Post Program Survey
The Role of Office Hysteroscopy for Infertility Evaluation
Originally Broadcast: Tuesday, March 16, 2021 at 2:00 PM EDT / 6:00 PM GMT / 10:00 PM GST
Course Objectives
Discover the ways direct visualization can advance infertility evaluation
Discuss methods of optimizing implantation and sustained pregnancy
Learn about a paradigm shift in patient evaluation and treatment
Presenter
welcome and thank you for attending this event is brought to you by Cooper Surgical, a leading provider of medical devices for women's health care. For 31 years, Cooper Surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive, surgical and obstetric solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization. We are fully committed to helping improve the delivery of health care to women and their families. Cooper Surgical Manufacturers over 600 clinically relevant medical devices used by health care providers and offices, clinics, operating rooms, labor and delivery suites and reproductive IVF clinics worldwide. Clinicians overwhelmingly say they trust our products for their reliability, innovation and efficiency. Here are some other interesting facts you may not know about Cooper Surgical. Since our inception in 1990 our focus has always been women's health care. With more than 600 medical devices and over 3200 product numbers across a broad range of market segments, physicians know and trust our products. We ship over 1450 orders per day, of which 99.7% are shipped the same day. Our customer service department handles over 2100 inquiries per day. We employ 1800 people worldwide. We are pleased to provide this educational opportunity on behalf of Cooper Surgical. Welcome and thank you for participating in tonight's event. My name is Alan Chips and I will be the meeting manager for this evening's program. A couple of notes on how the presentation will run. We will have approximately 25 minutes for the presentation, followed by a 15 minute Q and a section with Dr Ziegler to submit a question, please click. He asked a question button located under the player window to fill out the form. If your question is not answered, you will receive a response from Cooper Surgical. Following tonight's event. Times presentation is entitled The Role of Office Extra Skopje for infertility evaluation. Dr. Ziegler is a board certified specialist in reproductive endocrinology and infertility and medical director of the Reproductive Science Center in New Jersey. Now, Dr Ziegler, thank you very much for that introduction. I like to welcome all my colleagues from all over the world. And during this lecture we're going to be talking about the role of office history. Ross Copy for the Infertile Evaluation. I want to disclose that I am a consultant for Cooper Surgical, and I'm a speaker for Abby, as well as Cooper Surgical. The main thing that we need to keep in mind for our patients is we need an accurate evaluation of the uterine cavity because any abnormality in the uterine cavity can affect implantation and could affect the outcome of a pregnancy. We also need to keep in mind that we have macroscopic intra cavity, every disease and to see those lesions history. Ross Copy remains the gold standard for the diagnosis and the treatment. When we look at uterine cavity abnormalities, we have to understand the incidents of these defects in which we do see the prevalence of congenital uterine abnormalities in the general population is only 5.5%. However, history ask OPIC abnormalities are seen in the infertile population up to 60%. There's also an association between endometriosis and endometrial polyps. We find that patients that that have endometrial polyps, they have endometriosis in around 68% of those cases, and we also know that structural abnormalities are noted in patients with recurrent pregnancy. Loss is up to 38%. When we treat these abnormalities, we have seen an increase in implantation rates and pregnancy rates. There were some studies that came out that looked at performing a polyp victory before an intra uterine insemination and the pregnancy rates, after an intervention of removing these polyps increased from 28% up to 63%. Miscarriage rates decreased from 27% to 10.7%. When we look at sub mucosal melanomas, we know that they can affect implantation in removing these pregnancy rates have increased from 27% up to 43%. So how do we diagnose intra cavity terry lesions? Well, we have trans vaginal sonogram, but the sensitivity and specificity are not that high. We now have saline infusion sonograms, but again, you're looking at a specificity of uterine abnormalities of only 60%. We take a look at polyps and my Omagh's. They're still quite low compared to doing a diagnostic history Ross copy, which is the gold standard. So why don't we look inside the uterine cavity? Well, it's convenience. It's not convenient to do. It takes a lot of time. We have to set up the equipment. We have to set up some fluid management system. It's not well tolerated in our office to do a diagnostic history. Rosco P and the cost, the cost to the patient, the cost of the equipment. However, now we have an instrument that allows us to look inside the uterine cavity, and this is the end of the advance. It has a very manageable hand piece. It has a high resolution colored LCD touch screen, which is reusable. It's able to take still pictures as well as videos. At the same time, you can