Many women will choose to have regular annual health checks. The best doctor for this is one with whom the patient can develop a good rapport, one who they feel confident will give good advice and who has easy access to all the appropriate investigations. It is not essential that the doctor has well developed research or surgical skills but they must be accessible approachable and on the right ‘wave-length’ for the individual patient. This choice is best informed by personal recommendation by friends and colleagues.

The choice becomes more complex when it involves treatment of a particular gynaecological condition. For example, a woman with a fertility problem would not wish to see a gynaecologist with an interest in the menopause or cancer and vice versa.

In addition the emphasis should switch more towards determining the level of expertise and the type of treatment that the gynaecologist can offer for a specific problem. In the UK all gynaecologists undergo basic training. It is only some who continue their training to develop special interests and surgical skills in a specific area of gynaecology.

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Women are often referred to specialists by their General Practitioner who has an affiliation with a particular consultant gynaecologist. It is important to check that this is the right person to offer the treatment that is required.

The best way to find this out is to ask questions. Ask the GP specifics about the gynaecologist and the treatment options that they can offer. Women should also ask around, ask friends and colleagues. The internet can be extremely helpful too, but needs to be used with caution.

Once a doctor has been chosen it is also appropriate to ask him/her if this is a specialist area of interest and if an operation is required, how many of these procedures they would carry out on an annual basis, and could the surgery be done using keyhole techniques which are less invasive and have shorter recovery times?

In many instances choosing a gynaecologist is easy but if specific treatment is required then it is necessary to do a little research to be sure that the best available treatment is being offered by the best gynaecologist. If women are not sure then it may be worthwhile getting a second opinion.

An ectopic pregnancy is a complication of pregnancy in which the pregnancy implants outside the uterine cavity. Most ectopic pregnancies implant in the Fallopian tube but around 5-7% implant within the wall of the womb, either within the cervix, the intrauterine portion of the tube or within a caesarean section scar.

The most dangerous of these are probably ectopics in the interstitial portion of the tube (2.5%) which account for a fifth of all deaths from ectopic pregnancy.
With very rare exceptions, these pregnancies are not viable. UK NHS statistics state that one pregnancy in 80 is an ectopic, equating to roughly 12,000 a year. Although the chances of having an ectopic pregnancy are relatively low, the seriousness must not be under estimated. If it is left untreated, an ectopic pregnancy can be fatal, and the condition remains the leading cause of maternal mortality in the first three months of pregnancy. Serious outcomes usually result as a consequence of delayed treatment.

Causes:

Any condition which delays the passage of the fertilised egg down the fallopian tube may cause an ectopic pregnancy.
There are risk factors the most common of which are; increasing maternal age, tubal damage as a result of surgery or infection (particularly Chlamydia), and in-vitro fertilisation (IVF).
Contraception reduces the risk of ectopic pregnancy. However, if a pregnancy does occur in women after female sterilisation or insertion of an intrauterine contraception device then the chance that it is an ectopic is increased.

Symptoms:

The first symptoms of an ectopic pregnancy are usually seen between 5 to 12 weeks after the last normal menstrual period. These include, but are not limited to:

•      Symptoms of pregnancy; nausea, breast tenderness and urinary frequency.
Pain in the lower abdomen, particularly on one side, pain can be persistent and severe     but is not present in about 10% of women.
•      Abdominal bloating
•      Vaginal bleeding. This may present simply as a brown discharge but may also be heavy.
•      Feeling faint and dizzy due to internal bleeding.
•      Shoulder tip pain, due to irritation caused by blood under the diaphragm.

At this early stage, the differential diagnosis is between miscarriage, ectopic pregnancy, pregnancy of unknown location (PUL) and early normal pregnancy.

If women are worried that they may have an ectopic pregnancy, they shouldn’t hesitate to contact their gynaecologist and arrange for the necessary testing.

Diagnosis:

The current diagnosis of ectopic pregnancy is by a combination of ultrasound, serum β-hCG and Progesterone measurement. β-hCG is the marker used to test for a positive pregnancy. If levels are low and falling then most cases can be managed conservatively. Most units will use serial measurements of hormones to make the diagnosis.
An ultrasound can then be performed to locate where the pregnancy has implanted. If on ultrasound the pregnancy is not seen in the womb then this points towards either an ectopic pregnancy or a PUL. If the β-HCG is above 2000 IU/ ml and rising and the progesterone is above 10nmol/l (in the absence of an intrauterine pregnancy) then it must be assumed that there is an ectopic and either medical or surgical treatment is required. If these criteria are not met then it is safe to wait 48hrs to repeat the blood tests and the scan.

Treatment

Unfortunately, if an ectopic pregnancy exists the pregnancy cannot continue to a live birth. Most parents therefore face not only the loss of a pregnancy but also the need for an operation with the possible loss of a Fallopian tube and a reduction in future fertility. It is therefore essential that all treatment options include counselling for both parents.

Treatment is either surgical or medication based, the choice depending very much on the individual circumstances and the results of the investigations. It is important that women are able to discuss the different options open to them.

Medical treatment involves careful observation with or without treatment using Methotrexate. This type of treatment is only suitable if the pregnancy is small, the hormone levels are low (>3000IU/ml) and there has not been significant intra-abdominal bleeding as seen on scan.

Methotrexate is a drug used in the treatment of cancer. It is given by injection and acts on the placental tissue, causing the pregnancy to fail. This drug stops the growth of the embryo, which is then either reabsorbed by the mother, or passed with a menstrual period. As with all chemotherapy it is essential that the drug is given in accordance with very strict guidelines, for this reason Methotrexate treatment of ectopic pregnancy is not available in the private sector. Sometimes the dose of Methotrexate needs to be repeated as b-HCG hormone levels are not falling adequately and some women still require surgery.

Keyhole surgery (operative laparoscopy) to locate and remove ectopic pregnancies with minimal damage to the Fallopian tubes and with minimal scarring, is the preferred course of action for the majority of cases. Keyhole surgery offers clear advantages as the operating time, hospital stay and convalescence are all shorter and there is less blood loss. There remains controversy as to the best approach to the ectopic and Fallopian tube during the surgery. Clearly women want the option which best maintains their fertility prospects. The evidence base for the best course of action is weak. It is generally accepted that a damaged fallopian tube will be further damaged by the ectopic pregnancy and that retaining the tube also increases the possibility of a continuing ectopic. As a result women undergoing conservative surgery need much more follow up, a future successful pregnancy via the affected tube is unlikely and the risk of another ectopic pregnancy in the retained tube remains high. Many surgeons will therefore favour removing the damaged tube as long as the remaining fallopian tube looks normal. This hypothesis is currently being investigated by a large multi centre trial.

