Fertility: Structural Causes of Infertility

Podcast Transcript

Dr. Erica Newlin:

Welcome to OB/GYN Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Hi everyone. I'm your host, Dr. Erica Newlin. Welcome to our second episode of OB/GYN Time. During this season, we are focusing on topics related to infertility. On this episode, I'd like to welcome Dr. Jenna Rehmer who will be talking with us about structural causes of infertility. Dr. Rehmer, can you tell us more about your role in the Cleveland Clinic and a little more about your background?

Jenna Rehmer, MD:

Thanks so much, Dr. Newlin. It is truly an honor to be here today and to be speaking about fertility. I am a REI physician. REI stands for Reproductive Endocrinology and Infertility. REI physicians are double boarded in both OB/GYN and REI. So, we spend the first four years of our training as OB/GYNs, and then we do a subspecialty, a fellowship for fertility doing an additional three years of training in that field. So, I completed my fellowship training in REI here at the Cleveland Clinic in 2021 and stayed on here as staff afterwards.

Erica Newlin, MD:

Great. And in our last episode, we talked about definitions of infertility and what's entailed in the workup. Could you review what would be involved in the workup of a kind of structural or what we'd call anatomic causes of infertility?

Jenna Rehmer, MD:

Yeah, of course. So structural or anatomic causes of infertility can vary from problems with the ovaries such as ovarian cyst or endometriosis, to the uterus, such as things like a uterine polyp or uterine fibroids, or even problems with the fallopian tubes like a tubal blockage.

Erica Newlin, MD:

What are the imaging options usually? Where do people usually start?

Jenna Rehmer, MD:

Most of the time, the most common image that is done in women who are presenting with fertility issues are concerned about structural anatomical causes of infertility, start with a pelvic ultrasound. It's kind of our bread-and-butter imaging modality. And then if we feel like we need additional information, we may venture out into specialized ultrasounds or MRIs of the pelvis. Sometimes we do x-rays depending on exactly what we're looking for.

Erica Newlin, MD:

Yeah, it felt like for a while everyone was getting HSGs, when would you recommend an HSG for a patient?

Jenna Rehmer, MD:

Yeah. So HSG stands for hysterosalpingogram, which is just a fancy way of saying imaging of both the fallopian tubes and of the uterus. And HSGs are typically done in women who have concerns for fertility. And most of the time they're done when we want to rule out causes of infertility that relate to the Fallopian tubes.

Erica Newlin, MD:

So, it's not often the first line as far as workup, it would only be if you're suspicious?

Jenna Rehmer, MD:

If you're suspicious of fertility issues, yes.

Erica Newlin, MD:

Sure.

Jenna Rehmer, MD:

It's one of the first line evaluations.

Erica Newlin, MD:

And as we kind of talked about the fallopian tubes are the tubes down which the egg travels to meet the sperm. And then we kind of briefly touched on this, but what would you classify as tubal factors of infertility?

Jenna Rehmer, MD:

So, the fallopian tubes are these really delicate structures that connect the uterus to the outside world of the uterus. So, when an egg gets released from the ovary, it actually gets kicked out from the ovary and it's floating around inside the abdomen or inside the belly, until the fallopian tube picks it up and draws it in and brings it into the uterine cavity. So, if the fallopian tubes are blocked, it can cause issues with fertility because the egg can't make its way into the uterus. There can be blockages either at the, what we call proximal side, which means in close proximity to the uterus, or there can be a blockage of the tube at the distal side, which is the further end that's closer to the ovary and where the egg gets released. These different types of blockages have different implications on fertility.

Erica Newlin, MD:

In what way?

Jenna Rehmer, MD:

So, if a tube is blocked closer to the uterus on our imaging, say on an HSG, the tasks that we do to look at the fallopian tubes, if we see a proximal blockage, this could either be a true blockage like the tube is really blocked or it could be what we call a tubal spasm. So sometimes the tube will just kind of pinched shut or squeeze shut due to uterine cramping and tubal spasms that happened during the test. The test itself invokes spasms as we kind of push fluid through the area. So sometimes these blockages that are in the proximal side are really not that concerning, especially if the other tube is open and working and looks completely normal, whereas blockages on the distal side are more concerning. These are often due to adhesions or scar tissue, or some sort of damage either to the fallopian tube itself, or to the surrounding structure of the tube.

Erica Newlin, MD:

And so going back to HSG, you would be able to see this on the HSG, kind of based on where you're putting dye in and where the dye is blocked.

