Dr. John Lipman is founder of the Atlanta Interventional Institute and Medical Director for the Center for Minimally Invasive Services at WellStar Windy Hill Hospital in Marietta, Ga. As an Interventional Radiologist, Dr. Lipman specializes in minimally-invasive out-patient procedures that can replace the need for major surgery. His clinic is dedicated to treating women’s conditions – particularly uterine fibroids and fertility issues. His love for the profession began during his medical school training at Georgetown and during his residency at Brigham and Women’s Hospital, Harvard Medical School. He completed his training with a fellowship in Interventional Radiology at Yale, and today he is dedicated to bringing less-invasive treatment alternatives to his community in Georgia.
Fibroids1: Why did you decide to become an Interventional Radiologist, and how have you seen the specialty evolve since you started the profession?
When I was a medical student at Georgetown, Interventional Radiology was a fairly unknown specialty and relatively obscure, but fortunately that is starting to change. We are beginning to get out from being physicians’ consultants and becoming seen more as patients’ consultants. Today we’re involved in the longitudinal care of people rather than the episodic care; whereas in the old days, we used to perform a procedure and then we’d never see the patient again. Now it’s critical that we’re involved in the care, and it’s one of the reasons why I’m in solo practice now. Being able to practice 100 percent interventional in my own clinic is something I’ve wanted to do for some time, so it’s kind of a dream realized. We just celebrated the one year anniversary of the clinic. Patients came and shared a lot of testimonials, and the mayor declared it Uterine Fibroid Awareness Day.
Fibroids1: Your clinic specializes in treating women’s conditions through a non-surgical, mostly outpatient approach. Please tell us more about your Atlanta-based practice and the types of procedures you perform.
The center is very unique. It is a patient-centric center; everything was designed with patients in mind. Everything is self-contained in one area, the MRI, angioplasty room, and recovery room are all in one area – every patient gets their own nurse, so there’s one-on-one nursing which is critical. Patients feel like they’re the only patient of the day and they’re being treated like they’re a member of the family. My practice is centered around fibroid embolization. We are treating conditions that are primarily or exclusively seen in women, a lot of fallopian work – either sterilization for birth control, or fallopian recanalization for patients with infertility. We’re also doing other procedures that you would consider outpatient intervention, such as the treatment of varicose veins, but the focus is really women’s intervention.
Fibroids1: Please describe the uterine artery embolization procedure for treating fibroids.
We’ve performed about 2,000 fibroid embolizations to date. I tell my patients it is an outpatient procedure, meaning most of the patients come into our center and leave the same day. Of the last 300 fibroid embolizations performed at the center, all but five went home the same day, and those five went home the next morning. What we’re doing is cutting off the blood supply to the fibroids by delivering embolic particles. Without a blood supply the fibroids will start to wither away, the uterus stays alive, but the fibroids die off. After the procedure, fibroids will soften and some will go away completely, most will stay, but they’re in a much smaller, softer state.
Fibroids1: What kind of results can a woman expect following uterine artery embolization?
Fibroids cause their symptoms based on how hard and firm they are and where they are located in the uterus. If the fibroids are located in the front of the uterus they may press on the bladder like a paperweight causing urinary frequency and patients waking up multiple times in the middle of the night. If fibroids are near the center of the uterus they will stretch the lining, not allowing it to heal, and that will cause a woman to have heavy menstrual periods. That’s the most common symptom that you will see is a heavy, flooding, gushing menses. If fibroids are in the back of the uterus they might press on the colon and cause constipation, or if they’re located out laterally they might press on the pelvic nerves and cause painful menses. If a fibroid is near the cervix it might cause painful intercourse. So depending on where fibroids are located, and usually women will have multiple fibroids and multiple symptoms, I’ll tell them that we are going to cut the blood supply to the fibroids and because it’s a global therapy, it’s going to treat all the fibroids at once. Symptoms should go away in a large majority of women – somewhere between 85 percent and 90 percent of patients have profound improvements in all their symptoms.
Fibroids1: Which patients make the best candidates for fibroid embolization and how do you diagnose these patients?
The best candidates are those having symptomatic fibroids, usually between 12 and 16 weeks (analogous to fetus size and age) uterine size, also those with multiple fibroids causing symptoms. That would be a typical and reasonable patient to embolize. So you have to look at the history of the patient, listen to the symptoms they describe, and look at the MRI imaging to decide which patients are candidates for fibroid embolization. The mere fact that the patient has fibroids doesn’t mean the fibroids are causing the symptoms. A patient must first have symptoms and then the symptoms have to fit with the imaging. There’s a small percentage of women for which embolization doesn’t work. In my practice, those women typically fall into two categories; either they have adenomyosis, which can mimic fibroids or be present in addition to fibroids. This condition is hard to diagnose, but can be diagnosed with MRI. Or we’ll see patients with very large fibroids that are also not candidates for embolization. If the fibroids are in the cavity of the uterus, causing heavy bleeding, they would be amenable to hysteroscopic resection and not fibroid embolization. The gynecologist would go in from the inside and remove that fibroid from the cavity.
Fibroids1: So if a woman has symptoms that she thinks might be related to fibroids, should she go to her gynecologist first, or should she seek out an interventional radiologist?
