Dr. John McNaught is the founder and medical director of Fertility Ontario. He runs a cutting-edge practice for minimally invasive gynecology with a team of specialists. Their practice relies heavily on ultrasound based techniques, which have helped them develop non-surgical alternatives to hysterectomy. We recently interviewed Dr. McNaught at his practice to talk about alternatives to traditional gynecology in an office setting, and his minimally invasive approach to gynecology.
Please tell us a little bit about yourself and how you started using ultrasound in your practice.
I’m trained as a general gynecologist. I worked in the community for a couple of years upon graduation and used a number of different ultrasound devices from several different companies. Upon returning to an advanced fellowship in reproductive endocrinology and then fertility, I was exposed to several different types of programs and machines in terms of imaging. And pelvic imaging, particularly by ultrasonography, became a passion of mine.
How big is your practice?
We have eight sub-specialists on staff here, all with a varying degree of knowledge with respect to ultrasonography. Some of us who work in the fertility group use ultrasound on a daily basis. We also have a minimally invasive gynecology practice that uses ultrasound very heavily and in modern gynecology, the use of ultrasound-based techniques has been proven to help us develop non-surgical alternatives to hysterectomy. And that’s been a very important part of our practice. One of the reasons that we’re able to provide alternative therapies is quite literally we’re seeing things that we’ve never seen before.
What makes your clinic unique?
We have a lot of people coming in to study the minimally invasive approach to gynecology. Putting imaging right in the clinic rather than outsourcing it to an outside clinic, allows us to give the patient a diagnosis immediately rather than having to put them through a battery of tests. When people come in to do a preceptorship the first thing we do is show them the advantages of clinical ultrasonography. In this day and age, I don’t understand why a busy gynecologist or busy reproductive health specialist wouldn’t have an ultrasound in their office. Not one of those little laptop-based that have a grainy image on them. If you’re going to do your job you need the appropriate equipment and when people find out how relatively inexpensive it is to have a high fidelity ultrasound right in your office it makes a lot of sense to them right away.
Can you give me an example of what you might not have caught without using ultrasound in the office?
Using a technique called saline sonohysterography we see inside the uterus almost as clearly as if we were putting a camera inside. So we’re seeing polyps, fibroids and uterine anomalies that aren’t visible on a traditional ultrasound and often need a gynecologist to be performed. So although they can’t be performed in a traditional radiology setting, here in an office setting we do about 20 sonohystograms a day. And we’re seeing just a tremendous amount of pathology that allows us to target treatment. We know exactly what we’re dealing with right from the first day that we meet the patient. So one of the selling points of our clinic is you feel better faster because we get you from point A to point B in a fraction of the time.
What about fibroid treatments?
We use medical management of fibroids to shrink them using injections called GnRH analogs. We have a fluoroscopic procedure called uterine artery embolization which shrinks fibroids in a non-surgical way. It’s all about knowing what sort of pathology you’re dealing with. All of our fibroid patients get a saline sonohystogram done here first. If the fibroid is within the cavity of the uterus it’s usually resected hysteroscopically through a camera but if the cavity of the uterus is clear then we look to do something like either uterine artery embolization or a medical shrinkage of the fibroids. So we have a large portion of our patients who have uterine fibroids but very few of them go on to hysterectomy.
How do people who have these issues and want alternative treatment find a clinic like yours?
Well, we don’t advertise. The minimally invasive gynecology clinic has been up and running for six months. It’s something that several of us sub-specialists around town have tried to make happen for several years. When we opened Fertility Ontario we realized that a lot of the equipment we were using for our fertility practice was equally well-used in a minimally invasive gynecology approach. There are really only a handful of such clinics across Canada. We’re one of the only ones in Ontario and, once we publish our data, we feel that people are going to see it’s the ideal approach to outpatient treatment. We’re doing office surgical procedures right here in the office and we’re doing them under ultrasound guidance. Things that were typically done blind in the past right here in the office we have the advantage of the watchful eye of the ultrasound to make sure that we’re putting things where they ought to be.
Are many of your colleagues in Canada offering alternatives to traditional gynecology in an office setting?
No. In terms of our alternative to hysterectomy clinic, we are one of the only clinics in the province that run this particular system. We could not do it without high fidelity ultrasound equipment because without being able to image the uterus, fallopian tubes and ovaries we can’t make a targeted treatment. That’s one of the main tenets of our approach is figure out what causes the problem first and then direct therapy towards it. We rely on ultrasound very heavily in that setting.
Those of us who are what you might call classically trained in ultrasound have always found it very easy. What we’re seeing more and more is that the residents and even general gynecologists, who’ve never used ultrasound before, are finding ways to incorporate it into their clinical practice. It’s gotten to the point where it’s a routine part of the physical exam in many circumstances. The fidelity of the images is so crisp, you don’t need to be an expert in order to interpret them.
What about Health Canada? Do you have to deal with regulations?
Absolutely. We work very closely with our local college as well as the Ministry of Health. We’re registered as an independent health facility, which means we adhere to the highest standards available in terms of offering ultrasound practices. What we’re doing here is very safe. We had some great images of an endometrial ablation done under ultrasound guidance. It’s done here in the office in three minutes and it’s a tremendous alternative to major surgery. That’s something that would often need to be done in a hospital setting or end up as a hysterectomy. By doing it here in the office we’re saving the patient time and we’re saving the system money.
We’re hoping that that is going to take off. It’s certainly been done all over the world and it’s just a means of finding a mechanism to get it out to Canadian patients.
Are you planning to publish and papers on the work you’re doing with minimally invasive procedures?
We do have a large body of evidence that’s been generated on ultrasound with respect to what we’re finding in the Minimally Invasive Gynecology Clinic. We’re going to be set to publish that next year. The take-home message early on is if you don’t look you won’t find. And the amount of pathology that we’re discovering by using techniques like pelvic ultrasonography and saline sonohysterography is astounding and it’s far more than people would have thought. So when we publish that at our national conference next year I think people are going to start to take note of what’s capable in an office setting.
See part two of this interview regarding ultrasound in IVF.