It’s been difficult to train surgeons in the countries where MSF runs programs, however. Potential candidates might have other interests or they might have been assigned to other programs by their ministries of health. And fistula surgery is not easy. A lot of tissue loss can occur as a consequence of obstetric trauma, leaving less material to work with. Most fistulas are operated on through the vagina. Therefore, the handling of instruments can be difficult, because the operation field is limited and deep at the same time. An unsuccessful attempt to repair can result in additional scarring of the tissue, making things worse for the patient. The tissue can lose elasticity and become less usable for closure or reconstruction when another repair is attempted.