take a video and take a picture at the same time as you're videotaping the uterine cavity. There is the catheter itself, even though it's somewhat rigid, it is somewhat flexible, and it can help you get into those retro averted uteruses or get into the corneal areas so you can see the Tobolowsky. And the other part is that this has a docking station where you can download the video as well as pictures right into your M R. So traditionally, when a patient comes into our office, we do an initial screening, we would do follicular phase blood work on day 23 or four of a patient cycle. We would do a so no hissed a gram where sailing infusion sonogram to take a look at the uterine cavity. And if there was an abnormality, we would then need to schedule a operative history. Rosco p The problem that we were having in our own offices. We would get these false positive results whether the catheter from the saline infusion sonogram dug underneath the uterine lining. And now we have this little flap of tissue that me, we can't say it was a polyp or not a polyp in some cases in patients that we would send for a history. Scalping go Graham. We get a result back saying there's an irregularity in the wall of the uterus and they recommend further testing. So we were actually looking at getting a whole set up a whole history skop IQ setup. And then we found the end O. C. And that has revolutionized the way that we do our infertility evaluation. So from the time that we do a sanding, infusion, sonogram and if there's an abnormality to go for a history Rosco P. We are delaying a patience ability to go into treatment by 12 maybe three months, depending on when you can get that patient into the operating room. So now what we do is we have a patient that comes into our office. We do an ultrasound, we get blood work on day 23 or four, and then other cycle. We do the endoscopy. We look inside the uterine cavity, which is the gold standard to find out whether there is any uterine abnormalities. And at that point in time, everything is negative. We then can go right into treatment. So we have found that it has actually expedited a patient's care on the average of 1 to 2 months to get into treatment. And you have to realize that that that infertility patients want to be pregnant yesterday and anything that we can do to help expedite their care to get them into treatment sooner is going to benefit the patient, and it's going to improve the care you give to that patient. So these are some cases that I want to kind of go through to illustrate the benefit of doing office history. Skopje. You can see in this patient's case, we did a son. Oh, hissed a gram and we found an irregularity in the uterine cavity. We then did an endoscopy. A few days later, we brought her back in. After she was prepared to go through the procedure, we looked inside and the cavity was normal. In this situation, we would have had to take this patient two a surgery center to do a procedure of a history, Rosco P. So the patient would have to take time off from her schedule. If you have Children to find day care for those Children or someone to take care of them, they would have to come into the surgery center. They would have to get anesthesia. And as you're well aware, surgical facilities don't always run on time. So and personally, I really don't like the coffee with within the doctors language, and I'd have to take time off from my schedule to be there. And in this situation, her cavity is normal. So by looking inside, I have now saved the patient time in many cases, the patient money, because a lot of them have a deductible to go into a surgical suite, Um, in my time. So this benefits myself as well as the patient. And again, it does expedite their care. Here are some other cases we did a so no hissed a gram. And in case too, you can see that there's this defect in the fungal area of the uterus. This patient again, we looked inside by doing the Endo C and her cavity is normal. You can see the 22 blossoms and the uterine cavity is uniform. Just take a look. At number three, there is an irregularity on the posterior wall of the uterus. Is this a polyp? Is this a tuft of endometrium? What we looked inside and was actually a Cecil Pollo that we actually had to remove. Some patients that have polycystic ovarian syndrome may have a irregular lining like the one you see over on the left. The question is, is this a normal variant for this patient, or is there something actually going on there that we need to address? And then we take a look inside and we see all these little micro polyps, which again are characteristic in those patients that have polycystic ovarian syndrome. So This is a patient that has a history of recurrent pregnancy losses, and I want to show you the video that this camera can take. So let's take a look at it. You can see here in the uterus her uterine cavity. She has an adhesion between the anterior and posterior wall of the uterus. And with the NDC advanced, you can actually advance scissors to go in there to take out that adhesion in the office without anesthesia. Here are two other patients that have a history of infertility, and we take a look inside. The one on the left actually has a uterine septum, and the one on the right has uterine Sinica scarring, which again we can evaluate quickly. And then we can make a decision of whether or not we can address this in the office with