Before surgery women should be made aware of the fact that there is always a possibility that their Fallopian tube may have to be removed.

Most women are able to go home on the day of surgery or the following morning. It takes a few days to get over the surgery but the psychological impact can take much longer.

Fertility after ectopic pregnancy

The reported rates of spontaneous, intra-uterine pregnancy vary between 38 – 66% in women who have the tube removed and may be as high as 79% where the tube is conserved. However, the rate of another ectopic is also higher, up to 18% in women where the tube is conserved; so it would seem that conserving the damaged tube has both advantages and disadvantages.

It does not appear that medical management using Methotrexate further increases future pregnancy rates or reduces the risk of a future ectopic.

Psychological support

Women having an ectopic, have a life threatening condition, often need to undergo surgery, loose a pregnancy, may loose a Fallopian tube and have reduced future fertility. In addition there is often difficulty and delay in making the diagnosis which can lead to further distress.

It is crucial that women are given good quality information and that they are dealt with in a kind and sympathetic manner. If women feel they need additional help then the UK charity, the Ectopic Pregnancy Trust, is an excellent place to start.

Our approach at OBGYN matters

Women who are concerned can be seen the same day. Blood tests and high quality ultrasound scans are available on site so there is no delay in diagnosis. The modern operating theatres at the Portland hospital have all the state of the art facilities for first class Keyhole (“laparoscopic”) surgery.

If you are concerned that you may have an ectopic pregnancy then contact your doctor, email us or call us on 020 73908440.

This Specialist Private Endometriosis Clinic in central London aims to offer a comprehensive patient centered approach to the care of women with endometriosis. Both Dr Christian Barnick and Dr Alison Wright have a specialist interest in this field and often work in partnership in order to achieve the best possible results.

As in all areas of medicine the key to successful treatment of endometriosis is in the careful selection of the right treatment for each individual patient. Patients have different needs and it is important that these are acknowledged and that treatment is centered round them.

Endometriosis is a condition where tissue similar to the lining of the uterus (womb) is found elsewhere in the body usually the pelvis. It is a benign (non-cancerous) but a very painful condition which is characterised by the presence of endometriosis deposits mainly in the pelvis (the ovary, areas around the womb, on the bladder and the intestines).

Although women may not show any signs of endometriosis, the common symptoms of endometriosis include:

• Painful and or heavy periods.
• Painful sex
• Pelvic pain
• Moderate to severe pain at the time of ovulation
• Premenstrual pain
• Difficulty in becoming pregnant
• Pain when passing urine and or bleeding
• Pain and difficult with opening bowels
• Bleeding from the bowel with the periods
• Fatigue

The exact cause is unknown, although a few theories have been put forward.

• Retrograde menstruation. Some of the menstrual blood flows backwards down the fallopian tubes and into the pelvis. Some of this endometrial tissue implants and causes endometriosis.
• Lymphatic or circulatory spread. Endometrial tissue is carried by blood vessels and lymphatic channels.
• Genetic predisposition to the condition. Researchers are looking into the gene which could identify women predisposed to endometriosis. A woman who has a mother or sister with endometriosis has a six times greater risk of developing endometriosis.
• Immune dysfunction. There are theories which look at the immune response of the body which could lead to the development of endometriosis

At OBGYN matters we aim to carefully assess every woman who is trying toconceive, to see if fertility surgery may improve her chances of becomingpregnant.Many women will have a surgical assessment of their reproductive organsperformed prior to considering IVF. This usually takes the form of aHysteroscopy (looking inside the womb) and a Laparoscopy (looking insidethe abdomen to visualise the womb, fallopian tubes and ovaries).Unfortunately the standard to which this assessment is performed varieswidely between gynaecologists.

We feel that it is useful to consider an expert assessment and possibly the option of fertility surgery prior to commencing on the emotional ʻroller coasterʼ that is IVF.

Fertility surgery is usually performed using ʻkeyholeʼ surgical techniques as a planned ʻday caseʼ, as women usually feel well enough to go home on the day of their surgery and make a very quick full recovery. Day stay ʻkeyholeʼ surgery is so effective because most of the causes of infertility that are found, are small blockages of the fallopian tubes, adhesions or endometriosis, or abnormalities in the womb such as polyps, small fibroids or a septum.

These anatomical or physical abnormalities can be rectified using advanced surgical techniques that leave minimal scar tissue. A surgical division of adhesions, opening up of blocked fallopian tubes or removal of a small fibroid can have a profound effect on fertility and lead to a successful outcome without the need for further IVF treatment. Most women want to maximize their chances of achieving a natural pregnancy and through advanced fertility surgery at OBGYN matters we hope to help them achieve this aim.

All of our surgery is carried out at the world-renowned Portland Hospital, the only private hospital in the UK dedicated to the care of women and children.

If as we hope, women are able to conceive following their surgery, than at OBGYN matters we are proud to be able to offer a fully integrated service all the way from fertility surgery to antenatal care and delivery. LINK

Fertility surgery can be offered for a range of problems

• Treatment of problems in the womb
• Surgery on the Fallopian tubes
• Treatment of Endometriosis

Infertility and Uterine Surgery

There are a number of ways in which problems in the womb may be the cause of infertility or reduced fertility. The most common of these are:

• Developmental abnormalities (uterine septum)
• Fibroids
• Polyps
• Intrauterine adhesions

Uterine septum

A uterine septum is a band of fibro-muscular tissue, which extends down the middle of the uterine cavity. It is the result an abnormality in the formation of the womb and is present from birth. Some uterine septae are small and do not affect fertilty. In other women they are large and may affect fertility or contribute towards miscarriage. If the patient has a history of infertility or miscarriage then the septum is probably best removed. At OBGYN Matters the surgery is performed by placing a telescope in the cavity of the womb and then vaporising or cutting the septum (operative hysteroscopy). We also perform a laparoscopy at the same time to avoid damaging the womb. We aim to excise or vaporise the septum during one operation but sometimes two or three operations may be required to get a perfect result.

In order to keep the cavity of the womb open we normally leave a coil within the cavity of the womb at the end of the procedure.

Uterine fibroids

Many women have fibroids and these often donʼt affect fertility. They may cause problems if they are larger than 3cms, if they project into the cavity of the womb or if they compromise the fallopian tubes. They may be removed through the cervix or by laparoscopic or open surgery. Click here for more Info.

Uterine Polyps

These are small fleshy overgrowths of the lining of the womb. They may be small or quite large (3cms) and project into the cavity of the womb. The bigger they are the more likely that they will cause problems with fertility. As they sit within the cavity they may interfere with implantation of the fertilised embryo and as a result they may cause problems both with natural fertility and with IVF treatment.

Fortunately, they are easily removed at Hysteroscopy following which they are sent for histopathology to check that there is no other reason for concern.

