Dr. Reshef- News and Events

I haven't written here for awhile- most of the articles and issues of interest have been published by me on my Facebook page and on Bennett Fertility's Facebook page. Apologies. Please "friend me" on my Facebook page to view articles of medical interest from various sources, including New York Times, LA Times, Washington Post, Huffington Post, Slate, New England Journal of Medicine, JAMA, and medical news websites.

Common sense has prevailed! Currently, most insurance companies that cover progesterone supplementation to decrease prematurity will cover the compounded form that is much less expensive than Makena. I recently received a letter from Humana that in essence supports the use of the less expensive alternatives, urging physicians to be cost-conscious. KV Pharmaceutical's stock is significantly down. Most respectable OB/GYN publications ceased to allow Makena to advertise. When doctors and patients band together for a common, just cause, justice often prevails...

The most recent update from the American Society for Reproductive Medicine (ASRM) Annual Meeting this month in Orlando about PGD supports the data that the older method called FISH (Fluorescent In Situ Hybridiztion) to diagnose chromosomal abnormalities in embryos is inaccurate. There are new methods that are currently being studied, including SNIP oligonucleotide Microaarray (SOMA), that may have promise for improving the accuracy of detection of normal and abnormal embryos prior to placing them in the uterus in IVF. The older FISH method has not resulted in decreasing miscarriages or improving IVF pregnancy rates. The new methods hold promise but are not yet commercially available. Currently, the official view from respectable organizations such as the ASRM and the American College of OB/GYN (ACOG) cautions against the use of the older PGD method. It confirms our decision in our IVF program (Bennett Fertility Institute) several years ago NOT to apply PGD to clinical but rather wait for more reliable data. Stay tuned!

One morning in March, I get up with a tremendous heartburn. I tossed and turned the night before after hearing that KV Pharmaceutical (KVP) and its subsidiary, Ther-Rx, increased the price of progesterone injections (now known as Makena) to prevent premature delivery from $10 to $1500 per injection! All too often, physicians are very adept at articulating their frustrations, but they usually reserve their angst to surgical lounges and dining rooms. Several of us physicians in Oklahoma decided to actually act upon our frustration at KVP by boycotting the product. We made phone calls to the company's area representative to confirm the news. We then spoke to her district manager, and then to the public relations person at KVP in charge of marketing Makena to express our dismay and forewarn them about our plan to initiate a campaign to boycott their grossly overpriced drug in Oklahoma. We contacted the American College of OB/GYN and spoke with its executive director about national initiatives. We contact the local and then the national directors of March of Dime to express our dismay at their support of the FDA approval of Makena.

We joined national blogs and appeared on local TV news with our plan. Letters, faxes, and phone calls were sent and made to all Oklahoma OB/GYNs recommending a boycott but also informing our colleagues of the availability of locally compounded alternatives to Makena. KVP was besieged with local and national negative publicity, including calls for congressional action. The FDA informed the medical profession that it would not try to prevent local pharmacies from compounding their own progesterone. KVP just announced yesterday that it was capitulating to pressure and lowering the price of an injection to $690. Victory? NOT. Makena must be priced fairly, and KVP must not get away with travesty.

Say you need a new tire. Your local store, which usually charges $100 for one, has jacked up the price to $1500 after a consumer magazine gave that tire the highest mark for quality. Dazed and confused, then outraged, you storm out of this tire store and go elsewhere, ignoring the salesman's explanation that it is much more expensive to have a tire blow-out and its consequences than paying the new price for a quality tire. KV Pharmaceuticals, a company out of St. Louis, has just increased the price of Makena, an injectable progesterone, to $1500 per injection, after the FDA approved this medication to prevent premature labor. The generic form of Makena, 17-hydroxy progesterone caproate (17-OHPC), has been used for many years for other purposes, at $10-30 per injection (one vial costs $25-50 as opposed to $7,500 for Makena!). KV Pharmaceuticals CEO, Gregory Divis Jr., justified his latest decision by comparing his pricing with the high cost of prematurity. KV Pharmaceuticals and its subsidiary, Ther-Rx, have "graciously" offered assistance to any patient who can not afford Makena. Sort of like sticking a knife in your belly and then offering you a ride to the emergency room...