the instruments in which we can pass through the end, O. C. Or are these patients that we need to take to the operating room? It's a little bit out of, um, the scope of doing these procedures within the office. So this is another patient that came in, and by doing the end O. C. We were able to identify what we needed to treat and treated and treated quickly to expedite their care. So let's take a look at the video now. She had a very thickened uterine lining and no definite Palepoi lesion. So I put in the end O c. And you can see the polyp that is sitting in the middle of her uterine cavity. Now, this patient, I could not remove this polyp within the office. We actually had to go to the operating room to remove this polyp. And after removing the polyp, she actually got pregnant very soon after that procedure. So again, this may have been the reason why she was not conceiving. And therefore, by treating this quickly again, it made her happy to be pregnant. Um, and we kind of look like stars because we identified the problem that was preventing her from conceiving. Possibly. So. This is a patient of Dr Goldstein. There's a patient who is 27 years old. Grab it. A zero desire to get pregnant, and, uh, they needed to remove the i u d. But they could not see the strength. So what they used is the NDC to look inside and to take out the I u D. So let's play the video. So he was able to identify the I. U D and the end, grabbed it with the grasshoppers in the office and remove the i u D avoiding going to the operating room. You can get very good visualization of the I u D and therefore can expedite its removal. This is another patient of Dr Goldstein's. A patient has infertility and had uterine McComas. She's 38 years old. Gravity zero she status post of robotic assisted myomectomy. A history scalping go! Graham was performed. There was no spill from the left tube, and the cavity was distorted. So this is where they looked inside to find out what is destroying the uterine cavity. Let's take a look at the video that's in the cervix at this point, and you can see there is the sub mucosal melanoma sitting over at eight o'clock again. There are some lesions that we cannot take care of in the office, and we have to know our limitations. So this patient was scheduled for a mile shore by Dr Goldstein. Here's a patient who's 35 years old to grab it zero has been attempting conception for approximately two years. There is male factor infertility, so this patient needed to go to in vitro fertilization. So what we need to do is to make sure the uterine cavity is fine. Make sure it's normal. And I'm not going to trust a patient going through in vitro fertilization spending quite a bit of money on medications and the procedures on a procedure that's not as accurate as I like it to be. So in this patient we looked inside of the uterine cavity and her uterine cavity was normal, so we were able to again expedite her treatment and get her into an IVF cycle very quickly. This is a patient is 36 years old, grab it. A one has been attempting conception for close to a year. She was complaining about breakthrough believing, so therefore, what we did is we looked inside of her uterine cavity. We saw this little Palepoi lesion. We took the polyp. Grasshoppers advanced them through the end, O. C. Advance grabbed the pulp and we pulled it out. That's all that needed to be done. Her cavity was now normalized, and then we can proceed on with the rest of her workout. So this was a patient that we saw in our office, who is 30 years old. Grab it. A three para zero. She has a history of recurrent pregnancy losses, and when we were doing our ultrasound, the uterine cavity quite didn't look normal. So what I did is we took the endo, see Advanced, looked inside and we diagnosed a uterine septum. We were able to show it to the patient. We could explain to her why we needed to go to surgery, because many patients are very reluctant to proceed a surgery, especially within our current environment. So this helped to identify an abnormality. The patient felt comfortable going to surgery, and we were able again to expedite her care. So the advantages of the endo see advance. You have direct visualization of the uterine cavity, and that's going to give you a more accurate diagnosis. If something is there, and if something has to be taken care of either in the office or in the operating suite, the display is clear. It's a colour display again that provide you accurate visualization of the uterine cavity within our own office. Patients have very little discomfort. We do pre treat with Cytotec to help us advance the catheter. Patients do take motion beforehand, but they get more discomfort from inflating that balloon from assailing infusion sonogram than what they do from when we are doing the endo See advance. This can be done in any room in the office. So what I normally do is we set up a room that could be any any of our exam rooms, and my Emma goes in, sets up the room. We do the procedure, which takes maybe around maybe two minutes or three minutes to do. And when I'm done, I'm showing the patient the pictures and the video of what just transpired. And during that time, my Emma is cleaning the room, and then by the time I leave, that room is already clean, and it just has to be turned over for the next patient. So in doing this in our office, it does reduce visits to the operating room, and