to see the patient’s organs on a monitor, a harmonic scalpel for cutting and a uterine morcellator with a thin rotating barrel that removes the organs in tiny pieces through a long, cylindrical tube.

“Given recent advancements in technology and new instruments on the market we are able to accomplish a large operation inside the body through small, minimal incisions,” said Dr. Crockford. “We now have the technology to do this procedure safely and quickly.”

Both physicians affirm that wasn’t always the case, given the equipment of yesteryear. “It was dangerous when they first started doing laparoscopy in the 1950s,” said Dr. Groves. “Getting the initial point of entry used to be the most dangerous part of the surgery and they used monopolar electricity which resulted in burns.”

But with advances in equipment and technique, incandescent lights gave way to fiberoptics, blades for entry were set aside in favor of blunt, clear-tipped trocars, and air pumps were replaced with computerized equipment to monitor the precise amount of air being injected.

“We used to put our eye to the eyepiece and now we have a camera and digital images so it’s actually better than the naked eye,” said Dr. Crockford.

Unique Learning Curve

Dr. Crockford and Dr. Groves trained in LSH at Florida Hospital Celebration Health in Orlando under the medical direction of Steven McCarus, M.D., nationally recognized for laparoscopic surgical expertise.

“The learning curve with this procedure is a little different,” explained Dr. Groves, who earned his medical degree from Marshall University in Huntington, West Virginia and completed both internship and residency with Eastern Virginia Medical School. He practiced with The Group for Women early in his career and returned in 2000 to log a total of 12 years there.

“Normally with surgery things are very tactile, but this is a very visual thing, very remote,” he said, zeroing in on one of the major challenges physicians face in using robotic techniques. “We’re outside of the body so we have to work with visual cues without the benefit of the sense of touch.”

Dr. Crockford earned his medical degree from the University of Virginia and completed both internship and residency in obstetrics and gynecology at Barnes Hospital, Washington University School of Medicine in St. Louis, Missouri. He has been practicing with The Group for Women for 26 years.

Since completing their training in LSH, Dr. Crockford and Dr. Groves have performed 270 of these procedures with consistently positive outcomes and an estimated one percent conversion rate to abdominal hysterectomy. They perform an average of 2-5 per week, the vast majority of them at Sentara Leigh Hospital. While national averages indicate that 65% of women continue to have traditional abdominal hysterectomy, the frequency and demand for LSH at Sentara Leigh Hospital during 2003 actually reduced this figure to 45%.

To aid physicians like Dr. Crockford and Dr. Groves in their work, Sentara Leigh Hospital is in the process of developing a state-of-the-art operating room equipped for advanced laparoscopic procedures with voice-activated robotics.

Do No Harm

Leaving the cervix unharmed has many benefits for the patient. The cervix provides key support to the upper vagina. The uterosacral ligaments attach the vagina to the spine via the cervix and with LSH these supports are left intact. “What we’re doing with this surgery is we are saving the cervix,” said Dr. Groves. “The first rule of medicine is ‘do no harm’ and I think that applies very nicely here. With the availability of regular pap smears to screen for cervical cancer, there’s no reason to remove a healthy cervix. If it’s diseased, by all means take it out. But why increase infection rate, bleeding and the possibility of complications unnecessarily?”
One of the primary complications following total abdominal hysterectomy is posthysterectomy vaginal vault prolapse which results from not maintaining support to the top of the vagina.

“LSH preserves the pelvic floor so we’ll see fewer complications and less need for corrective surgery down the road by maintaining the cervix than we would by taking it out,” said Dr. Crockford.

Benefits for the Patient

By minimizing pain and trauma to the body, LSH provides significant benefits for the patient. The procedure reduces pain, minimizes scarring and significantly shortens recovery time. The patient can be home within 24 hours and back to their normal activities in just 1-2 weeks.

Kathryn Hall, 46, a patient of Dr. Crockford’s, elected to have the procedure in 2002 for severe uterine fibroids when she learned the recovery time with regular hysterectomy would require 4-6 weeks of missed work.

A regional manager with Landmark Property Services, Hall said, “I’m a work-aholic. The number one reason I chose the surgery was they told me I could be back to work in a week. My employer didn’t believe me at first.”

“The next day after surgery our patients are up and dressed, eating their breakfast and waiting on us,” said Dr. Crockford. “This procedure has fewer complications and patients are back living their lives sooner and they’re loving it.” “It was the most amazing thing,” said Hall. “I was stunned at how well I did and how easy the surgery was. I stayed in the hospital one night and when I came home I took Ibuprofen one time. You’re sore and you have a little bit of a problem getting up and down, but you don’t feel pain.”