Such egregious behavior and callous comments leave you speechless but deserve a response. KV Pharmaceuticals has had its share of problems recently. Most of its products, including prenatal vitamins, antifungals, antibiotics, and iron preparations have been recalled or withdrawn from the market. The company has been embroiled in legal battles, notably related to the distribution of oral morphine tablets. One wonders whether the outrageous price tag for a medication that costs pennies to manufacture has anything to do with recouping the losses from a drastically-declining market share from the other medications. But speculations aside, how can one justify such a monumental price hike in an era when health care delivery is dangerously strained, and many deserving individuals can't earn a paycheck or pay their health insurance premiums? I can't think of a single instance when the price of an item climbed 100-fold (not even hyped-up wine...). Can you?

As physicians who care about their patients, several of us who practice OB/GYN in Oklahoma decided to respond. After ascertaining that 17-OHPC can be compounded by several local pharmacies at a fraction of the cost of Makena, we are recommending to our colleagues to ignore Makena and use the generic brand. We contacted KV Pharmaceuticals to express our outrage, but also recommend to our colleagues to reconsider admittance of Ther-Rx salespersons to their office until the price of Makena is drastically lowered. We have contacted national organizations such as the American College of OB/GYN (ACOG) and members of Congress to investigate KV Pharmaceuticals questionable practices. I distinctly remember a gas station next to my hospital that suddenly raised its prices drastically at a time of high demand. Public outrage and media exposure drove it promptly out of business. Would KV Pharmaceuticals be next?

The recent claims that vitamin D-deficiency plagues a large proportion of Americans and Canadians have been rebuffed by a report by the Institute of Medicine (IOM). The report shows that most Americans and Canadian receive adequate Vitamin D and calcium from diet and sun, and that there is no connection between vitamin D deficiency and cancer, cardiovascular disease, diabetes, immune dysfunction, multiple sclerosis, or pre-ecclampsia. After reviewing nearly 1000 studies, the IOM recommended only to slightly increase daily vitamin D intake to 600-800 IU (up from 200-600 IU), with an upper limit of 4000 IU. For calcium, North Americans need 700-1300 mg daily, most of which can be obtained from a healthy diet rather than supplements. Excess vitamin D can cause high calcium; retarded growth in infants; and increased mortality from cancer, cardiovascular disease, falls, and fractures. Excess calcium can cause kidney stones; calcium deposits in tissue; prostate cancer; constipation; and problems with iron and zinc supply.

Bottom line: "everything in moderation." Physicians must be careful not to jump on the bandwagon of few studies and apply their results indiscriminantly to their patients when a solution to all ailments is offered. In my practice, I have seen patients given as much as 50,000 IU vitamin D daily by other physicians! A third of vitamin D comes from sun exposure. Excess sun exposure may lead to skin cancer. For people unlikely to be exposed to sun, vitamin D supplementation in moderation is appropriate. Before prescribing excessive doses of calcium for bone protection, one must consider dietary habits, especially dairy intake. Thank goodness the vitamin D myth has been dispelled. If you are a patient, test your doctor's knowledge of the IOM report- your kidneys may thank you...

