Dr Rasmus Schmädecker is an experienced gynecologist who heads the endometriosis and fertility surgery clinic at the Women’s Clinic of the renowned Uster Hospital. With his extensive training and many years of experience, he has specialized in the treatment of endometriosis and fibroids, as well as all types of fertility surgery, and performs complex procedures. At the modern gynecology clinic at Uster Hospital, patients benefit from a wide range of gynecological services, which, under Dr Schmädecker’s leadership, are designed to meet the highest standards.
A central component of his work is ultrasound diagnostics, particularly the early detection of deep-infiltrating endometriosis. He uses modern technologies to make precise diagnoses and develop targeted therapies. His expertise also extends to 3D ultrasound diagnostics of uterine malformations, enabling him to accurately identify congenital abnormalities of the uterus. These precise diagnostic capabilities are crucial for planning subsequent treatment steps.
In the surgical treatment of deep-seated endometriosis, Dr Schmädecker places great emphasis on interdisciplinary collaboration with other specialist fields. In myomectomy, he employs state-of-the-art techniques ranging from minimally invasive hysteroscopic and laparoscopic procedures to open surgical procedures. Another key aspect of his practice is fertility surgery. Dr Schmädecker specializes in tubal surgery, which aims to preserve or restore his patients’ fertility. In treating endometriosis cysts, he relies on ovary-sparing procedures, such as sclerotherapy and plasma ablation, to preserve ovarian function.
His holistic approach to gynecological care is complemented by diagnostic office hysteroscopy, which enables therapeutic procedures to be carried out efficiently and gently. Dr Schmädecker’s extensive expertise, his specialization and his commitment to providing individualized care for his patients make him a highly respected expert in his field. Women suffering from endometriosis or fibroids will find not only advanced treatment in his practice, but also empathetic support on their journey toward a better quality of life.
The editorial team of the Leading Medicine Guide was able to learn more about deep-infiltrating endometriosis, fertility surgery and minimally invasive gynecological surgery in a conversation with Dr Schmädecker.
Deep-infiltrating endometriosis is a complex and challenging condition that can severely impair the quality of life and fertility of many women. This form of endometriosis is characterized by the growth of endometrial tissue outside the uterus, particularly in the pelvic organs, leading to pain, inflammation and functional limitations. The treatment of this condition often requires interdisciplinary approaches, particularly in fertility surgery, where the aim is to preserve or restore the fertility of the women affected. In this context, minimally invasive gynecological surgery is becoming increasingly important.
The causes of endometriosis are not fully understood.
“There are several theories regarding the cause of endometriosis, but none has been definitively proven. What is certain, however, is that endometriosis is a condition affecting menstruating women. Today, we live in an era where women experience almost ten times as many menstrual cycles over the course of their lives as in the past. Around 100 years ago, a woman had an average of 40 menstrual periods, as women were pregnant much more frequently or suffered miscarriages, and family planning was very different. Today, a woman experiences 300–400 cycles over the course of her life. As endometriosis is particularly noticeable during menstruation, it is a condition we are confronted with much more frequently nowadays. Symptomatically, endometriosis manifests as painful periods, known as dysmenorrhea. In addition, endometriosis can cause various specific and non-specific symptoms. Classic specific symptoms include chronic lower abdominal pain, pain during sexual intercourse, when urinating during menstruation, or during bowel movements. Non-specific symptoms manifest as a bloated abdomen, fatigue, respiratory tract infections and bladder infections,” explains Dr Schmädecker, adding what measures are taken if endometriosis occurs shortly before a couple plans to start a family:
“Fertility, that is, a woman’s ability to conceive, is an extremely complex phenomenon. That is why it is not enough to focus solely on the organic changes, which is of course my primary concern as a fertility surgeon. Many factors play a role, for example endocrinological aspects, but also immunological processes in the uterine cavity or the abdominal cavity, which can have an influence. Consequently, fertility surgery cannot resolve all problems in every case. Of course, treatment is always carried out according to strict scientific criteria, and infertility itself is clearly defined in medicine. If a couple has been having regular sexual intercourse for over a year, yet the woman does not become pregnant despite having a regular cycle, we refer to this as infertility. This is recognized in all national and international guidelines. In such cases, it must be investigated whether there are changes in the uterine cavity, the fallopian tubes or the abdominal cavity, with endometriosis being one of the most common causes. Other factors may include the formation of fibroids or adhesions, which can occur following infections, for example. In some patients, such changes can even be detected by ultrasound before infertility is officially diagnosed. In such cases, a joint decision must be made as to whether to deviate from the medical definition. For example, in the case of a fibroid measuring 7–8 cm that alters the anatomy of the uterus, it might be recommended to treat it before the twelve-month period expires, so as not to be officially classified as infertile. Ultimately, it is always an individual decision made together with the patient. Unfortunately, scientific studies in this area are often unsatisfactory, as few women are willing to volunteer for research purposes when it comes to fertility – after all, fertility is a very personal matter.”