Jenna Rehmer, MD:

That's absolutely right. So, the HSG is an x-ray test, it's actually done under what we call fluoroscopy. So, it's kind of almost like a continuous x-ray, if you want to think about it like that. Women come in and they're in a specific phase of their cycle, we typically like them to be between days 5 and 11. So they're done with their period done bleeding, but it's pre-ovulation, so the lining is thinner, we're able to see better, and fluid is able to move more easily through the uterus and through the fallopian tubes.

So, women come in during this phase of their cycle, and they initially, they will lay flat on an x-ray table, and they have what feels very similar to a pelvic exam. So, we place a speculum, we find the cervix, we place a little straw like structure, it's called a catheter through the cervix. And we use that to inject fluid into the uterus. The fluid that we're putting into the uterine cavity shows up as bright white on an x-ray, because it's contrast dye. So, we inject the contrast dye into the uterus, and then it has nowhere else to go except for flowing into the fallopian tubes and hopefully spilling out the ends. If a tube is blocked, we won't see the spillage. Instead, what we often will see if the tube is blocked distally is that the fluid kind of backs up into the tube and forms what's called a hydrosalpinx. Hydrosalpinx just means water on the tube. So, it means that the tube is dilating with fluid. 

Erica Newlin, MD:

What then?

Jenna Rehmer, MD:

So hydrosalpinx is often the more worrisome sign of infertility because it tells us that there's a blockage and potential damage to the tube. And it depends on the severity. So really mild hydrosalpinx can sometimes be repaired surgically, whereas very severe hydrosalpinx often don't do well with repair and often means that the tube needs to be taken out. Now, it depends on whether or not they have a functional tube on the other side as to what we'll do after that. But if they end up having both tubes that are damaged, it sometimes commits women to IVF for pregnancy.

Erica Newlin, MD:

What kind of risk factors might someone have that would lead you to be more suspicious for tubal blockage?

Jenna Rehmer, MD:

So, I always counsel my patients in clinic that there's a couple of risk factors or like what I call red flags. As I'm doing an intake history for infertility, I think about these things, and I question whether or not I'm concerned about the tubes before we ever even go to HSG. The most concerning risk factor is the history of an STD or an STI. Sexually transmitted infections, especially those like Gonorrhea and Chlamydia, can really cause damage to the cellular structure of the tubes. As this damage happens, and it heals itself scar tissue often forms between the linings of this tubal lumen and so that can lead to damage in the tube that prolongs and persists for many years and even decades after the initial insult.

So, someone can have an episode of an STI in their teens or early 20s and then are seeing me in their mid 30s and still have damage from that infection. Other things that can cause tubal damage our history of other infections in the pelvis, most specifically things like a ruptured appendix or appendicitis that was kind of delayed and it's an evaluation or treatment, can lead to infection in the pelvis. Patients who have a history of ulcerative colitis or Crohn's are more susceptible to pelvic infections and to pelvic disease. Patients who've had a history of prior pelvic surgery of any kind, whether it's bowel, bladder, or of the G-Y-N organs, like the uterus, ovaries or tubes. And then patients who have a history of endometriosis, so endometriosis is a disease that can cause adhesions in the pelvis as well. Although most of the time it tends to spare the fallopian tubes.

Erica Newlin, MD:

Are there other sorts of imaging other than an HSG, which might tell you things about the tubes?

Jenna Rehmer, MD:

Yeah. So, there's other types of tests that we can do to look at the tubes, although the HSG tends to be kind of the gold standard as far as providing the most details about the fallopian tubes. Sometimes though, we can do a test called a Sono-HSG. And so, this is a test where we actually place a saline like fluid or other types of fluid into the uterus in a very similar manner to how we do it with the HSG. Except we are going to image, instead of with x-ray, with an ultrasound. So, ultrasound is able to watch the fluid move through the fallopian tubes, and we see it moving through on the ultrasound image as flow. So, we see this kind of rapid movement of the air bubbles of the fluid moving through the fallopian tubes.

It's not as great about telling you the structure of the fallopian tubes, or whether or not there is some mild dilation if it's not real obvious, but it can tell you a lot of details about the movement of fluid through the tubes. And it can pick up on other things. So, if you have other concerns at the same time, for things in the uterus like a fibroid or a polyp, it might be nice to kind of knock out two tests with one. So rather than doing a separate pelvic ultrasound and an HSG, you could do the Sono-HSG all at once.

Erica Newlin, MD:

For sure. And I know, traditionally, the HSG has had a reputation of potentially opening up the tubes with contrast.

