A surgeon's choice of equipment is occasionally limited by its availability in a particular hospital's operating room. Many of the advanced operative laparoscopic and hysteroscopic tools used by reproductive endocrinologists are available in operating rooms in which infertility specialists routinely work.

Familiarity with the specific tools (equipment) to be used is of paramount importance. The operating room personnel ("the team") as well as the physician must know how to operate the equipment to facilitate the preparation of the patient and "the room," enhance intraoperative communication between members of the surgical team and guide postoperative care. Troubleshooting is an ongoing and critically important aspect of surgery. As a surgeon changes the approach taken during a case or the tools required for the case in response to specific intraoperative findings the OR team must be prepared to respond in a timely and accurate fashion. Each member of the surgical team must understand their responsibilities so that

• the patient is adequately and accurately monitored prior to, during and after the case
• the equipment is properly cleaned, in good working order and prepared for use by the surgeon
• use of fluids (if any) is adequately and accurately (provided and) monitored during the case
• the instrument and gauze pad counts are accurate at the conclusion of the case
• settings for the equipment (on variables such as power) are accurately provided as requested by the surgeon
• communication between the surgeon and the rest of the team is accurate and meaningful

Miscommunication between members of the surgical team or failure to understand one's responsibilities in the operating room can result in mistakes. These mistakes can have a variable impact, ranging from an annoying delay in the completion of the case to a poorer than expected surgical outcome to even a surgical tragedy (longterm morbidity or death). It is prudent for each surgeon bringing new technology into a hospital's operating room to make sure that the team using the new equipment is adequately prepared and familiar with the equipment prior to the actual case so as to avoid mistakes. If the hospital's operating room is familiar with the equipment to be used, then the surgeon usually lets the OR know his preferences for types of solution, suture material, power settings and the like.

Occasionally, a patient will request a particular tool be used for the performance of her surgery. I have several patients who specifically request that a CO2 laser be used for the treatment of their endometriosis and may even recommend the wave form (ultrapulse or superpulse versus continuous) that I use. Fortunately, I am very familiar with the most modern lasers available for this type of laparoscopic surgery and these lasers are available in the operating rooms in which I work. Therefore, I am able to provide the highest quality of care that I am capable of by applying cutting edge technology and using my extensive experience with these sorts of cases.

On the internet, I am often asked questions like "which is the best tool to treat endometriosis- laser, harmonic scalpel, or cautery."

I am the moderator for the "Endometriosis and Polycystic Ovarian Syndrome" bulletin boards for INCIID ("www.inciid.org"). INCIID is the "InterNational Council on Infertility Information Dissemination" (pronounced "inside") which is a nonprofit organization dedicated to educating infertile couples about the latest methods to diagnose, treat and prevent infertility and pregnancy loss. INCIID is currently (1998) one of the internet's most active bulletin board and chat group sites and couples from all over the world visit it to ask questions about their situation.

In my hands I strongly prefer the ultrapulse type CO2 laser. However, couples asking this question come from anywhere in the world and one must recognize that in another surgeon's hands this type of laser may be much less effective than another tool that the particular surgeon is more familiar with. I always recommend allowing the surgeon who will be performing the surgery to decide on the equipment to be used since (s)he will know which tools are available in the chosen operating room. The most important concern for the patient should be finding a (considerate) surgeon with a good track record at achieving the goal desired (pain relief, fertility, etc.) for the surgery contemplated.