The Bottom Line

Hall said in conducting Internet research prior to surgery she learned that LSH is somewhat more costly to perform than traditional hysterectomy because of the technology and equipment investment.

“It is more expensive,” said Dr. Crockford. “But we have to look at the long run and gross national product. These women are back to work 4-5 weeks sooner and that’s got to have a tremendous economic impact. Not to mention, how do you put a dollar figure on the overall impact of recovery time on their families?”  Hall expressed concern that many women, despite being better educated health care consumers via the Internet, don’t seem to know about LSH.

“I know someone who had a regular hysterectomy and I was telling her about laparascopic and she had no idea what I was talking about,” said Hall. “She had never heard of it. This is an option for women and I believe physicians should learn about it and offer it to their patients.”

Physician Awareness and Training

Research presented in the Journal of Obstetrics and Gynecology last year suggests that few OB/GYN physicians in our region of the country discuss laparoscopic alternatives to total abdominal hysterectomy with their patients. In an effort to change that, Dr. Crockford and Dr. Groves serve as consultants for Ethicon, Inc. and GYNECARE, subsidiaries of Johnson and Johnson Company who manufacture minimally invasive equipment used in the procedure.

They offer half-day to full-day training sessions for physicians every 2-3 months at Sentara Leigh Hospital. The sessions involve viewing a live surgery with twoway audio-visual feed so they can discuss techniques with their colleagues during surgery.

“We’re happy to share. We’re trying to get people trained,” said Dr. Groves. “Gynecologists are slowly coming on board. I never thought we’d have a professional relationship with a surgical equipment company, “ he added. “But we really feel passionate about this.”

by Jeffrey M. Wentworth, MD

Within recent years, the field of operative gynecology has seen many changes. These include outpatient laporoscopic hysterectomies, new suburethral incontinence procedures and advances in pelvic floor reconstruction. Now, women seeking permanent sterilization have an option  that may soon be the new  standard of care. In-office hysteroscopic sterilization offers an innovative alternative to traditional tubal ligation with a number of advantages and benefits, both to patients and physicians.  The Group For Women is now offering this option to its patients.

In this new in-office procedure, a 5 mm hysteroscope is inserted through the cervical canal into the endometrial cavity and micro-inserts are placed into the proximal fallopian tube. The micro-inserts are spring devices made of titanium, stainless steel and nickel, which induce an inflammatory response at the point of deposit. This natural inflammatory response occludes the fallopian tubes. The procedure takes approximately 1⁄2 hour to complete and the patient is in the office for about 1 hour.

The benefits of in-office hysteroscopic sterilization are numerous. The procedure is safer, cheaper, more efficacious, with an easier recovery and quicker return to normal function. Because it is an incision-less procedure, it is obviously safer than tubal ligation. Patients generally report minimal levels of pain:  levels of 1 – 2 on a 10-point scale (as compared with menstrual pain reported at level 3 on the same scale). The pain associated with the procedure is managed with a paracervical block and NSAIDS.

Recovery time is less than 1 day, with most patients returning to work and routine activity the day after the procedure. Failure rate with in-office hysteroscopic sterilization is approaching 0%, based on current studies; this supercedes any other existing method of sterilization! Compared to laporoscopic tubal ligation, the in-office procedure is 30 – 50% less expensive.

This non-surgical procedure may be especially appealing to certain patients: those who have had prior pelvic surgeries or those who are obese (and would therefore be subject to greater surgical risk). The only patient population that may not be suitable for the in-office procedure are those who have difficulty with basic office procedures, i.e. Pap smears. These patients may require additional medication or hospital-based anesthesia.

A hysterosalpingogram (HSG) is scheduled approximately 3 months following the procedure to ensure that the tubes have occluded. Prior to this confirmatory HSG, another form of birth control is required. One effective way of managing this variable is the administration of a Depo- Provera (DMPA) 1 – 2 weeks prior to the in-office sterilization. Not only does this provide the necessary 3 months of birth control, but also the progesterone effect of Depo Provera relaxes the fallopian tubes, facilitating the procedure.

Clearly, the aforementioned benefits are quite significant. For patients, being treated in a comfortable office setting by trusted, familiar staff members reduces anxiety. For physicians, we can take comfort by providing a safer, cheaper, less invasive and more convenient method of sterilization. What more could we (or our patients) ask for?! Dr. Jeffrey M. Wentworth joined The Group For Women in 2000. Dr. Wentworth is board certified and is a Fellow of the American College of Obstetrics and Gynecology. In his work at The Group For Women, Dr. Wentworth is regularly involved in the implementation of clinical trials with various pharmaceutical companies.