Uterine adhesions

Adhesions with womb can occur after any damage to the lining of the womb. These typically occur after instrumentation of the womb for an incomplete miscarriage (ERPC) or after termination of pregnancy. They may also occur after a normal birth or a Caesarean section.

They are a significant cause for infertility in women who have had a previous pregnancy (secondary infertility). The adhesions may be thin and filmy (like a net curtain) and easy to divide. Unfortunately they may also be very thick and widespread (Ashermannʼs syndrome) in which case treatment may sadly not be so successful.

Surgery on the Fallopian tubes

The fallopian tubes may become scarred, caught up in adhesions or blocked and as a result women may be infertile or have reduced fertility. Tubal surgery was developed to overcome these problems. The surgery is usually carried out laparoscopically as the operating field is magnified, there is minimal tissue handling, the tissues do not dry out and very fine instruments and sutures may be used. All of these surgical techniques are important in minimizing the trauma of the surgery, optimizing results and speeding up recovery. Tubal surgery is particularly useful in mild disease at the ovarian end of the tube or where the tube is blocked right next to the womb.

Unfortunately, not all tubal disease is amenable to surgery and if the damage to the tubes is severe then it is important to consider that success rates from IVF may be superior. However, if the tubal disease is severe then surgery may still be helpful as there is evidence that the presence of the damaged fallopian tubes may reduce success rates of IVF treatment. In these cases or where the tubes are blown up with fluid (hydrosalpinges) then the fallopian tubes are probably best removed or clipped.

Treatment of endometriosis

Endometriosis is found in around 35% of infertile couples. There are many treatment options for this but surgery is probably the best. The success of treatment is very dependent on the severity of the disease. However, endometriosis can be excised or ablated with an impressive doubling of pregnancy rates even in moderate disease. If the endometriosis has caused scarring then this can be divided and normal pelvic anatomy can be restored and if there are cysts present then these can be removed to improve success rates of IVF.

Click for further information on endometriosis.

Most gynaecologsits are not able to perform keyhole surgery for fibroids and even in those who do their expertise in this area varies widely. What Mr Barnick aims to do is to perform this type of surgery to the highest possible standard, thus maximizing the success of surgery and minimizing possible complications, even in fibroids up to 12cms in diameter.

Mr Christian Barnick Specialist in laparoscopic surgery for fibroids

Christian Barnick is a consultant at OBGYN Matters and is an expert in keyhole surgery. He runs the Fibroid clinic at OBGYN Matters and is lead for Laparoscopic surgery at the Homerton University Hospital NHS trust in East London. He has been managing fibroids for over 20 years. His main interest is in the laparoscopic, surgical excision of fibroids. He has three operating lists every week during which he performs keyhole surgery for fibroids, endometriosis and also other benign gynaecological conditions. He is well recognized as an expert in this field and is recognized as a surgical trainer in laparoscopic surgery by the Royal college of Obstetricians and Gynaecologists.

WHAT WILL HAPPEN AT YOUR FIRST APPOINTMENT?

At the first appointment a detailed history will be taken and you will be carefully examined and an Ultrasound scan may be performed. You will be asked about your symptoms and the extent to which your lifestyle is being affected. The information gathered will form the basis upon which your treatment will be planned; a detailed treatment plan will be made at this visit. At OBYN matters we offer a comprehensive service for the treatment of fibroids. Fibroids or Leiomyomas are the commonest benign growth in women. They are not usually dangerous but can cause a number of symptoms which can have a negative impact on quality of life and may reduce fertility. As a result it is common for women with fibroids to seek medical assistance. Unfortunately this does not always lead to a satisfactory outcome as women are often advised to either do nothing or to have maximally invasive, open abdominal surgery.

At OBGYN matters we aim to offer individualised advice and treatment for women with fibroids, taking into account the individual patient needs and fertility requirements. This treatment may take the form of simple reassurance, embolisation therapy, minimal access surgical treatment or very rarely open surgery. Information will be given to you about fibroids and available treatment options. At this appointment you will have the opportunity to discuss issues concerning your treatment and any future fertility concerns. Any other necessary investigations will be arranged (blood tests, MRI).

What are fibroids?

Fibroids are benign, non – cancerous growths of the smooth muscle of the womb. They are not in fact fibrous, but are made up of smooth muscle cells compacted into a fibrous looking mass. As they are smooth muscle tumours the correct name for them is leiomyomas.
Uterine leiomyomas are extremely common and are found in up to 30% of women at the time of autopsy. They are oestrogen dependent growths and grow during adult life up to the menopause. They can also grow rapidly during pregnancy and are more common when oestrogen levels are high. As a result they are also more common in obese women. Normally the smooth muscle fibres of the womb do not multiply, as there is something within their genetic make-up, which prevents this. If for some reason this genetic system fails then a muscle cell may start to divide. If this continues then eventually a large ball of muscle cells grows forming a fibroid or leiomyoma. The genetic defect that allows this is more common in West African and West-Indian women who are much more likely to have larger and more numerous fibroids.

Some women will have only one fibroid but it is more usual for women to have multiple fibroids as there are many cells within the muscle of the womb which have started to divide in a similar fashion. These fibroids grow, developing their own blood supply form the surface of the fibroid. As the fibroid grows the blood supply is eventually out-stripped and the fibroid cannot grow any further. All fibroids are therefore supplied by small blood vessels and the extent of their growth is dependent on the success of this neo-vascularisation. As a result some fibroids will only grow to one or two centimetres but rarely can they grow beyond 12cms in size. Clearly, if there are several fibroids they will vary in size and the total fibroid mass may be very large.

Gynaecologists usually describe the size of the uterus enlarged by fibroids by the equivalent size of a pregnant womb. So we may talk of a womb being 12 weeks in size or at the other extreme 36 weeks! All leiomyomas are benign growths, and whilst they may sometimes be overactive and grow quickly, they very rarely if ever have any malignant potential.

Classification of fibroids

Fibroids are classified according to where in the womb they are found.

Submucosal

The leiomyoma is under the inside lining of the womb, projecting into the uterine cavity. These fibroids can grow as polyps, on a stalk, or can be more deeply embedded in the muscle of the womb.

Intramural

These fibroids grow within the muscle of the womb itself. They enlarge the womb and increase the blood supply to the womb. They may also enlarge the cavity of the womb by stretching it.

Subserosal

Fibroids found on the the outside of the womb are classified as subserosal. Again they may grow on a stalk or be embedded in the womb but projecting into the abdominal cavity.

It is not uncommon to find fibroids in different locations within the same patient as seen in the MRI scan below.

Symptoms of fibroids

Many women do not have any symptoms and fibroids are picked up at routine examination or ultrasound scan.