therefore it will save you time. And it's more convenient for the patient. As I mentioned that the average time of the procedure is less than three minutes. It's very quick It's a low cost investment, and there is reimbursement for this procedure that you're doing within your office. So when we look at reimbursement, these are the codes in which are used for a diagnostic history. Rosco P. And for a surgical history, Rosco P. And based on what your negotiated fees are, will determine what your reimbursement is. But the reimbursement that you're getting in doing this procedure in your office is just as much as if you do it in the operating suite. And if you have any questions about reimbursement, there is the reimbursement hotline, which is on the slide. It's over to the right hand side. So the office based history skah pic procedure enables us as physicians to combine a diagnostic approach and how to expedite treatment and how to manage this patient effectively. We don't want to have multiple interventions we don't want. We try not to have the patient have anesthesia, if at all possible. This approach produces a substantial cost savings to the insurer as well as to the patient. As I mentioned, a lot of patients haven't have a surgical deductible that they would need to meet. Many patients prefer going to a familiar environment of your office. Many patients don't want to go to the hospital or to a surgery center, especially again with the pandemic going on that they feel more comfortable coming to your office. Also, that the office setting is not as quote unquote sterile of an environment as going to a surgical suite. The physician benefits from the ease of scheduling the procedure because it because it could be scheduled during their normal office time, it's more efficient use of their time. Also improved reimbursement compared to take him to the hospital or to an ambulatory surgery center. And these are things that you need to weigh out. However, it seems to be beneficial for the practitioner to move this procedure into the office setting. So in conclusion, the end OC advance gives direct visualization of the uterine cavity. It has high accuracy of diagnosis. You can see septum, polyps and fibroids as well. Scar tissue decreases time to treatment. I know I've mentioned that multiple times during this presentation. It improves patient care because you can directly visualize what's in that cavity versus using an indirect assessment of a so no hissed a gram that made you do some false positive results. It maximizes your time as a physician. Your time is valuable, so maximize that as best as you can. And again, it's a cost effective for both the practice as well as for the patient. So I'd like to thank you for your time, and I hope that you will take the take home points from this lecture and analyze them and see how they would benefit your patient's as well as your practice. So again, I like to thank you for your time, and I like to open up the Florida questions. All right, Thank you, Dr Ziegler. We're not going to turn to the Q and a portion of the program. Just as a reminder. You can ask a question by using the ask a question button below the player window. If you're in full screen, you will have to leave full screen to see that button. With that, I'm going to turn it over to Christopher Kahn from Cooper Surgical. Excellent talk, Dr. Ziegler. It's great to speak with you again and thank you very much to our audience for your time today. My name is Christopher Kahn, and I am, the senior global product director at Cooper Surgical. It's my pleasure to be a part of this program. The submitted questions are coming in their excellent. Please continue to type any questions you have, and we will be able to see those in real time and then for any questions we don't get to today and to request follow up. Please do check that box in the polling questions to request a sales representative. Follow up. Okay, let's get started with the questions. Dr. Ziegler. First, would you please describe the components of NBC? Advance that arrive in the packaging. That's a great question. Um, it comes in a package that looks like this. It's a field pack. Inside, you have the NDC advanced catheter. You also have a PayPal underneath your biopsy catheter. We do use this at the time of doing the end of C advance, mainly because we want to make sure that there's no like there's any inflammation or anything like that that we need to address before they go on for fertility treatment. The catheter itself, it is it does have markings for and then for sounding the uterus, which is quite important for us it basically the handle swings down. Your fluid would insert into, uh, it's like a Laura lock at the bottom of the catheter, the base or the camera, I should say, or the screen looks like this. It slips right onto the catheter. So now you are able to insert the catheter into the uterus, and you, the buttons on the side allows you to take video as well as still frames. You can take a video and do still frames at the same time, which is quite which is quite nice when we're done with the patient procedure to show the patient. What are we doing? You can hit playback, and you can see by the picture here. If you take a look, it's very clear you can see that there's a polyp located on the back wall and then of the uterus. You can also, as I mentioned before about taking videos, and