Jenna Rehmer, MD:

Yeah. So, we tell our patients, I tell all my patients after I do the test that most of the studies show that there is an improvement in fertility for the next three to four months afterwards. So, it offers the benefit of being diagnostic, it tells us are the tubes open or whether they are closed, and it also offers a therapeutic benefit. So, we do see a boost in pregnancy rates even if the tubes are open on the test, just the act of flushing them and removing any small amount of mucus or debris that was kind of hanging out in there, allows that egg and sperm to meet up better.

Erica Newlin, MD:

Great. And then you briefly touched upon polyps, fibroids. Can you talk more about the definitions of those and how they might impact fertility.

Jenna Rehmer, MD:

So, there's a couple of different structural things that can happen with the uterus, one, that I haven't mentioned yet is just congenital anomalies. So sometimes we find for the very first time in a fertility workup that the patient was born with a different structure or shape to their uterus than what we find most typically. And so that's one thing we can find. Fibroids and polyps are considered a kind of growth that comes on over time. So, unlike the congenital things that people are born with, these are things that occur later in women's lifetime. Most commonly they occur over the age of 35. Although you can see them in younger women.

They are often hormonally influenced, especially polyps, they tend to grow more rapidly when there is estrogen. So that can either be from fertility treatments or from women who have higher levels of estrogen or don't get their periods regularly. These are all risk factors for developing polyps. And with fibroids, there's often a genetic component. So, we see certain populations for example, the African American population has a higher rate of fibroids, and we see that it tends to kind of run in families. Oftentimes, if somebody is known to make a fibroid, other individuals in their family may have had fibroids as well.

Erica Newlin, MD:

And you would usually pick up polyps or fibroids on an ultrasound?

Jenna Rehmer, MD:

Yeah, a lot of times you can. So, polyps are a little bit trickier, fibroids are often very obvious on ultrasound. Polyps when they get larger, are easier to see on ultrasound, but you can't always pick them up on that initial ultrasound. We do a special ultrasound where we can place some fluid inside the cavity and kind of separate the walls apart and then polyps become more obvious. Polyps are essentially an overgrowth, if you want to think of it that way, of a certain cell within the lining of the uterus. So, they grow from the lining. And I kind of tell patients to think about it like a small marble hiding inside like shag carpet. So, if you've got the lining of the uterus growing thick every month and you've got a marble sitting down inside that lining, if it's really thick, and really kind of a thicker shag, so to speak, in that shag carpet, the marble might not be as obvious to see.

But the thinner the lining is, the more obvious that marble is to see. So, during certain phases of the menstrual cycle, if a woman is getting an ultrasound, we can see polyps more clearly. Other times it's harder to see, putting the fluid in kind of separates those walls apart and makes it easier for us to see. So, there are techniques we have to be able to visualize it better if we're very suspicious of it.

Erica Newlin, MD:

And what if you do see a polyp in your imagination? How much do those impact fertility? What do we do about them?

Jenna Rehmer, MD:

Yeah, so the question about how much they impact fertility is still a little controversial. So, there's not great data that suggests that if we find a polyp and we take it out, we're actually improving fertility significantly, however, you're going to be hard pressed to find any REIs who will leave it behind because it could impact the area in which the embryo tries to implant. So, they are very simple procedures to take out, which is also I think, another reason why we favor taking them out and getting a really pristine cavity for an embryo to implant in. They're done either in the office or in the OR. And the procedure is essentially the same whether you're doing it in the office or in the OR, it really comes down to patient and physician preference as to which is the best location.

And if it's done in the office, it's typically done with like a little bit of local anesthesia or small amount of sedation, but is very safe, very well tolerated, typically takes about 10 to 15 minutes. And if they don't receive any type of like in office sedation, they're able to like, you know, get up drive themselves home, which is a nice benefit to doing them in the office. And when we go to the OR, patients normally have to be sedated more fully either with some IV sedations, or they either receive a breathing tube or some sort of gas to help with sedation. And that can just be a little bit more invasive for patients, but they then don't have any memory of it either, which is sometimes patients appreciate that, they appreciate not having to have a memory of having a procedure done to them. So sometimes in the OR it is better for those patients for that preference reason.

And again, it typically takes about 10, 15 minutes and then the procedure is over. We go through the cervix, so there's no incisions and we end up directly into the uterus. Once we pass the cervix, we use a small camera and a small instrument to essentially just kind of snip the polyp off from its base.