Frequent symptoms are:

• Heavy, prolonged, painful regular periods
• Passing clots
• Anaemia
• Irregular bleeding throughout the cycle
• Lower back pain
• Pain during intercourse
• Pressure symptoms
• Urinary frequency
• Constipation
• Abdominal swelling
• Infertility
• Problems during pregnancy

Heavy Menstrual bleeding

Symptoms of heavy painful bleeding can be very distressing and can lead to severe anaemia. Passing large clots is very unpleasant and painful. Some women need to use double protection in the form of Tampons and pads and may need to use pads or towels to protect their bedding at night.

Women who become anaemic are pale and get very tired and out of breath with the slightest exertion. They may occasionally faint if the anaemia is severe.

Pain and pressure

Pain is either caused because the fibroids themselves are tender or because they are pressing on adjacent structures such as nerves in the pelvis or on the sacrum (the lumbo-sacral nerve roots). Fibroids typically become painful when they out-grow their blood supply and degenerate (red degeneration). They may also cause pain if they twist on their own blood supply. This may happen with a pedunculated subserosal fibroid. Pain during sex occurs when the womb is stuck in position by fibroids or by pressure on the fibroids themselves.

Fibroid size and symptoms

Symptoms are not always related to size. For instance a small fibroid within the cavity of the womb may cause severe bleeding problems and problems with fertility, whereas a large subserosal fibroid may cause no problems. A 6 cms fibroid embedded in the pelvis may cause severe urinary and bowel pressure symptoms whilst a large intra-abdominal fibroid will not.

Infertility and pregnancy problems

Fertility can be effected at a number of different stages.

• If the womb is enlarged it may not be feasible for the egg and the sperm to get together.
• Fibroids around the opening of the fallopian tubes may block or distort the fallopian tubes.
• Intramural and subserosal fibroids may distort the pelvic anatomy making it more difficult for the egg to get to the fallopian tube.
• Small fibroids within the cavity of the womb can irritate the lining of the womb and cause difficulties with implantation of the fertilised egg.

Pregnancy problems can similarly occur at different stages.

• Ectopic pregnancy can occur if the fallopian tubes are distorted or partially blocked
• Early miscarriage may occur if the cavity is distorted or if the embryo tries to implant over the site of a fibroid.
• Late miscarriage (20-23 weeks) may occur if there are multiple fibroids and the womb is unable to expand properly to contain the growing baby. This may manifest itself as preterm premature rupture of the membranes with the leakage of amniotic fluid.
• Premature birth due to difficulty in the proper expansion of the uterus.
• Growth restriction of the fetus due to poor placental attachment over fibroids.
• Pain because of rapid fibroid growth during the first part of the pregnancy followed by red degeneration.
• Difficulty during childbirth due to obstruction of the birth canal by cervical fibroids in particular.
• Haemorrhage after the birth due to poor contraction of the womb following delivery of the placenta.

Treatment of fibroids

This needs to be carefully individualised for each patient. Decisions regarding treatment must be made in partnership, particularly taking into account the type of fibroids, the severity of symptoms and the desire for future fertility. At OBGYN Matters there are a number of treatments that may be considered.

Treatment options:

• Medical treatment
• Uterine Artery Embolisation (UAE)
• MRI guided Focused Ultrasound (MRgFUS)
• Hysteroscopic resection (TCRF)
• Laparoscopic myomectomy
• Open Myomectomy
• Hysterectomy

Medical treatment:

Watch and monitor size with ultrasound scans Drugs to make periods easier. The oral contraceptive pill Progesterone Ponstan and Cyclokapron GnRh analogues to stop periods and temporarily shrink fibroids (no medical treatment will have a sustained beneficial effect on fibroid growth).

Uterine Artery Embolisation (UAE)

As mentioned above, fibroids have a blood supply that is mainly made up of small blood vessels. As a result fibroids are relatively easy to embolise. During embolisation small particles are injected into the blood supply to the fibroid which block these small blood vessels and as a result the fibroid dies and shrinks in size. How much the fibroid shrinks depends on how solid it is but on average they shrink in volume by about 40%.

The procedure is ideal for women who have multiple intramural fibroids where surgery is contra-indicated.

How is it performed?

• It is performed as an outpatient procedure under local anaesthetic.
• A tube is passed into the main artery in the groin
• This catheter is manipulated into the uterine artery under X-ray guidance
• An arteriogram is performed to check the blood supply to the fibroids
• Small particles or foam are injected into this blood supply.
  
• A further arteriogram demonstrates that the correct blood vessels are blocked
• The catheter is removed
  

Complications:

• Bleeding from the catheter entry point
• Damage to blood vessels (uncommon)
• Premature menopause
• Infection, rare but serious
• Persistent vaginal discharge due to breakdown of fibroid

Women are sent home on the day of the procedure and most make a quick recovery.

Hysteroscopic resection of fibroids

This treatment of fibroids is used to remove small sub-mucosal fibroids as these can be accessed through the cervix.

How is it performed?

• Under general anaesthetic
• The cervix is dilated
• A telescope is inserted into the womb
• The fibroid is visualised
  
• The fibroid is cut away in pieces and removed
• Most patients go home the same day

Complications:

• Problems with anaesthesia
• Bleeding, usually not severe
• Perforation of the womb with the subsequent need for laparoscopic or open surgery to check for bowel damage
• Excessive absorption of the fluid used for visualisation of the fibroid

Problems rarely occur unless attempts are made to remove large fibroids this way.

The surgery normally takes up to 30minutes and women are discharged a few hours after surgery.

Women can return to normal activities within 3 – 5 days following surgery.

Laparoscopic Myomectomy

Key-hole surgical techniques are ideal for removing up to 3 fibroids of up to 7 centimetres each, in diameter. The major determining factors are the skill and experience of the surgeon, the amount of space within the abdomen and the position and number of the fibroids. If the womb is larger than 18 weeks in size it is difficult to insert the necessary instruments and get an adequate view of the womb and fibroids. If there are too many fibroids then multiple incisions need to be made into the womb and this may lead to excessive bleeding. If the fibroids are very low down behind the womb then they may be difficult to access Pedunculated fibroids are the easiest to remove using this technique.

The Major advantage of this technique is that patients make a much quicker recovery following the surgery. In addition to this the incisions are very small and cosmetic, The amount of blood loss and the risks of subsequent adhesions is also reduced. Despite these major advantages over open surgery it is often not performed because most gynaecologists do not have sufficient expertise in keyhole surgery to perform this procedure.

How is the operation performed?