that's why I can show you what they look like. This is coming directly from the camera itself so you can show the patient what exactly is going on with them and why you may need to do surgery. Or what did you think was going on within the uterine cavity. You can then download those to just your m r. And that's the pictures you saw within the video. Like those videos in which we, uh, in which we talked about Thank you. And there's one other thing I want to explain. There's also here There is an operative port where you can insert instruments they have reusable, and that's and that's what we use within our office. There is also disposable ones, Um, and they work very well. Then the camera can actually just slip right off the hand piece. This is disposable that gets tossed away, and this gets put into a docking port. So it's just so you can download the videos and then as well as the pictures. I'd like to ask you about the components further, and please describe which components are reusable, which are disposable. You mentioned the instruments. Could you also talk about the monitor and the cannula for NBC? Advance right. Can't. The cannula is disposable again. The pipe l is disposable, but this is reusable. We just wipe it down and we put it back into the port. Okay. Thank you. Our next question is, in your opinion, what is the most important factor in using endorsee Advance in your practice. The most important factor that is a benefit to us is that again that it can be It can be used in it can be used in any room. We don't use any anesthesia. We do give the patient motion beforehand, and we also have them use side attacked vaginally the night before. It makes it a lot easier. Uh huh. I've heard of other physicians that in which they use a tin actual, Um, sometimes to help get in the catheter. I've never had to do that. I may use a cervical loss finder to maybe dilate a little bit so I can get in the catheter. But the benefit to us is that we can directly assess the uterine cavity before they go on to fertility treatment or those that have failed an IVF cycle. And I'm concerned that maybe we are missing a Cecil Polyp or something like that so I can directly look inside before they go on to another, either a fresh transfer or for a frozen embryo transfer. And even in our donor egg patients, the ones that are using donor egg again. They're spending a lot of money to purchase these eggs, whether it's frozen. Or maybe they're using fresh. You want to make sure that that uterine cavity is normal. You don't want to. You don't want to be someone. And then after the fact you put in these embryos and they actually had something that was irregular on the back wall and then of the uterus, Um, I always look at I always. I always explain to patients which and and just embryos are like airplanes. Airplanes don't like landing on mountain ranges. Neither do embryos, so we want to make that as smooth as possible. And the best way to identify whether there's anything going on in there is to directly look at it. Okay, thank you. The next question is, when an ultrasound scan is normal, how would you justify to stakeholders that routine history Skopje is worth doing and cost effective in cases of sub fertile women? Well, if you take a look back at the lecture, you can see how the sensitivity and specificity of even a a standing infusion sonogram is not as good as doing a diagnostic history. Rosco p just looking inside. And if you're doing a straight trans vaginal sonogram, that's very inaccurate. So we explain to the patient that it is beneficial to take a look inside so we can maximize their fertility potential. And they're not wasting their money with fertility medications. The lab work. Um, and if they're using, like donor egg or refusing and donor sperm or even donor embryo, that we're maximizing their chances in getting pregnant. Thank you, Doctor. You mentioned using Cytotec the night before and Motrin to manage pain. Can you elaborate a little further on how you explain the procedure of NBC? Advance to your patients, get them ready? Well, we always, um we always want to compare it to something. And a lot of times patients have had Maybe they've had an HSG test before coming to our office. Or maybe someone else did assailing infusion, sonogram. Or they may have not even had a procedure before. And now we are discussing about doing this procedure within the office to help mitigate their concerns. We I always compared to menstrual cramps and even though I have never had them for the obvious reasons, um, we always we always use patients experiences. So when I'm talking to a patient, I'm talking about doing this procedure to look inside their uterus. I tell them it feels like bad menstrual cramps because that's what's referred to us. I find more patients have a discomfort if they've had a saline infusion sonogram when you inflate that balloon, and that patient can feel that that's more discomfort than what the end O. C. Is. So I do explain to patients that we want to do this within the office it takes. It takes maybe less than a minute to do. We get a lot of information. We're going to help alleviate a lot of your discomfort by having to use a medication the night before, as well as Advil or Motrin around an hour prior. And it's very well tolerated. I I haven't really had any. I haven't had any patients in which I had to stop the procedure because it was