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Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and joining me today is Dr. Magdy Milad. He's the Chief of Minimally Invasive Gynecologic Surgery in the Department of Obstetrics and Gynecology at the Northwestern Medicine Center for Comprehensive Gynecology. He's joining us today to discuss how surgical innovations have improved patient outcomes and safety for the treatment of tubal disease. Dr. Milad, thank you so much for joining us again. Tell us a little bit about your title, your area of expertise. Kind of explain that to us.

Dr. Magdy Milad: Well, I'm the Albert B. Gerbie Professor of Obstetrics and Gynecology and board-certified in both obstetrics and gynecology and in reproductive endocrinology and infertility, which just means that my main focus is that on infertility and reproductive surgery, and we've created a center around that topic.

Melanie: Well, thank you so much for that, doctor. So tell us exactly what is tubal disease.

Dr. Magdy Milad: Sure. Well, tubal disease is a disorder in which either one or both of the fallopian tubes are blocked or damaged. The tube can be blocked at proximal end towards the uterus, or it can be blocked at the distal end, which is near the ovary. The most extensive form of distal disease is hydrosalpinx where the inside of the tube actually fills with fluid. And that can be categorized as mild, moderate, or severe, depending on how wide the diameter of the hydrosalpinx is.

There's also bipolar disease, which is where the tube is blocked both at the beginning of the tube at the proximal end and at the distal end, that's actually got the worst outcome when it's blocked at both ends.

And then another form of tubal diseases where a patient has actually had a tubal ligation. Their tubes have been tied, and yet they still want to get pregnant. And so that's absolutely considered tubal disease.

Melanie: Wow. That's definitely something that many of us did not know. So give us a brief history of the surgical treatments available for tubal disease. And how has that evolved in recent years?

Dr. Magdy Milad: Sure. Yeah. So tubal disease was really one of the only things that we could really do for patients that were suffering from infertility. And a lot of times we didn't even really know if they had tubal disease, they'd undergo a big surgery and a laparotomy, and then we'd bring in an operating microscope and operate under that condition.

For distal disease, if the tube was blocked at the end of the tube, then we would create a new end to that disease. And back in the old days, if there was proximal disease, then we would actually reimplant the tube into the uterus, although I have to say it really didn't have a very high success rate.

Melanie: So then tell us a little bit about the role of minimally invasive surgery, what does that had in treating women with tubal disease?

Dr. Magdy Milad: Well, yeah, it has completely re-revolutionized the care for patients that have tubal disease. Nowadays, we use minimally invasive surgery techniques to repair the fallopian tubes. We can perform a tubal cannulation hysteroscopically to relieve proximal obstruction. The way that's done is we pass a guidewire, a lot like they do for cardiac catheterization or for gallbladder disease and so on. We passed the wire right through the scope into the proximal tube using laparoscopy scope through the belly button to be able to sort of guide it.

And then for distal disease, we can do the repair laparoscopically. And the success is really correlated with how bad the tube was damaged in the first place. So if it's mild disease, if the tube is dilated, let's say one centimeter, then that has the best outcome. But in a patient that has really severe disease, if the tube is actually dilated to like three centimeters or more, while we can do that repair, it doesn't work quite as well.

Melanie: So you mentioned tubal ligation, and that now, if someone has fertility issues, they want to get pregnant, that's considered tubal disease. So how does this affect fertility and why is treatment so important for women who do desire future fertility?

Dr. Magdy Milad: Yeah, well, tubal disease can interfere with the egg mobility, the sperm mobility, or the embryo mobility in arriving back in the uterus. And so in about 30% of cases, it's tubal disease that’s the cause of the infertility. So one great way to treat tubal factor infertility is with IVF. We bypass the tubes altogether. Patients undergo an ovarian stimulation with fertility drugs. The eggs are retrieved under ultrasound guidance. They're fertilized in the lab and, three to five days later, an embryo is transferred back through the cervix, bypassing the fallopian tubes altogether.

So that's a great way to treat infertility in the presence of tubal disease. Unfortunately, in patients that have really severe tubal disease, if they have a severe hydrosalpinx where there's a lot of fluid that has accumulated inside the fallopian tube, that can actually significantly drop the success rate with IVF.