• The surgery is performed under general anaesthesia.
• An instrument is placed within the womb from the vagina, to manipulate the womb during the surgery
• A needle is inserted through the navel and Carbon Dioxide is used to insufflate the abdominal cavity forming a space for the surgery.
• A 10mm instrument is then inserted through the umbilicus
• A telescope and light source are inserted through this trochar
• A good view of the internal organs is obtained
• The patient is tilted head down
• Two 5mm inscision are made below the bikini line on either side of the abdomen
• Two instruments are inserted to perform the surgery
• The womb and fibroid are visualised

• The fibroid is then removed using a special instrument , morcellator, which cuts the fibroid into thin strips which can be removed through a
• 12mm inscision
• The CO2 is released from the abdomen
• The small skin incisions are sutured and glued.
• The whole operation takes about 1-2hrs depending on the fibroids!

Recovery:

• After surgery patients are usually in hospital overnight
• They feel tired and bloated for two to three days following the surgery and then rapidly return to normal. Pain killers are used immediately postoperatively but are usually not needed after 2-3 days
• Most women are feeling well by two weeks and are completely back to normal within four to six weeks.

Complications:

• All surgery carries risks associated with general anaesthesia
• In addition there are risks of bleeding, deep vein thrombosis and infection Special precautions are taken to minimise the risks of these complications which are all rare.
• More specifically to keyhole surgery there are risks of damage to internal organs: bowel, bladder or major vessel trauma (these are rare but may require open surgery to repair)
• Open surgery to complete the surgery if the fibroids cannot be removed or if there is excessive bleeding.
• Adhesion formation following surgery
• Weakening of the womb requiring caesarean section for safe delivery in subsequent pregnancy

Open surgery for fibroids

This should be reserved for those case where the fibroids are very large or numerous. Up to 20 fibroids may be removed at a single operation!

How is the surgery performed?

• The surgery is usually performed through a “bikini line “ incision but a large vertical incision may be required.
• The surgery takes 1-2hrs for the successful tratment of fibroids

Recovery

• Patients are in hospital for 3 – 5 days
• After about a week they are able to walk around
• After six weeks things a re returning to normal
• It may be another 6 weeks before all normal activities can be resumed

Complications

These are similar for the surgery above but there is a greater risk of:

• Major bleeding
• Blood transfusion
• Return to theatre
• Emergency hysterectomy
• Adhesions
• Wound breakdown
• Future caesarean delivery

Conclusion

It important to remember that fibroids are benign and usually not life threatening. The decision of whether or not to have the treatment of fibroids should therefore rest with the patient. If a decision for treatment is taken then the possible complications should be minimised and future fertility plans should be paramount.

As in all areas of medicine, the key to successful treatments for endometriosis is in the careful selection of the right treatment for each individual patient. Patients have different needs and it is important that these are acknowledged and that treatment is centered round them.

For many conditions medical treatment is sufficient to either control symptoms or cure the disease. However, endometriosis is particularly resistant to medical treatment and often surgery is required to achieve treatment aims.

Most gynaecologists are able to perform keyhole surgery for treatments for endometriosis but the extent of their expertise in this area varies widely. What Mr Barnick aims to do is to perform this type of surgery to the highest possible standard, thus maximizing the success of surgery and minimizing possible complications, even in cases of advanced stage IV endometriosis.

Mr Christian Barnick Specialist in laparoscopic surgery and endometriosis

Christian Barnick is a consultant at OBGYN Matters and is an expert in the management of endometriosis and endometriosis surgery. He runs the Endometriosis centre at OBGYN Matters and also the Endometriosis centre at the Homerton University Hospital NHS trust in
East London.

He has been managing endometriosis for over 20 years. His main interest is in the laparoscopic, surgical excision of endometriosis. He has three operating lists every week during which he performs complex surgery for endometriosis and also keyhole surgery for fibroids and other benign gynaecological conditions. Each year he performs more than 250 operations for endometriosis alone.

He is well recognized as an expert in the field of complex keyhole surgery and is one of only a few surgical trainers in laparoscopic surgery accredited by the Royal College of Obstetricians and Gynaecologists.

The Endometriosis surgical team at the Portland Hospital

WHAT HAPPENS AT THE FIRST APPOINTMENT?

At the first appointment (30-60mins) a detailed history is taken and a carefully examination is performed. Patients are asked about their symptoms and the extent to which their quality of life is being affected. A trans-vaginal Ultrasound scan is used to visualise the pelvic organs.

The information gathered  forms the basis upon which a detailed individual treatment plan is made in discussion with the patient.

Information is provided about endometriosis and all available treatment options. At this appointment there is also the opportunity to discuss issues concerning details of treatment and any future fertility concerns. Any other necessary investigations are arranged (blood tests, MRI) and if indicated a laparoscopy (looking inside the abdomen) and/or a hysteroscopy (looking inside the womb) are arranged. If desired, these can normally be performed within a few weeks.

Two weeks following this surgery there is a further consultation. This is arranged to check patient progress following the surgery and to give a full explanation of the operative findings. This includes a review of all the surgical images and a DVD is often provided to further improve understanding of the nature of the endometriosis and the surgery that has been performed.

This is also an opportunity to discuss fertility plans and future treatment options.

What is Endometriosis?

Endometriosis is a condition where tissue similar to the lining of the Womb (endometrium) is found elsewhere in the body, usually the pelvis. It is a benign (non-cancerous) but often painful condition, which is characterized by the presence of endometriotic deposits mainly in the pelvis (the ovary, areas around the womb, on the bladder and the intestines).

Each month this tissue breaks down causing internal bleeding which has no way of leaving the body. This leads to inflammation, pain and the formation of scar tissue. In the ovary the endometriosis tissue can bleed and cause fluid contained areas which are called endometriomas (chocolate cysts). These cysts are usually detected by an ultrasound scan.

Endometrios is very common, it is estimated that endometriosis is present in between 10% – 25% of young women and up to 35% of  women with fertility problems.

What are the Symptoms/Signs of Endometriosis?

Although women may not show any signs of endometriosis, the common symptoms of endometriosis include:
• Painful and or heavy periods.
• Premenstrual pain
• Pelvic pain possibly radiating to back and thighs
• Moderate to severe pain at the time of ovulation
• Painful sex
• Pain when passing urine and or blood in the urine
• Pain and difficult with opening bowels
• Bleeding from the bowel with the periods
• Difficulty in becoming pregnant

The amount of endometriosis does not always correspond to the amount of pain and discomfort. A small amount of endometriosis can be more painful than severe disease depending on the site of endometrial deposits. The majority of women with this condition will experience some of these symptoms. Some women will have no symptoms!

Why does Endometriosis Occur?