Erica Newlin, MD:

And then let's talk about fibroids. So, fibroids, also called leiomyoma, how might they impact fertility? What are all the different locations of fibroids? What are treatment options? A lot of big questions.

Jenna Rehmer, MD:

A lot of big questions. So, fibroids come in all kinds of various shapes, sizes and locations. And the answer to each one of those questions is going to be very specific based upon those things. So, fibroids that impact the uterine cavity or the lining where a pregnancy would implant and set up shop, those typically always need to be removed in a woman who is seeking fertility. Now, they don't have to be, women can get pregnant whether or not they have that fibroid in place or not. However, pregnancy rates may be impacted by it. So, we may see a higher rate of infertility, a higher rate of miscarriage, a higher rate of early premature birth and these kinds of things when fibroids significantly impact the cavity.

So, we typically recommend that those always come out. However, not all fibroids cause infertility or need to be removed, especially those that don't impact the cavity. So sometimes fibroids are found within the muscle wall of the uterus, or even on the outside layer of the uterus. And those, if they're not impacting the cavity, typically don't need to come out. So, we take into account lots of different factors when we're thinking about whether or not a fibroid need to be removed, its location, its size, how fast it's growing. And then we also consider other symptoms that aren't related to fertility. So sometimes a woman will have multiple fibroids in her uterus that are not impacting a cavity. But she has lots of symptoms like pelvic pressure and bulk symptoms and needing to urinate frequently or constipation or pressure and pain with intercourse.

So, we may move forward with removing those fibroids in that case, not necessarily for fertility. So, this is where really careful imaging to know the exact location and counseling with your REI can be really helpful to make the right decision for each individual patient.

Erica Newlin, MD:

Yeah, it's really tough because like a small fibroid that's inside the cavity may impact things a lot more than the large fibroids that are just hanging off on the outsides.

Jenna Rehmer, MD:

That's right. You can have a very large like, you know, size of a small orange or your fist that's on the outside of the uterus, and most of the time, if patients aren't having other symptoms, I recommend leaving it alone because it's unlikely to impact, you know, fertility. But you can have a pea size fibroid inside the cavity and that needs to come out.

Erica Newlin, MD:

Right. You briefly touched on congenital aspects, sort of structural issues with infertility, can you talk about the different things that you might see on imaging?

Jenna Rehmer, MD:

Yeah, so the uterus can come in many shapes and sizes. So most classically, the uterus has an inner cavity that is shaped like an upside-down triangle, and that has at the top of that on both sides of the, what we would classically think of as the base of the triangle, is where the fallopian tubes insert into the uterine cavity. And then as you come down towards the peak of that upside down triangle, that's where the cervix is out. And most pregnancies will implant along that top region, kind of broad base of the triangle that is at what we call the fundus, or the top of the uterus. And that area of the uterus can come in multiple different shapes. So, some women are born with two cavities in their uterus. So, women are born with a remnant of tissue called a septum inside the uterus that we can remove surgically.

Some women are born with a single, like half of their uterine cavity rather than the full upside-down triangle, they only have like half of that triangle. Some women have two cervixes or cervices. And so, there's a lot of different ways that these congenital anomalies can present.

Erica Newlin, MD:

And it can be complicated depending on how much it affects fertility. I have plenty of pregnant patients who have two cervices.

Jenna Rehmer, MD:

Yeah. And they often do really well.

Erica Newlin, MD:

Yeah.

Jenna Rehmer, MD:

So, it really just depends on the, like you're saying the anomaly and their history. We really take all of that into account, as we're thinking about, you know, is it worth doing something about? Is there anything that can be done because not all of these anomalies can have interventions done to improve outcomes? So, we really take all of that into account.

Erica Newlin, MD:

Great. Let's switch gears a little bit. I know that endometriosis is a huge topic in itself, but could you briefly just describe what endometriosis is and how it may just alone impact fertility?

Jenna Rehmer, MD:

Yeah, there is a lot about endometriosis that we still don't fully understand including the exact pathogenesis or exactly how it happens, why it happens in some women but not others. What we understand and our best working hypothesis, not a 100% certain but our best working guess is that the lining of the uterus every month when it sheds is known in women to not only exit out through the cervix and through the vagina like we expect with like routine menstrual bleeding, but it also goes backwards out the fallopian tubes and ends up in the abdomen because it's an open channel and fluid can move in either direction.