We don't know exactly why. We think maybe it might be a mechanical flushing of the fluid from the fallopian tube back into the uterus or maybe some kind of a toxic effect of some sort. But we know that women, young women, should have a success rate of let's say 50-60 percent or greater, their success rate will drop by half if they have hydrosalpinx present.

Melanie: Isn't that interesting? So, Dr. Milad, as you've told us about the role of minimally invasive surgery, what about robotic-assisted surgery? How has that changed outcomes and recovery time for women with tubal disease versus traditional procedures?

Dr. Magdy Milad: Well, it's so interesting. You know robotic surgery was first applied to tubal disease, isn't that interesting? Now we have robotic surgery for almost every kind of surgical condition, but the very first procedure that the robot was used for was for tubal disease.

Melanie: Wow.

Dr. Magdy Milad: Isn't that interesting? Robotic-assisted surgery has now completely transformed the tubal repair landscape. We're now able to see almost the same like operating microscope, bright light, 3D vision, full range of motion with regards to inside the belly without having to obviously open the patient. We just use these four 8-millimeter incision sites. Patients go home the same day and they can start trying to attempt pregnancy as soon as they feel up to it, which is typically a couple of days to a couple of weeks.

Melanie: How fascinating that is, Dr. Milad. So tell us how it's improved safety and recovery time. And while you're doing that, tell us some of the unique procedures or techniques the Northwestern Medicine Center for Comprehensive Gynecology offers for women with tubal disease. Tell us about your multidisciplinary care and about the center in general.

Dr. Magdy Milad: Sure. Well, first thing is instead of opening patients and doing a laparotomy, we do the laparoscopy. Instead of being in the hospital two to three days, now they go home the same day. They can be back to their usual stuff as soon as they feel up to it and they can start trying right away. So minimally invasive surgery has completely transformed the recovery. And we do think that it probably lowers the risk of complications.

So our center is unique. I mean, we have a multidisciplinary team from interventional radiologists to physical therapists, physical medicine. We've got a whole range of providers. And, for tubal surgery, it's really a dying art. I mean, most fertility specialist don't do enough surgery to remain proficient in tubal repair. And so at the Center for Comprehensive Gynecology, we have high volume surgeons and we're doing six to ten cases a week each of us, to remain skilled in our surgical arts. This is all we do, like we don't do any annual exams, we don't do pap smears. We focus strictly on being experts in surgical gynecology.

And then we have a robust research program. We've got more than 20 studies that are looking at different types of surgical outcomes for this specific condition of tubal disease. We've been using a technique that was originally started in the plastic surgery literature, where we inject a dye to demonstrate the blood flow after we've done a tubal reversal. So we're able to demonstrate that there's good blood flow to the fallopian tubes after we've done the tubal repair.

Melanie: Nice. Do you have any other exciting research projects on the horizon you'd like to mention?

Dr. Magdy Milad: There are some interesting studies looking at tubal disease and cancer. We do think that about up to a third of patients that have ovarian cancer may come from the fallopian tube. And so there is some studies that are coming up, we're actually doing them yet where we actually look inside or sample the inside of the fallopian tube to see if there's some precancerous cells. But we actually haven't not started that study yet, but will definitely let you know when we do.

Melanie: Certainly would welcome you to come on and give us any updates that you have. So, Dr. Milad, as we wrap up, what else would you like other providers to know and take forward to optimize patient outcomes for tubal disease?

Dr. Magdy Milad: Well, we certainly invite providers to refer their patients in for consultation if there is tubal disease present. We work with everybody. I mean, we've got providers that are here at Northwestern that are fertility specialists referring to us, but we also have providers all over the country because tubal surgery is actually kind of rare nationwide. So we've got people from downstate from Wisconsin, from other states that are coming in for their tubal surgery and then returning back to their fertility specialist to be able to undergo the treatment. So we invite referring providers to send those patients in for a second opinion about whether there is a tubal surgery that would benefit this patient.

Melanie: That's great information and such an interesting topic. Thank you so much, Dr. Milad. You're an excellent guest.

To refer your patient, please our website at ccgyn.nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.