Most patients I see come referred to me from gynecology. When I first started embolizing fibroids, patients came to me through word of mouth or they found out about the procedure through the Internet. Over the years it’s matured to where the large majority of patients come from gynecologic referral. Plus, gynecologists have become more comfortable with the procedure. We now have 10 years of data on the procedure and they’ve seen how robust and durable the procedure is. We have a registry of more than 3,000 women who were treated with fibroid embolization and we were one of the core sites that participated in that registry, which is the single largest collection of fibroid data ever. As gynecologists see the data appearing in their journals they are becoming more comfortable with the procedure. There’s always going to be skepticism about new procedures, but the data speaks for itself and it’s hard to argue, and that is why gynecologists are referring their patients to us.
Fibroids1: Are fibroids preventable? Has there been any new research on why fibroids develop?
Fibroids are particularly common in African American women, and it’s the single most common reason why women have a hysterectomy in this country. One in every 3 women by age 65 has had a hysterectomy. There are some reports that almost three-quarters of African American women of child-bearing age have fibroids – fortunately not all are symptomatic. Nobody knows why specifically fibroids occur, but we do know there is a genetic component. At a recent meeting at the National Institutes of Health, they announced that they’re starting to localize chromosomes involved in fibroids and hopefully we’ll get to the gene and hopefully be able to impact fibroids before they become a problem. We also know that the more body fat one has, the more likely they’ll be symptomatic from fibroids. That’s why African American women have more fibroids than the average Caucasian woman, who has more than the average Asian woman, because in general that’s kind of the body fat distribution. And since estrogen is stored in fat, the more body fat you have on you, the more estrogen stimulation, and the more fibroids can grow and become symptomatic.
Fibroids1: Your clinic offers a non-surgical alternative for permanent birth control called fallopian tubal occlusion. How is this treatment different from having your “tubes tied?”
The traditional surgical procedure of getting your tubes tied is done laproscopically, and they usually go through the naval and there are one or two other holes made in the abdomen, and the tubes are either clipped, or burned or ligated in some fashion. It’s a surgical procedure, it is less invasive than an open procedure, but it’s still surgical. It’s typically done in a surgical center under general anesthesia. The next generation is hysteroscopic placement of metallic inserts into each tube to close the tubes, which is also done under anesthesia. What we’re doing is even less invasive than that. We’re putting the inserts in through smaller catheters rather than through a hysteroscope and the benefit of entering through smaller catheters is that you don’t have to dilate the cervix and insert this big scope through the cervix. Instead, you’re putting in a tiny catheter that the patient doesn’t even feel. I can do a case in 15 to 20 minutes, she might stay another 20 to 30 minutes to recover, and she goes home. It’s a clear advantage. The devices are FDA approved but that indication, of placing the metallic inserts via fluoroscopic guidance, is an off-label use. It’s as safe as undergoing hysteroscopic placement, and I hope we will be able to compare outcomes of the two procedures at some point because I think fluoroscopic placement would be equivalent or better. The one difference between fluoroscopy and hysteroscopy is that fluoroscopy is done under X-ray guidance so there is a very small radiation dose, but the amount of fluoroscopy time is so quick that the exposure is miniscule. Interventional radiology and other interventional disciplines are commonly doing things off-label, but if you’re careful and thoughtful about your approach, and explain to patients why you are doing something off-label, then the patient can decide if the procedure is right for them.
Fibroids1: You have had much success treating women with infertility problems related to blocked fallopian tubes. Please tell us how this procedure is performed.
It’s a very under-utilized procedure that many patients don’t know about, and should be done more often. It’s common for women with infertility to have blocked fallopian tubes, and it’s unfortunate if a gynecologist is not aware of someone with an expertise of being able to recanalize patients. Our fertility rate is about 40 percent which is pretty high. It’s a simple procedure to perform and takes about 45 minutes and a woman will typically recover in the center for about an hour and then go home. It works promptly; if they’re going to get pregnant, women are typically pregnant within the first 3 months following the procedure. We have a number of baby pictures in our center, and that makes our day. We treat women of all ages. We had a woman who had gotten pregnant very easily and then she went six years without being able to get pregnant because she had bilateral tubal occlusions. She was going to give up, but somehow she heard about the work we were doing and wondered if she was a candidate. Her gynecologist referred her for evaluation, we unblocked her, and within two months she was pregnant, and eventually delivered a baby. Stuff like that is just tremendous; it’s such a simple procedure to do. There needs to be more awareness of the fallopian recanalization procedure because it could be done in a lot more patients. Many women have had tubal blockages and they end up getting IVF (in vitro fertilization), which is extremely expensive. This is very inexpensive and completely non-surgical. I tell patients there is a blockage in the fallopian tube, which is a mucus plug or a cap, and basically we’re unblocking the drain, if you will, by getting rid of that mucus plug. It is essentially a clogged drain, the fallopian tube is healthy it’s just got a blockage in it, and so we go into the opening of the fallopian tube with catheter and guide wire technology and do a little roto-rooter and unblock the tube gently. We tell patients strike while the iron is hot, because now the tube is open, then we usually let them go six months and if they haven’t become pregnant in six months we do another exam. If we find that the tubes are still open and everything looks fine, then the gynecologist or reproductive endocrinologist consultants on the hormonal issues. Or, since she’s formed mucus plugs before, she may have reformed them and so I will offer them one more time of unblocking because sometimes they will get pregnant on the second unblocking.