Wednesday, April 17, 2013

When to stop The Pill before trying to conceive?

How long should you be off of the birth control pill before starting to try to get pregnant?

First of all ... good for you for planning ahead for a healthy pregnancy.  In the past doctors recommended waiting 2-3 months after stopping the pills to establish normal menstrual cycles.  The Idea behind this was more to ensure that the correct due date was established upon becoming pregnancy.  However, now with the accuracy of ultrasounds this is not as important. 

Depending upon what method you are using you may want to stop a few months ahead of the month that you plan to conceive if you are over 35.  Women over 35 may have a slower resumption of normal cycles and ovulation after stopping hormonal contraception than others.  Ultimately, the time frame for stopping birth control depends heavily on you social situation. 

Some people want to try to do their best to conceive during a certain time of year (e.g. many teachers try to have summer babies).  If this is the case, then you may want more time off the birth control to start charting your ovulation and cycle length. Medically, if you have a history of: irregular periods before you began the pill, difficulty conceiving in the past, endometriosis, or are over 35, it may take longer to conceive and thus you might want to factor this in as to when you want to stop birth control. Also, remember to start a prenatal vitamin a month before becoming pregnant.  Also schedule a preconception visit with your doctor.   Avoid alcohol, tobacco and drugs, and be mindful of what prescription and over the counter medications you take before conception.

Best wishes for a wonderful pregnancy!

Thursday, April 4, 2013

What a mesh we're in!

Patients with pelvic organ prolapse present with varying symptom states.  Treatment is guided by the patient’s degree of symptoms and functional defects.  The recent controversy fueled by the trial lawyer escalation of FDA committee reports has left many confused as to appropriate treatment options for these patients.  Before providing my opinion on the use of mesh I want to stress that we offer non-surgical and surgical treatment for symptomatic pelvic organ prolapse with or without the use of mesh.  The approach is individualized dependent upon the patient’s symptoms, anatomic defect, surgical history and the patient’s personal opinions.   

I have used mesh for select patients for 11 years and have been very pleased with the results.  In my opinion mesh augmented surgery has revolutionized the care of women with pelvic organ prolapse for the better.  Of course it certainly is not appropriate for every patient with pelvic organ prolapse.  No procedure is for this matter.  However for the many women suffering from debilitating symptoms as a result of prolapsing pelvic organs that I have treated with transvaginal mesh; it was a lifeline.   For every woman with a mesh complication there are 20 women who are extremely pleased and much better off than prior to surgery. 

There is a huge discrepancy between what the FDA said and what trial lawyers would like you to believe.  For the most part basically what the FDA said was that physicians placing mesh should be well trained, patients informed of the risks associated with mesh, and appropriate studies be performed on mesh products before coming to market.  They did not say that all mesh is bad, the products should not be used and should be recalled.  Most of the complications listed with mesh augmented surgeries are not unique to mesh surgeries and can occur with procedures that are not augmented with mesh.  The only complication listed that is unique to mesh augmented procedures is the risk of mesh erosion. 

With proper placement of mesh, the erosion rate is less than 4%.  The reoperation rate for recurrence of prolapse when mesh is not used is known to be 30-40%.  More than 99% of mesh erosions are exposures in the vagina that can be treated in the office or with a same day surgical procedure.  On the other hand, recurrence would  require a complete redo of the surgery.  Given this, erosions are not a reason to discard mesh.  To be fair, mesh erosions into visceral organs like the bladder or rectum would be more complicated, but these are extremely rare.

The first decade of the 21st century was a period of rapid evolution in the care of women with pelvic organ prolapse. Most of the issues that have occurred are a function of how rapidly this area of medicine has changed.  Most gynecologists in practice at the start of this revolution had no history or training in the use of transvaginal mesh.  Researchers and developers needed time to perfect better delivery systems.  The mesh products utilized required closer inspection and thought.  Changes such as larger pore sizes and lower mesh  loads  have dramatically impacted tissue ingrowth and decreased mesh exposures.  

Without a doubt, placement of transvaginal mesh for pelvic organ prolapse should be used cautiously by experienced surgeons with extensive training in pelvic surgery.  With 11 years of experience with pelvic floor surgery and the use of mesh transvaginally, I’ve had the advantage of personally performing many surgeries.  I’ve performed repairs with and without mesh, with sacrospinous ligament fixation, with site specific mesh repair, abdominal sacrocolpopexy, laparoscopic sacrocolpopexy and transvaginal mesh kit repairs.  Every approach or procedure has a place and time.  No two patients are the same and care must be individualized.  No one surgical approach will fit all. 

 When needed, I am a believer in the use of transvaginal mesh .  An unbiased view of the data supports using mesh in the appropriate patient.  Moreover, I’ve seen it with my own eyes.  The use of mesh provides good anatomic repair without narrowing or shortening of the vagina which is common with the old imbrication repairs that most gynecologists were taught.  It provides an efficient, fast and complete repair for even the very elderly.  It is durable and safe.  It works. 
Melvin Ashford, MD