uncomfortable. Even when we when we put in fluid and the way that we do it, we do not use a syringe. We use the pressure back. We get either a 500 cc or 250 cc bag of normal, sterile saline or or even lactating ringer because we do procedures within our office for egg retrieval. So we have those and then at our disposal, and then we use the pressure bag. We pump it up to 150 millimeters and mercury pressure. I can adjust the pressure right by a stop cock. That is right on the I V tubing itself. Um, so I can adjust the pressure, and it's very unusual that a patient would have any complaint about that. Um, if you don't have a pressure bag, you can always use a blood pressure cuff and just put that around the I V bag and pump it up, and then you can reuse that by and then just wipe it down. But that's how we kind of explain to patients. And and as I'm doing the procedure, I'm explaining to them what I'm doing. And we may even have some side conversations and then about the weather or about the work that day. So it kind of distracts them from the procedure itself, and then we're all done. A lot of them are very surprised in which the procedures done even if I have to take out Apollo. Um, so I guess setting expectations are explaining to them of what is coming down. The pike is very beneficial. We also give them a hand out beforehand. That kind of explains everything so they know what's going to be happening. Thank you. And how do you manage visualization if there's any bleeding during the procedure? If I encounter any bleeding a lot of times by just putting up the pressure helps with that because it does that there is some influx. So therefore, it does wash out the uterine cavity or the other thing, that that's very beneficial as you take out the camera and you can actually put in the people itself. And you can withdraw some of the fluid and then put the camera back in, and the picture is normally clear. If you're running into where maybe you bumped into a fibroid and you started some bleeding again. If you can't get good visualization within the office, then probably going to the operating room would probably be within this best would be in the best interest and just for this patient. But even with large fibroids that I find inside that are 34 centimetres. Um, that, uh, if I'm looking inside, I'm seeing What is the extent of this? I've not had a problem with getting getting visualization. Uh, and if I do get into some bleeding again by just pumping up the pressure a little bit will help. Um, alleviate that. Thank you, Doctor. Which therapeutic procedures are you comfortable using? Endo. See, Advance for in your clinic. Um, I do take out fibroids as long as they're podunk related. Uh, if they're very large again, that if if there's a if it's if there's a significant amount. Then again, I do not do that within the office. I do take down some a Sherman's again, but you have to know your limitations. So there were some patients in which had just mild Ascherman syndrome. So I would take I would take the scissors and I would take down those adhesions within the office taking out small polyps because there are the polyp grasshoppers, um, step Tums. As long as they're not large septum. If they're confined to the upper part of upper part and then of the fund this, then I will take those down with using the scissors. Thank you. And specifically on polyps. What size polyp are you comfortable removing in your office? And there was a second question here around. What process do you use as you're handling both the cannula and the instrument after you detached the polyp from the endometrial lining? Do you remove both the cannula and the instrument at the same time? Well, again, when it comes down to pops, it all depends in if it's a podunk related to the point that I can grab the stock and pull out the entire pile up, I will definitely do that. There is no size as long as I can grab the entire base. Um, you have to take a look and then the grasshoppers if and how firm is the polyp? Because I know there that in my experience there could be different consistencies of Parliament, So it all depends on how easy it is to grab. Sometimes I run into pops, which is sort of like playing a video game, and every time you're trying to grab it, it just bounces right out of your way. Um, in that situation, I would decrease the pressure, so I can wedge it between, um, the two, uh, the ante and post your aspect and then of the uterus and then grab it. So do I have a size that I will not take out? Um, there really isn't. It just depends on whether or not I can get to the base. And in removing the removing any pathology, I try removing it in one full motion. I removed the scope as well as the catheter. Um, so I bring it all out at one time. Great. Do you ever find it necessary to determine the depth of the uterus before conducting a direct visual assessment? No, I have never done that again. You can use the endo, see to see how deep the uterine cavity is, but that really does not affect of it doesn't affect what I'm going to be doing. It may relate to the amount of pressure I may need to descend the cavity, but I will make that determination. And once I get inside, so what I do is again. It's very like if I have to dilate, it's mainly because I want to see which way the uterine cavity is going and and then our cervical lost finders are very are I graduated. So I really want the