In fertility surgery for women with endometriosis or fibroids, minimally invasive techniques such as laparoscopy and hysteroscopy play a key role.
“In the past, up until the 1990s, fertility surgery was performed via an abdominal incision. Today, 99.9% of procedures are minimally invasive. There are very few exceptions where an abdominal incision is still necessary, for example when there are 25 fibroids spread over a large area. However, minimally invasive surgery, i.e. laparoscopy, offers so many advantages that we always try to opt for this approach. The smaller incisions reduce blood loss during the operation, the post-operative recovery time is shorter, and fewer complications occur. Furthermore, the scars are less noticeable cosmetically, and patients return to their daily activities more quickly. “As the tissue is subjected to less stress during minimally invasive procedures, there is also a lower likelihood of adhesions forming after the operation – a common problem with open surgery that can further restrict fertility,” explains Dr Schmädecker, adding further details:
“The traditional procedure involves a hysteroscopy, which is performed through the vagina. This involves looking into the uterine cavity via the cervix to determine whether there are any pathological changes. These can include endometrial polyps, adhesions from previous curettages, fibroids in the uterine cavity or congenital malformations. The patency of the fallopian tubes is then checked, a procedure known as chromopertubation, to find a way to reopen blocked fallopian tubes. Laparoscopy is used to examine the organs relevant to reproductive medicine: the uterus, the ovaries and the fallopian tubes. This allows us to determine whether endometriosis is present, which requires treatment. The removal of all endometriotic lesions leads to a significant improvement in pregnancy rates. We can break up adhesions, open blocked fallopian tubes and remove fibroids that are inaccessible from the uterine cavity – all of which contribute to a higher pregnancy rate.”
A particularly important use of laparoscopy in endometriosis is the removal of deep-infiltrating endometriotic lesions, which can cause severe damage to the reproductive organs. With this technique, endometriomas (ovarian cysts) are carefully excised while healthy ovarian structures are preserved, which is crucial for maintaining fertility. Hysteroscopy, on the other hand, is performed via the vagina and allows access to the uterine cavity. This technique is particularly suitable for the removal of fibroids, polyps or scar tissue that could impair the implantation of a fertilized egg. For fibroids that protrude into the uterine cavity (submucosal fibroids), hysteroscopy is frequently used as it precisely removes the fibroids without causing excessive damage to the surrounding tissue. This minimizes the risk of scarring that could hinder future pregnancies.
Minimally invasive surgical procedures in fertility surgery, such as laparoscopy and hysteroscopy, offer many advantages. There are few risks and complications.
“The risks of hysteroscopy are extremely low; in theory, it can even be performed without anesthesia. I always offer this option, but many patients prefer to have the procedure carried out under anesthesia. Laparoscopy certainly also carries risks, but these are minimal and in the per mille range. Of course, these are procedures that can be crucial for fertility. That is why such procedures should only be performed by highly qualified fertility surgeons. One of the most important principles guiding our work is to remove the condition – particularly in the case of endometriosis – as thoroughly as possible, while at the same time preserving fertility function as much as possible. “The aim is always to improve the situation; otherwise, surgery would make no sense,” emphasises Dr Schmädecker, adding:
“The techniques we use here at Uster Hospital are particularly gentle on patients. For instance, we use laser and plasma ablation on the ovary, which is not comparable to the conventional removal of ovarian cysts. The latter often causes significant damage to the ovary. Our method does not remove the endometriosis surgically by cutting it out, but instead ablates the diseased tissue with plasma and has no impact on ovarian reserve. At a conference in Geneva this year, there was discussion as to whether this method, as an established procedure, should become the new gold standard.”