The exact cause is unknown, although a few theories have been
put forward:

•Genetic predisposition to the condition
Researchers are looking into the gene that could identify women predisposed to endometriosis. A woman who has a mother or sister with endometriosis has a six times greater risk of developing endometriosis.
• Retrograde menstruation
Some of the menstrual blood flows backwards through the fallopian tubes and into the pelvis. Some of this endometrial tissue implants and causes endometriosis.
• Lymphatic or circulatory spread
Blood vessels and lymphatic channels carry Endometrial tissue into the pelvis where it proliferates.
• Immune dysfunction
There are theories suggesting an altered immune response that could lead to the development of endometriosis possibly by failing to prevent implantation of endometrial tissue that has entered the pelvis by retrograde menstruation.

How is Endometriosis Diagnosed?

History and Examination:
A thorough history may highlight suspicion about endometriosis.  The commonest  symptom is pelvic pain which may be worst around menstruation or after intercourse. However, many women have atypical symptoms and the diagnosis is often delayed or missed altogether.
A vaginal  examination may demonstrate painful symptoms or  reveal nodules of endometriosis in the pelvis.

Ultrasound Scan:
An ultrasound scan may show the presence of endometriosis cysts, although not all cysts are
caused by endometriosis and some types of endometriosis may not be seen on a scan.

Diagnostic Laparoscopy:
This is the only definitive way to diagnose endometriosis. In this operation a telescope is
inserted into the pelvis under general anaesthesia via a small cut near the navel. This allows
the surgeon to see the pelvic organs and any endometrial spots or cysts. It may also be
possible to surgically treat the endometriosis at the time of diagnosis.

Tissue biopsy

Slide showing endometrial glands and stroma from outside the womb

Treatment for Endometriosis

Aims of treatment:
• Pain relief
• Reducing endometrial growth
• Removing the endometriosis by excision
• Delaying recurrence of the disease
• Optimizing and preserving fertility

For effective long-term treatment of endometriosis various treatments are available. The treatment varies according to a variety factors:
• Age at diagnosis
• The severity of symptoms
• The severity of the disease
• Most importantly, the desire to have children

The treatment is carried out as a partnership between the patient and doctor.

• Conservative management (‘wait and see’)
If the symptoms are very mild, fertility is unaffected or if menopause is approaching, this approach may be suitable.

• Drug treatment for endometriosis
- May bring about an improvement in the pain symptoms
- May shrink or slow down the progression of the condition
- Is commonly used before surgery or before IVF treatment
- Delays recurrence of the disease
- Is NOT effective in the long term
• Commonly used drugs:

-Testosterone derivatives
‣ Danazol
‣ Gestrinone
‣ Progestogens
‣ Medroxyprogesterone (Provera)
‣ Dyhydrogesterone (Duphaston)
‣ Norethisterone (Primulut)

- GnRH analogues
‣ Triptorelin (Gonapeptyl)
‣ Goserelin (Zoladex)
‣ Leuprorelin (Prostap)
GnRH virtually stop all ovarian activity. They stop the ovaries working and thus reduce the production of oestrogen. This results in a temporary but reversible state of menopause (not actual menopause). These drugs are used prior to surgery to shrink and reduce the vascularity in the endometriosis and to facilitate surgical treatment.
These drugs are given as an injection once a month for three to six months but may be sometimes used for longer.

- Other Hormonal
‣ Combined oral contraceptive pill
‣ Mirena coil
‣ Depo- Provera

With the exception of the oral contraceptive pill the Mirena coil and Depo-Provera, none of these drugs offer effective contraception and alternative contraception must be used.

Side Effects:

All of the hormonal treatments have potential hormonal side effects, these include:
• Hot flushes, sweating
• Mood wings
• Anxiety
• Irritability
• Lethargy
• Vaginal dryness
• Decreased sex drive
• Osteoporosis with longer use

If these menopausal side effects are severe or treatment is prolonged then Hormone Replacement Therapy is given in the form of Tibolone, a synthetic steroid with oestrogen like activity.

Contraindications:
Gonapeptyl or Zoladex must NOT be taken:
• If there is any suspicion of possible pregnancy
• During breast feeding
• If  abnormal vaginal bleeding is present

Because there is an initial hormone surge with this treatment, symptoms of endometriosis and ovarian cyst size may temporarily increase with the first injection of GnRH. Similarly, the first period after the injection may be irregular and painful. These problems usually settle down after the second injection.

Gonapeptyl is not a cure, as the symptoms recur when the treatment is discontinued, although the interval of reappearance of symptoms varies from one person to another.

It is important to remember that the use of Gonapeptyl or Zoladex does not guarantee contraception.

Surgical treatment options for endometriosis:

• Diagnostic laparoscopy with or without treatment.
This is a technique in which a thin telescope is inserted into the abdomen to inspect the pelvic organs. A 1 cm incision is made within the umbilicus and the abdomen is filled with gas. This distention allows the surgeon to inspect the pelvic organs to confirm the diagnosis of endometriosis.

Another small incision is made close to the pubic hairline to insert a second surgical instrument to manipulate the pelvic organs . If any endometriosis is seen then a further incision is made to allow treatment to the affected areas. The surgeon will then either burn out or remove the affected areas.  Conservative, laparoscopic surgery, depending on the severity of the disease, aims to excise, ablate or vaporize the endometrial tissue. This can be achieved using a number of different energy sources (diathermy / laser / harmonic scalpel). The endometriosis may be ablated or excised. It is not clear exactly what the best option for treatment is but at OBGYN matters we aim to excise all the endometriosis wherever possible.

Patients may be discharged on the same day, though in some cases an overnight stay is needed. The duration of stay depends on the extent of the endometriosis and the amount of post-operative pain. It is important to realize that extensive surgery can be achieved through keyhole surgical techniques.

Endometriosis in the pelvis on the Utero-sacral ligament

Endometriosis is excised using mono-polar scissors

Endometriosis fully excised

Endometriotic cysts (endometrioma)

This is the commonest cyst in the ovary that requires treatment. Endometriomas can cause pain and infertility. Repeated surgery on endometriomas will decrease ovarian reserve and thus fertility. These ovarian cysts can either be treated by cyst removal (cystectomy) or cysts destruction (drainage and coagulation).

Which type of surgery is better for endometriomas ?
Cystectomy
– reduces the risk of the cyst coming back (Recurrence) but there is a
possibility of more ovarian tissue being destroyed.
Draining and coagulation (burning)
– this destroys less ovarian tissue and may be better for fertility treatment.
The risk of the cyst coming back is higher.
A pre-operative measurement of Anti Mullerian Hormone (AMH) may be helpful in assessing ovarian reserve and in planning the type of surgery that is performed.
This decision is made in discussion with the patient taking into account their desire for having a baby.

Risks of Surgery:

All surgery has some risks. In this particular instance these depend on the type of surgery and extent of endometriosis.
All operations have risks associate with:
• Bleeding
• Infection
• Deep vein thrombosis.

