Luis Alonso Pacheco | Director, Gynaecological Endoscopic Surgery Unit, Centro Gutenberg, Málaga; Specialist in Reproductive Surgery, Hospital Quirónsalud Málaga, Spain
Author: Alena Sofieva, EMJ, London, UK
Citation: EMJ. 2026; https://doi.org/10.33590/emj/14GCBK6N
As Scientific Chair of the 35th European Society for Gynaecological Endoscopy (ESGE) Annual Congress, what were your main priorities when developing this year’s scientific programme, and which topics were you particularly excited to see discussed?
The objective was to bring the latest innovations in surgery into the programme. We included reproductive surgery alongside established topics such as endometriosis, oncology, and the other subspecialties. For me, reproductive surgery and hysteroscopy were particularly important.
For the first time, we also introduced a practical pre-congress course on ultrasonography. We are surgeons, but we need ultrasound. In some countries, ultrasound examinations are mainly performed by radiologists; in others, the doctor performing the examination is also the surgeon. I see a great advantage in assessing the same patient from both perspectives, because this can help us plan surgery more precisely.
I often compare preoperative imaging to a GPS. Before entering the operating theatre, we need to understand what we are dealing with and how we intend to proceed. Whether we use MRI or ultrasonography, that assessment should happen before surgery to minimise surprises.
Much of your work has explored the intersection between hysteroscopy and reproductive medicine. What role should hysteroscopy currently play in the investigation and management of women experiencing infertility or recurrent implantation failure?
I started my private practice in 2002, working in an IVF centre and performing hysteroscopy and ultrasonography in patients with reproductive problems. At the time, relatively few people were doing this work. Over the past 24 years, I have seen a considerable evolution. Ideas that were questioned 15 years ago are now more widely accepted, particularly in southern European countries such as Spain, Italy, and Portugal.
Spain and Italy have many IVF clinics and experienced doctors. In my view, a better understanding of the uterus, through 2D and 3D ultrasonography and hysteroscopy, has contributed to the reproductive outcomes we see. These examinations have an important role in assessing patients with fertility problems.
We published a paper a couple of years ago examining the benefits of routine hysteroscopy before a first IVF treatment. However, the question is not simply whether to perform hysteroscopy. It is also about using the right technique and knowing what to look for. You need to recognise what you are seeing and understand whether it may affect fertility. The same examination performed by someone with less experience may not provide the same information.
My work focuses on evaluating uterine factors before IVF, rather than performing IVF cycles myself. The uterus is only one part of the assessment, but we need to identify problems that could affect both conception and the subsequent pregnancy. Becoming pregnant is not the only objective; some patients conceive but then experience repeated miscarriages.
Conditions we assess include uterine malformations, submucosal fibroids, intrauterine adhesions, chronic endometritis, Caesarean scar defects, and adenomyosis. Understanding these conditions is an important part of evaluating the uterine contribution to reproductive difficulties.
How can training help clinicians develop the skills needed to assess these patients accurately?
Training is essential, and I am particularly interested in the educational side of our work. New tools, including those based on AI, can help clinicians gain experience more efficiently.
For example, we have developed a training programme in reproductive ultrasonography that allows participants to work through real cases without examining patients directly. They can assess many different cases themselves within a concentrated period. Our experience with residents suggests that this approach can substantially shorten the learning curve.
The tools are available, but clinicians need to find the right training resources and use them. We need to train not only our hands, but also our eyes and our interpretation of what we see.
You have published extensively on T-shaped uterus and hysteroscopic metroplasty. Which patients are most likely to benefit from surgical correction, and where do important uncertainties remain regarding its impact on reproductive outcomes?
This remains a hot topic, and there is considerable debate. Some clinicians question whether surgical correction of these uterine anomalies has a role.
In my experience, a T-shaped uterus can be associated with very poor reproductive outcomes. I consider it a developmental uterine abnormality rather than necessarily a congenital malformation. We are also exploring medical approaches to improve uterine function and, in selected cases, the shape of the cavity.
A diagnosis of T-shaped uterus does not automatically mean surgery. However, when a patient has this finding alongside poor reproductive outcomes, we need to consider whether the cavity can be improved medically or surgically. In our service, we reserve surgery for patients with recurrent miscarriage or implantation failure.
In our series, the reported live birth rate after surgery was 64%, compared with no live births before surgery in those patients. These are results from our own practice, and they should be explained in that context.
This approach is not covered by guidelines. Guidelines depend on the available studies, and the evidence is stronger for some questions than for others. Systematic reviews and meta-analyses can also reach different conclusions depending on which studies meet their inclusion criteria. This is one of the difficulties when interpreting the literature.
For me, ethical practice is central. I need experience in the procedure, confidence in my ability to perform it, and evidence from my own practice that it can help. Before proceeding, I explain to the patient that the broader evidence is limited and discuss the results from our series. That transparency is essential.
It is also important to look beyond the shape alone. The shape is an image of the uterus; what matters is how the uterus functions. In my view, a T-shaped uterus can be associated with functional changes involving endometrial development, implantation, and uterine contractility. The issue is therefore more complex than whether the cavity resembles the letter T.
New surgical techniques and technologies can enter practice before high-quality evidence becomes available. In gynaecological endoscopy, where do you think the greatest evidence gaps remain, and what research is most urgently needed?
It is difficult to establish robust evidence for a new surgical technique. We need RCTs, but surgery introduces challenges that are less prominent when studying a medication.
In a multicentre surgical study, each centre has different surgeons, equipment, and experience. Even when the procedure has the same name, it may be performed differently. That makes it difficult to compare outcomes consistently.
My own results today are different from my results 10 years ago because I have gained experience. If my performance changes over time, imagine the challenge of comparing it with that of surgeons working in different countries, using different tools and techniques.
With a medication, a specified dose is the same dose for each patient. In surgery, the human factor can influence the entire procedure and its outcome. We still need well-designed randomised trials, systematic reviews, and meta-analyses, but their methods must account for these differences.
There is also a challenge with studies from a single surgeon. If I report good results in 60 patients, the reasonable question is whether those results can be reproduced by someone else. We need research that examines both whether a procedure works and how transferable its results are across surgeons and centres.
Looking ahead over the next 5–10 years, which developments do you believe have the greatest potential to transform gynaecological surgery?
I think AI and technologies that make surgery safer and quicker have the greatest potential. We are working with models that combine AI, virtual reality, and augmented reality to help identify the precise location of a lesion and guide the procedure.
I also believe we will reach a point where robots perform parts of an operation with AI assistance. I am not suggesting that the entire procedure will be automated, but certain steps may be.
I compare this with an aircraft’s autopilot. The surgeon would introduce the camera or hysteroscope, establish the conditions for the procedure, and supervise the automated steps, checking that everything is progressing safely.
I expect to see some of these developments before I retire. The surgeon will remain involved, but AI-assisted robotics could take on selected parts of the operation in the future.