And so, this is called retrograde menstruation. It's common, it happens in almost all women. So very frequently, like if you were to do a surgery and look inside the belly after or while somebody is on their period, you would see blood outside of the uterus, in the abdomen. And in this blood product, there are little, tiny pieces of the lining of the uterus. This lining typically gets cleaned up, the immune system comes along, sees it as debris and cleans that tissue up and gets rid of it. However, in women who have endometriosis, for unknown reasons, the body sees this almost like a wound that needs to be healed or fixed or repaired. So rather than kind of like eating the tissue up and getting rid of it and disposing of it, it allows it to kind of set up shop and to grow and shed and grow and shed every month just like the lining of the uterus does.

Well, when this happens outside of the uterus in the abdomen, it creates a very high inflammatory environment. So, lots of inflammation is going on as this lining is shedding every month and causing a lot of tissue damage and destruction because of the inflammation. Our bodies don't like inflammatory processes. And when they experience that, they often try to come in and create a healing scar. And so, you get scar tissues, things within the pelvis stick together, the ovary might stick to the back of the uterus or to the sidewall, you might get bowel sticking to the uterus. And so, as these implants form, adhesions form as well too.

Exactly how it contributes to infertility is also not 100 percent known. But one of the leading theories as to why it contributes to infertility is that when the egg is released from the ovary, like we were saying earlier, it's kicked out into the abdomen and is floating around in the fluid. Well, we know that women who have endometriosis have really high inflammatory markers in this fluid compared to women who don't have endo. We assume or think that perhaps the inflammation that is happening in the egg is being exposed to this inflammation can cause some damage to the egg, so that overall, the egg does not do as well or survive as well.

And its fertilization and growth into an embryo is overall impacted. We also know that there is some decrease in fertility even when that egg is not exposed to the environment. So, for example, when women undergo IVF, which is a treatment for endometriosis sometimes, and we go to place an embryo back into the uterus, that their overall pregnancy success rates are slightly lower than women who don't have endometriosis. So, we know that endo is also impacting the lining of the uterus, even when the egg is not exposed to endometriosis.

Erica Newlin, MD:

And people who know they have endometriosis who aren't immediately attempting pregnancy or thinking about pregnancy in the future, sometimes we talk to those patients about being on birth control correct?

Jenna Rehmer, MD:

Yeah. So, I would actually recommend to patients if they're, if they don't have other contraindications as to why they can't be on birth control, that it's really a great treatment for endometriosis. And a lot of women respond very well to that. Not only can endo cause infertility over time, but it can also cause scar tissue and pain. And being on birth control helps prevent all of those things from happening by controlling the disease process. The endometriosis lesions within the pelvis that are like setting up shop, they respond really well to these hormonal treatments and so they regress in size. They regress in their intensity of inflammation and all kinds of positive changes that happen when women are on birth control.

Also, it can help with overall fertility in the future by decreasing the disease burden. So, although we know that infertility isn't directly correlated to the amount of disease, so women can have very little disease in the pelvis and still have infertility, whereas other women can have a lot of disease and get pregnant, so there's not a direct correlation. And the same is true for pain. But we do see a trend. We see a trend that the more disease there is, the more pain women have and the more infertility they have. So being on a hormonal birth control pill can help with decreasing the overall disease burden and hopefully improve fertility in the long run.

Erica Newlin, MD:

When would you recommend surgical evaluation for endo?

Jenna Rehmer, MD:

That's often a tricky question. And it is very highly debated. There's a lot of studies looking at it, and it's often a great topic of debate at our scientific conferences and stuff, is like when is the right time to operate on a patient with endo? So outside of fertility, a great patient candidate for surgery or surgical intervention is somebody who has a disease that is very debilitating. So, they are frequently missing daily activities, hanging out with friends, going to work, going to school, because their pain is so severe, and they've failed to respond to other interventions. So, they've been on hormonal birth control, they've tried using NSAIDs around their period or like Ibuprofen and things like that. And they're not seeing an improvement or a significant enough improvement in their overall quality of life.

So patients with pain, who have not responded to other treatment options are often a good candidate for surgery, because surgery can go in and kind of clean up all of the disease that they're able to, and take down a lot of the adhesions, and this kind of resets the playing field, to which then being on hormonal birth control and other things can help improve their pain. For patients who are seeking fertility, it really becomes about their overall goals. So, in a patient who may have other reasons to go straight to IVF, or invitro fertilization for fertility purposes, we most classically don't recommend doing surgery in those patients if they're not also dealing with pain at the same time.