external osk to be a little more dilated. And then then what? The internal losses. And then the catheter floats in very easily. So I can still maintain the distention in which I want. And if it if I need to get more pressure? Yes. Have I pumped the the pressure higher than 1 50? Yes, I have. Um, but again, we're using only 250 or 500 fee fi bags. So even if they would absorb all that, it's really not a problem. Thank you, Doctor. You previously mentioned sometimes using a tin acura. Um, during this procedure, what are your thoughts on using a true vaginal skah pick approach for the entry of undersea advance? Vaginal, vaginal skah, pick, approach. I've never done that. I usually put in a speculum so I can see the cervix. Um, so I've never did a badge in I'm not sure about, is it without using a speculum? I'm not sure if that's the case without a speculum. Um, well, again, I rarely use I haven't needed to use a tin Oculus. Um, but by putting in. I've never done a vaginal approach. I've always put in the speculum. And then I saw the cervix. I guess you can always do a vaginal Oscar P. Um, And again, that's always something that you could also ask That you could consider Those are pediatric, that you think that there may be a foreign body within the vagina that you could do and use this to take a look inside and actually grab any foreign body, which could be in there. Um, but I have not done that within my patients. Okay. Thank you. How do you handle and manage a severely anti averted uterus? If I have an anti diverted uterus in using the catheter like this, I put my fingers within the vagina. And if it's very anti averted, I can move this. I'm not sure if you can see this, but I can actually bend this between my fingers. So if I'm my fingers within the vagina, I can actually, I can actually, um, deflect this so I can see any part any part of the uterus, even if I want to see the two velocity. Um, I can turn this, and I can actually move it so I can see where of where I need to go. Even in retro averted uteruses. I've gotten that question before again. This is turned over, but your monitor keep in mind anterior is still going to be towards the ceiling. And then you can actually move your fingers and you can deflect it downward so you can put your fingers within the vagina. And you can direct this to whatever corner of the uterus or anterior posterior in which you want to go to. Okay, thank you. And here's a similar question with physician who previously used generation won Endo. See, that's the version that came out prior to Ngoc Advance and their issue that they ran into was in the Nallet Paris patient. Um, the cannula proved to be a little too flexible. Uh, and it made it difficult to enter into into that type of a patient. Can you compare and contrast that version with the new NBC advance? This one is stiffer. Uh, so the other one was a little bit more pliable. This is stiffer. So it does go in a bit easier with those patients who are now Liberace. Um what I would recommend again. I recommend the Cytotec the night before to soften the cervix and then maybe use a cervical loss finder to slowly maybe dilate. Um, the internal cervical loss again. The type we use as I mentioned before the end of it is, has a smaller diameter than what it is Further back, it's sort of like using the practice violators. However it goes, it goes pretty, uh, the and the diameter is pretty small. It probably goes down to a good, um, three or four millimeter in diameter. And you can actually just slowly introduce that so that the catheter that you're putting in will float in very nicely. If you need to use a tin Oculus to bring down the uterus, even those that are severely anti diverted or retro averted, you can definitely do that again. I've not had to do that, but that is always another possibility. Next, Dr. After doing an embassy advance for direct visual assessment of the cavity, do you also recommend and do an H S G to evaluate the fallopian tubes? So what we have done in our offices, we actually combine the end o. C with doing an air sailing sonogram. So we actually put in a catheter and we put in basically air bubbles and we watched by ultrasound. We watch it go down the fallopian tubes. So I know the tubes are open. We do that in those patients who I have no history of P i d. No history of any sexually transmitted diseases. And they haven't had any pelvic surgery. If I think there could be Perry tubal adhesions, Yes, I will do an HSG, um, to look for that abnormality. But still, if if you take a look back at the chart in which was presented just during the lecture, you can see how hs GSR really are. Not that are not that sensitive either, that there is a high, uh, false positive rate. So that's the reason why we started using the Endo say, even the first generation. Because we kept getting reports from radiology stating that they found an irregularity on the back wall front wall. There's an irregularity within the fund us, and they recommend further testing. And then we're always going off to to do a history Ross copy in the operating room and we find nothing so in those patients that have a that have an HSG, I will still do an endo see to take a look inside. I will not. There are some practices, even with our own area in which we'll do an HSG and then do a sailing infusion sonogram that that's going to give you the same information. You need something more. And