In surgery for mild endometriosis the risk of major complications requiring a laparotomy occurs in about 1 in 1000 cases.

In more surgery for severe endometriosis there are increased risks of:
• Damage to bladder and ureters.
• Damage to bowel
• Damage to nerves and blood vessels
• Risk of delayed complications including bowel injury and haematoma (collection of blood in the abdomen).

If any of these complications occur, a laparotomy (open surgery through a larger cut) may be need to correct the damage or to stop bleeding.

Combination therapy for endometriosis:

If the endometriosis is severe or is covering large areas of the pelvis it may not be possible to excise all the endometriosis at the first laparoscopy. This particularly occurs in stage IV disease, when the bowel or ureters are involved by endometriosis. In this situation the ovarian endometrioma are drained, adhesions divided and as much of the endometriosis as possible is excised. This is then followed by a 6 months course of LHRH anologues (Gonapeptyl, Zoladex, Prostap). These are given to switch off any remaining endometriosis, reduce inflammation and reduce the blood supply to the pelvis. This in turn helps in making the endometriosis less bloody, thus enabling a more complete excision at a second laparoscopy.

Radical surgery that includes removal of the ovaries and the uterus is considered only if the symptoms are extremely severe and of long duration, fertility goals have been accomplished, and all other forms of treatment have been exhausted.

Pain Management in endometriosis:

Pain Killers
- Neurofen
- Diclofenac (Voltarol)
- Tramadol
- Oxycodone

Painkillers reduce pain but do not prevent the recurrence of endometriosis.

Neurogenic pain is best treated with nerve block or drugs that work directly on the nervous system. We have close links with a pain management team if these are deemed necessary.

Complementary Therapies:

Many women will seek to use complementary therapies to help with their endometriosis. This may often help
to deal with difficult, persistent symptoms, or energy levels which can be very low in endometriosis. At present there are no clinical trials that conclusively show benefit but many women still find this approach useful. Options include acupuncture, Chinese or Western herbs, homeopathy and dietary changes.

We have close ties to various clinics within the Harley Street area and can arrange appointments if this is an area which needs to be pursued.

Endometriosis and Infertility:

There is a definitive link between endometriosis and infertility. Endometriosis is seen in about 20 to 35% of women referred to the fertility clinics worldwide.

Endometriosis can affect fertility in various ways as it:
• Distorts the pelvic organs
• Changes the position of tubes and ovaries and creates adhesions
• Alters hormonal function
• Interferes with Ovulation
• Creates a hostile inflammatory environment
• Causes decreased implantation of the fertilized egg
Pain during sex may also cause additional problems!

Surgical treatments for endometriosis, the division of adhesions and restoration of normal pelvic anatomy improve pregnancy rates. Excision or ablation of endometriosis both improve pregnancy rates.

IVF treatment removes gametes (sperm and oocytes) from the hostile, inflammatory, pelvic environment created by endometriosis and thereby maximises the chances of conception

How long should one wait after surgery to get pregnant?
It is probably advisable to start trying to get pregnant without delay! Evidence suggests that pregnancy rates are highest in the first six months following surgical treatment. In addition, there is evidence that women with endometriosis have an earlier decline in their fertility with age and an earlier menopause.

The decision when to try start trying to conceive may be assisted by tests such as a baseline FSH and Anti-Mullerian Hormone (AMH) as they give some idea of ovarian reserve and future fertility chances.

If women are not pregnant within 6 months of trying and are over 35 it is probably best to proceed straight to IVF as fertility will only decline over time.

Are success rates of IVF lower in women with endometriosis?
Compared to other patients, there is some evidence that pregnancy rates in IVF may be lower in women with endometriosis. There is evidence that women require a higher dose of drugs to stimulate the ovaries in endometriosis.
Ovarian reserve may be decreased in women with severe endometriosis and stimulation of ovaries may produce fewer eggs.

Can pregnancy rates be improved in endometriosis?
There is evidence that in cases of severe endometriosis, long suppression of ovaries by GnRH analogues may improve implantation. Before proceeding to the first IVF cycle, women are given three courses of Gonapeptyl after which they are started on the IVF drugs. This is a variation of the long protocol for IVF. The AMH level may also be useful as it allows fine tuning of the IVF drug dose and may improve pregnancy rates.

Operating on small endometriomas is best avoided especially in the presence of a low AMH level as it may further decrease ovarian reserve.

Preventing Recurrence of Endometriosis:

Endometriosis is a disease that can recur with the painful symptoms coming back. About 25% of women are likely to have recurrence of endometriosis within five years. In a few women, this recurrence comes earlier. This probably depends on how well the initial surgery is performed and how much of the endometriosis is removed, however, it is important to discuss the various methods of reducing the risk of recurrence.

Suppressive treatment:
In this treatment the ovarian hormones are suppressed, thus lowering the risk of endometriosis
recurring.
Combined contraceptive pill - these given in three monthly courses are the most effective means of suppressing endometriosis. They may cause some breakthrough (irregular) bleeding.
Progesterone only pill.
Depo-provera – is reasonably effective, but can cause abnormal bleeding.
Mirena contraceptive device.

Mirena for Endometriosis
Mirena is a small T-shaped intrauterine contraceptive device that has been used for
endometriosis. It contains the hormone progesterone, which is released into the uterus over a
period of 5 years.
It is a very effective contraceptive and a few studies indicate that it may be effective for the treatment of endometriosis.

How does it work?
The Mirena probably works by suppressing the growth of the endometrial implants causing them to waste away. It may also reduce some endometriosis-induced inflammation (swelling). The Mirena usually stops menstruation and thus reduces the pain that occurs with periods. It may also stop ovulation, although this is not always the case.
This IUCD may be introduced in out-patients but it may be preferable to have it inserted at the time of laparoscopic surgery.

More on “Treatments for Endometriosis” below:

For further information:

The National Endometriosis Society
Suite 50
Westminster Palace Gardens
1-7 Artillery Row
London
SW1P 1RR
Tel: 0207 222 2781
Helpline: 08088082227
www.endo.org.uk

ENDOMETRIOSIS.ORG
Tel: 0870 7743665
www.endometriosis.org

One of the main difficulties in laparoscopic surgery is in repairing the womb once the fibroid has been removed. A proper repair is essential to minimize bleeding at the time of surgery and to strengthen the womb for a future pregnancy. Up until now it has been necessary to close the womb with interrupted stitches, each one individually tied, to obtain a proper closure.

A recent, dramatic advance is the development of the Quill knotless closure system. This is an absorbable suture which has barbs placed along its length which only allow the stitch to be pulled through the tissue in one direction. This enables wound closure with a single continuous suture without knots!