So, if a patient presents have a known history of endometriosis, pain is overall not too bad, pretty well controlled, and they're planning on going to IVF for other reasons, or maybe just because of the endometriosis, they will typically not go to the OR. However, if a patient presents to my clinic and says we don't want to do IVF for either their own personal reasons, emotional reasons, financial reasons, whatever it might be that IVF becomes limiting to them as an individual, we will consider going to the OR because in the same way that removing disease improves pain, it also improves fertility. So, there are studies out there that have looked at fertility outcomes, and we see an improvement almost back to baseline fertility rates in women who have undergone surgery to clean up the endometriosis disease in the pelvis.

Erica Newlin, MD:

What about when we just find things like endometrioma?

Jenna Rehmer, MD:

Yeah.

Erica Newlin, MD:

Like an implant on the ovary.

Jenna Rehmer, MD:

So, endometrioma is a cyst on the ovary that is caused by endometriosis. So, an implant or disease of endometriosis sets up shop on the ovary, starts to grow. It fills in the cystic fluid full of kind of like, we actually call them chocolate cysts, they get kind of like a dark, blood colored on the inside. And they can grow quite large. Sometimes they're small, sometimes they're very large, they can be similar to the fibroids we were talking about earlier, they can be the size of a pea, or they can be the size of a large orange. I've even seen ones as large as your head, so they can get very large in size, and can cause various symptoms depending upon size.

We typically recommend not operating on those unless they're over four to five centimeters in size or if they're associated with significant pain. And it also depends on goals as well in this situation also. So, in patients who are seeking fertility and are planning to do IVF, we know that when we go in to operate on the ovary and take the cyst out, there's always a little bit of a hit to the ovary. No matter how hard we try and no matter how excellent the surgeon is, the ovary is always going to sustain some small amount of damage as we cut through it to take the endometrium out.

Now oftentimes over time, the ovary will kind of recuperate and recover that hit but it can take three to six months. And so if a patient is looking to move forward very quickly with IVF and only has, say, a four centimeter endometrioma and it's not large enough that it's going to be in our way while we're doing the IVF procedures, we'll oftentimes leave that alone and stimulate them without messing with it because we don't want to decrease the reserve in their ovary right as they go into a fertility procedure.

Erica Newlin, MD:

Great. And then just in closing, do all REIs perform surgery? And can you tell me more about REI as surgeon?

Jenna Rehmer, MD:

Yeah. So, REI is like I said, are OB/GYN trained. So, OB/GYNs go through what is considered a surgical specialty. So, they all receive surgical training throughout their OB/GYN residency. And then as we enter into the REI fellowship, surgery becomes very diverse. So, in some fellowship training programs, the surgery is pretty limited, and in others, there's a really heavy focus on surgery. REIs used to be really well surgically trained for fertility purposes because things like IVF were not as successful. We didn't have that as an option to overcome things that surgery wasn't able to do. So, now, IVF often is kind of the first line choice and surgery tends to kind of be a little bit of a back burner thing for some REI fellowships.

Here at the Cleveland Clinic though it is considered one of the more predominant surgical programs for REI. It's why I chose to come here because I wanted to be an REI surgeon. And I think that being an REI surgeon really broadens the number of patients that I can take care of well and the number of patients in whom I can meet their individual needs. So, in other REI practices, if an REI surgeon is not available to offer surgery, the patient will often be referred out to other specialists or sub-specialists. So, either general OB/GYNs, minimally invasive gynecologic surgeons, or MIGS, or even Gyn Onc, which are the specialists who specialize in GYN cancers. So, these surgeries will kind of get spread out amongst the other sub-specialists. Whenever an REI surgeon though is involved in the case, I think there's just a different lens in which we look at that patient's fertility journey.

So, we're thinking not only about like, we see a fibroid got to get it out, but it's more about, we see a fibroid, how does getting it out impact their fertility? And the technique in which we go about taking that fibroid out is, in my opinion, very different. So, for us, we're spinning a lot of care and a lot of detail to make sure that everything we're doing throughout the surgery is improving their overall fertility, not necessarily just the other symptoms that come along with having a fibroid. So, I think just having somebody who has, you know, that lens on and is always thinking about that and that is at the forefront of all their decision-making in the OR really adds a benefit to having surgery done with an REI surgeon.

Erica Newlin, MD:

And that's great. Well, thank you again for joining us.

Jenna Rehmer, MD:

Yeah.

Erica Newlin, MD:

Is there anything you'd like to add?

Jenna Rehmer, MD:

No, this was wonderful. Thank you so much for the time and I appreciate being able to sit down with you guys and go over this. 

Erica Newlin, MD:

Great, thank you. Thank you for listening to this episode of OB/GYN Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.