The age group of affected women varies greatly. Women in their 20s are sometimes affected, for example if family planning begins as early as 18, and the age then varies up into their 50s.
Interdisciplinary collaboration between gynecologists, reproductive medicine specialists and other specialist fields is crucial for the optimal treatment of fertility disorders.
Gynecologists contribute their expertise in female anatomy and conditions such as endometriosis or fibroids, and identify the need for surgical intervention. Reproductive specialists complement this with in-depth knowledge of hormonal regulation and assisted reproduction techniques, such as IVF (in vitro fertilization). Endocrinologists contribute their knowledge of hormone regulation, which is crucial to the success of fertility treatments, particularly in cases of endocrine-related disorders such as polycystic ovary syndrome (PCOS).
“As mentioned earlier – fertility is a highly complex field whose causes are not limited to the organs alone. That is why collaboration with reproductive medicine specialists is extremely important. For a long time, there was a sense of rivalry here, because before the advent of reproductive medicine, fertility surgeons were solely responsible for treatment. With their artificial insemination techniques, reproductive medicine specialists have, so to speak, rendered the fallopian tubes superfluous. As a result, surgery on the fallopian tubes has fallen somewhat into disuse, and most surgeons no longer master these procedures because they never learnt these techniques. Nowadays, if a fallopian tube is blocked, the woman is usually referred directly to a reproductive medicine specialist to plan artificial insemination. However, it must be borne in mind that this method is subject to many conditions, requires greater effort and is ultimately more expensive. Furthermore, hormone treatment places a considerable strain on the woman. I work very closely with reputable fertility specialists, and we recognize that both disciplines – fertility surgery and reproductive medicine – are important, much like hardware and software complementing one another. Ultimately, it always comes down to the appropriateness of the respective treatment,” explains Dr Schmädecker regarding the two different treatment options.
Psychosocial factors have a profound influence on the decision-making of women who opt for minimally invasive fertility surgery.
The most common psychological burdens include anxiety, uncertainty and stress, which often result from the emotional challenges of infertility. Many women may have already undergone several frustrating treatments, leading to increased emotional strain. These fears can affect perceptions of the surgical procedure, with concerns regarding the risks, effectiveness and long-term effects of the treatment playing a central role. Various support options are available to address emotional and psychological needs.
“Psychological support is definitely a major factor, but one that is predominantly felt or becomes apparent in reproductive medicine, if only because reproductive specialists see the women much more frequently. We might see the women concerned once or twice, while the reproductive medicine specialist might see them 20 times. Personally, I believe it is very important to provide patients with thorough information. This can provide significant psychological relief and offer help through concrete information. We try to help patients move away from constantly scrutinising their bodies. Constant cycle monitoring has not proven effective. We recommend that couples hoping to conceive have sexual intercourse twice a week – that is still the best option. We also have patients who have no difficulty getting pregnant despite having endometriosis. Unfortunately, there are also doctors who are too pessimistic, often simply because they are not sufficiently familiar with endometriosis. This often leads to a negative experience for the patients and is ultimately counterproductive. Of course, realistic expectations are very important, because ultimately everything is based on facts. However, far too much pressure is often built up – entire marriages have failed because of this. This is where I try to encourage the women,” criticizes Dr Schmädecker.
Challenges in fertility surgery and new hope through targeted therapeutic approaches.
“Fibroids always carry the risk of returning. This isn’t about the fibroid I’ve surgically removed, but rather that fibroids start as very small nodules that are invisible to the naked eye or on ultrasound and can, in theory, grow quite large within a few years. There are now very good studies from Chicago showing that the administration of vitamin D and green tea extracts can prevent recurrence,” says Dr Schmädecker, leaving room for concern at the end of our conversation:
“Unfortunately, fertility surgery is not given very high priority in Germany – the situation is quite different in Italy, France or Switzerland. There is also no certification for fertility surgery. That is why it is rather difficult to find a specialist in Germany, even though they do, of course, exist. A certified endometriosis center is essential for the guideline-compliant treatment of endometriosis. For a long time, proper facilities were lacking here, and the question for patients remained: where can I find a doctor who is skilled in this area? With the introduction of certified centers, a change is now taking place. I also believe that we are in the midst of a generational shift, where patients are increasingly doing their own research to find the right doctor for them.”
Dear Dr Schmädecker, thank you very much for this fascinating insight into the complex world of female fertility.