At the Portland hospital a 35 year old woman complaining of heavy bleeding was found to be anaemic and to have a 9cms fibroid deeply embedded in the muscle of her womb. A decision was made to perform a laparoscopic myomectomy.

At the time of her surgery the fibroid was found to extend throughout the whole muscle thickness of the womb. The fibroid was shelled out, the lining of the womb was left intact, but a large cavity was left with a full thickness defect through the muscle of the womb.

This was closed with two continuous Quill sutures. No knots were tied and an excellent result was achieved. The fibroid cavity was completely obliterated, there was minimal bleeding throughout the procedure and the operating time was approximately 45minutes less than anticipated.

This revolutionary new suture system makes it possible to rapidly and effectively close the uterus at the time of myomectomy. This should make the laparoscopic approach to this operation more widely available as more gynaecological surgeons become confident with this technique.

Dr. Christian Barnick

Chris now practices privately at the Portland hospital with OBGYN Matters and still works part-time in the NHS at the Homerton University Hospital.

This public revelation raises awareness of a not uncommon problem. A stillbirth is officially defined as ‘a baby delivered with no signs of life, known to have died after 24 completed weeks of pregnancy’ and occurs during 1 in 200 pregnancies.

This compares with one sudden infant death per 10 000 live births.

The stillbirth rate has remained generally constant since 2000 despite considerable efforts to reduce it. It has been speculated that rising obesity rates and an increase in average maternal age might be behind the lack of improvement (a recent large scale review of possible causes, identified these as the more common risk factors for stillbirth).

All stillbirths are reported and the care given during the pregnancy is analyzed by an independent body which concluded in its most recent report (The 8th Annual Report of the Confidential Enquiries into Stillbirths and Deaths in Infancy) that sub-optimal care was evident in half of the pregnancies where stillbirth occurred. This doesn’t mean that the stillbirth could definitely have been prevented in all of these cases, but shows that the standard of care given was below that which would be expected.

Overall, over one-third of stillborn babies are born smaller than they should be for the stage of pregnancy, indicating that there must have been a placental problem leading to poor fetal nutrition and growth restriction. However, half of stillbirths still remain unexplained even after extensive investigation into possible causes have been performed.

Parents need to know that when a cause is found it can crucially change care in a future pregnancy and maybe help lead to a normal live birth in the future. It is also really important to try and identify a cause, as for many parents, it makes it far easier to get closure, knowing that there was a specific reason why things went so badly wrong.

For these reasons it is recommended that a number of standard tests are performed to identify possible underlying causes.

Common pregnancy related problems are abnormality in the baby, viral or bacterial infection, bleeding or separation of the placenta, blood pressure problems such as pre-eclampsia and problems such as diabetes.
Not many infections can cross the placenta and cause problems but there are a few that have been identified. These include infections such as cytomegalovirus, syphilis, parvovirus B1934,
as well as listeria, rubella, toxoplasmosis, herpes simplex, coxsackie virus, leptospira, Q fever, and Lyme disease. Blood test should be done to test for all of these.

Some babies may be infected by bacteria from the vagina travelling up into the womb. This can happen even if the waters haven’t gone. Swabs should therefore be taken from the vagina to look for bacteria such Escherichia coli, Klebsiella, Group B Streptococcus, Enterococcus, mycoplasma/ureaplasma, Haemophilus influenzae and Chlamydia.

The baby and the placenta also need to be carefully examined and wherever possible samples may be taken from the baby with the mothers consent. These would include simple swabs and maybe blood tests. Sometimes it is useful to take samples of the skin or perform an X-ray or scan of the baby. It may sometimes also be useful to perform a post-mortem on the baby but many couples find it understandably very traumatic to give consent for this.

As Obstetricians, we do everything possible to prevent this terrible pregnancy outcome. We suggest careful individualized care to identify risk factors and carry out regular antenatal visits, thorough, high quality investigations such as blood tests and regular ultrasound scans. Where risk factors are identified we consider early delivery by inducing the labour or performing a Caesarean section if required
In labour we offer one to one care, monitoring where necessary and top class medical, midwifery and anaesthetic support.

Sadly this combination of efforts still doesn’t guarantee a good outcome for every pregnancy, but at the very least we strive to give every pregnancy the best possible chance of success.

Our sincere sympathy goes out to Amanda and Chris and all those other couples out there who have suffered a similar tragedy.

Losing a baby at this late stage of pregnancy is devastating for the whole family and friends. It is not something that women and their partners ever recover from and all women and their partners should be offered counseling and follow up. In addition to any physical effects, stillbirth often has profound emotional, psychiatric and social effects on parents, their relatives and friends.

In recognition of this there are voluntary organizations such as Sands (Stillbirth and neonatal death society), which have been developed to offer help to both partners and their families during this difficult time.

Many women will choose to have regular annual health checks. The best doctor for this is one with whom the patient can develop a good rapport, one who they feel confident will give good advice and who has easy access to all the appropriate investigations. It is not essential that the doctor has well developed research or surgical skills but they must be accessible approachable and on the right ‘wave-length’ for the individual patient. This choice is best informed by personal recommendation by friends and colleagues.

The choice becomes more complex when it involves treatment of a particular gynaecological condition. For example, a woman with a fertility problem would not wish to see a gynaecologist with an interest in the menopause or cancer and vice versa.

In addition the emphasis should switch more towards determining the level of expertise and the type of treatment that the gynaecologist can offer for a specific problem. In the UK all gynaecologists undergo basic training. It is only some who continue their training to develop special interests and surgical skills in a specific area of gynaecology.

Women are often referred to specialists by their General Practitioner who has an affiliation with a particular consultant gynaecologist. It is important to check that this is the right person to offer the treatment that is required.

The best way to find this out is to ask questions. Ask the GP specifics about the gynaecologist and the treatment options that they can offer. Women should also ask around, ask friends and colleagues. The internet can be extremely helpful too, but needs to be used with caution.

Once a doctor has been chosen it is also appropriate to ask him/her if this is a specialist area of interest and if an operation is required, how many of these procedures they would carry out on an annual basis, and could the surgery be done using keyhole techniques which are less invasive and have shorter recovery times?

In many instances choosing a gynaecologist is easy but if specific treatment is required then it is necessary to do a little research to be sure that the best available treatment is being offered by the best gynaecologist. If women are not sure then it may be worthwhile getting a second opinion.

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If you have any queries on our services or would like to make an appointment,
please do feel free to give us a call. We are always happy to help.

For Chris Barnick, please call Lene on: 020 7390 8440 or email

chrisbarnick@obgynmatters.co.uk

For Alison Wright, please call Debbie on:07540 128755 or email

alisonwright@obgynmatters.co.uk