that's where doing the end O. C. Is beneficial. Because then if there is something in which they found that that was a little irregularity, like on patients, um, with PCOS in which could have those little micro polyps and they find okay, it's irregular. Okay, Whether it's on a sailing of fusion sonogram or whether it's on HSG, I'm gonna need to take a look inside. Let me take a look inside in the office to find out whether this is a true positive and whether I and whether I can take care of it in the office at that time or do I need to go off to the operating room? Thank you. Now let's talk about training office staff to be able to assist during these procedures. What have you found to be the best way to bring others up to speed and to play the role that you need them to play during a direct visual assessment with NBC Advance. It depends on the way that you're going to want that procedure to run like we use pressure bags like I mentioned before. So we we basically teach them how to set up the room to set up the I V bag the pressure bag, um, as well as the I V tubing. How they connected to the end of C, um and then what things of how we set up the room. So we use a lot of the blue chucks where we put one underneath the patient. And there's another one that's underneath the patient that goes into the basin, which is in the shelf that gets pulled out, and that's where their legs would normally leg. So we put their legs in stirrups. We have. We push back the top top and then of that shelf. So now we have the Chuck is actually funneling the fluid down into that little pan so it doesn't get all over the place. Um, then when we're done with the procedure, I basically disconnect the screen. And as I'm explaining it to the patient, my Emma is actually cleaning the room. And when I'm all done explaining what my findings are to the patient, the room has already turned over, and all we need to do is to clean up at and then after the patient leaves. So it's very easy to train them of what, what you want to do. Um, if you're going to be using syringes again, you have to teach them of how to push the syringe. That was our issue was. Sometimes I don't need that full pressure all at once. But when I do, I needed to be done in a certain way. And that's what the pressure bag really helps us out. Thank you, Dr Ziegler, in our last question today is you previously mentioned employing endorsee advance earlier in your treatment paradigm. Can you review again for our audience? How meaningful that gain and efficiency in doing that earlier assessment is for you, for your practice and for your patients. Well, again, as you're all aware that that infertility patients want to be pregnant yesterday, so anything that we can do to expedite their care into treatment is going to be beneficial. So the way we work it is again, As I mentioned in the lecture, a patient comes into our office. We order blood work on day 23 or four, they call us, and then with their period. And they come in between day six and day 11. And we do the endo say, Um, what that does is now we have a direct assessment of the uterine cavity. I'm not relying on indirect assessments from from an HSG or from assailant infusion sonogram. So I'm actually taking a look inside and say Okay, yes, we need to go to surgery for some pathology or no, we don't. And that helps us get right into treatment. Because we can get the same analysis, really? And just at any time. So we have that, um, getting analyzed as we're getting the other, uh, two other factors. The uterine issue that's coming from blood works way. So I know the way they're. I know they're ovarian age, and I know the uterine cavity is normal. If I do need to find out whether or not there and whether their tubes are open or closed at that same time I do an air saline sonogram within the office. Their tubes are open. Or if their tubes, if And if I'm putting in the fluid and I'm not seeing the bubbles coming through, then yes, there could be either tuple spasm or tubal pathology, and that's another reason to go to surgery. But I'm not using again. I'm not relying on, um, on the Stanley infusion sonogram, and I'm not wasting the patient's time going to a radiological facility to have an X ray done or going to a place which they're not familiar with. They came to you. You are their doctor. If you can do if you can curtail things to put things all in your office, it's going to make it a lot more comfortable for the patient. Um, and it will also expedite their treatment course because again they want to get pregnant quickly. How can we expedite that care? Anything that we can do to do that is going to be beneficial for the patient. Thanks so much for sharing your insights with us today, Dr Ziegler. Very well done. And thanks to our audience to for attending, uh, this concludes our Q and a Allen. May I turn it back over to you? Sure thing. Thanks, Chris. Thank you as well, Dr Ziegler. We do appreciate it. This is going to conclude our Q and A for today. As a reminder. Cooper Surgical will follow up with any questions that Dr Ziegler could not answer it this evening. Please take a few minutes to complete the brief survey about tonight's program. It is right below the video player right next to the asking question. But if you don't see it just to refresh your page and you'll see it right there Thank you. And have a good rest of your day.
William Ziegler, DO, FACOG