Like road rage, what appears to be a sensible idea for somebody one moment may degenerate into a nightmare of unintended consequences for all. In this legislative session it is “Fetal Personhood” bills, presented in both Oklahoma House and Senate, that illustrate how uncontrolled passion may drag our state into an embarrassing swamp of inadvertent legal, medical, and administrative nightmares.
“Fetal Personhood” bills attempt to accord the status of a Person to an “Unborn Child,” defined as any human entity from fertilized egg to birth. It is a clear attempt by passionate anti-abortion activists to indirectly overturn Roe V. Wade. Regardless of one’s position in the hotly-debated abortion issue, however, Fetal Personhood bills should be viewed as a black eye to common sense, human rights and dignity, and the reputation of our state.
Consider this: by giving a fertilized egg, an embryo, or a fetus “all the rights, privileges, and immunities available to other persons, citizens, and residents of the state,” we are creating a new class of legal persons, and thus single out an existing class of persons (fertile women) for unequal treatment by the law. A man’s body would not be subjected to the same scrutiny. By granting the embryo equal protection of the laws, the state would be forced to deny the same to the woman. Should we prosecute women for smoking or running a marathon during pregnancy should something happen to the fetus “person”? Personhood laws would allow the government to infringe upon one of citizens' most fundamental rights, the right to privacy free from governmental intrusion. Ironically, the same people that decry such intrusion are at the forefront of promoting such onerous legislation.
In nature, only 30% of fertilized human eggs become babies. The remainder is genetically defective and most are therefore spontaneously miscarried. By the new definition, a miscarriage is essentially an unexplained death of a “person”. Must the state then issue a death certificate, investigate every pregnancy loss, and consider the womb a crime scene or require a coroner’s report? If we bestow a person status on any embryo, must we then transfer any embryo, healthy or not, into the womb during the in vitro fertilization (IVF) procedure? Should a laboratory technician be prosecuted for murder if some embryos do not survive laboratory conditions?
The 14th Amendment instructs us to carry out a census every 10 years. Must we then count all embryo “persons” in frozen storage in IVF labs throughout the U.S.? And think about the tax code. If you have a woman who might experience two, three, four miscarriages in a year, can she claim those unborn people on her taxes? As absurd as these examples are, the unintended consequences of Fetal Personhood are far-reaching and will erode the fabric of our Constitution, our privacy, and of sound medical and legal principles.

I call on House Speaker Steele, Senate Pro-Tem Bingman, and Governor Fallin to restore dignity to our legislative process by opposing Fetal Personhood bills, as was done by many of their Republican colleagues in other states.

Eli Reshef MD practices medicine in Oklahoma City.

In a short time, our assisted reproductive program at Bennett Fertility Institute will offer egg freezing and storage (oocyte cryopreservation, OC). The procedure, which is considered experimental by the American Society for Reproductive Medicine (ASRM), has been approved by our Institutional Review Board (IRB). Oocyte cryopreservation (OC) is indicated for the following situations:

1. Women in the reproductive age about to undergo cancer treatment (radiation, chemotherapy, surgery) that might render them sterile or infertile. An example is a patient with breast cancer about to undergo treatment.

2. Women who wish to delay childbearing for social reasons (e.g. career considerations). An example is an unmarried woman in her 20's who is pursuing a career, realizing that fertility declines with age.

3. Women who are scheduled to undergo gynecologic surgery for benign reasons that may result in removal of both ovaries.

4. Women at risk for premature menopause. An example is a woman in her early 20's with strong family history (mother, sister) of early menopause, and or tests indicative of impending ovarian failure.

* This procedure is still considered experimental, due to its short track record (only approximately 1000 deliveries world-wide since 2002). There is no long-term reliable information regarding safety (e.g. rate of birth defects, chromosomal abnormalities, infant or child health).

* For now, success rate is limited. It is approximately 4% live-birth per frozen-thawed egg, perhaps 20% per embryo transfer procedure. . Remember that not all eggs survive the freeze; not all will fertilize successfully; not all that fertilize will develop into healthy embryos; and that not all healthy embryos will result in a live birth.

* If you are considering OC, please remember that freezing eggs beyond age 35 further lowers the success rate (OC does not slow down the ovarian aging process).

* OC requires in vitro fertilization (IVF), an expensive process where oocytes (eggs) are fertilized with sperm in the laboratory (in vitro).

We will announce the availability of the procedure to the public soon. Stay tuned...

As I anticipated in my Op-Ed in the Oklahoman (Oklahoma's largest daily newspaper) last month (see "Place Oklahoma Policy Focus Where it Belongs" below), personal agendas are abound in the upcoming Oklahoma legislative session, including multiple anti-abortion and "Fetal Personhood" bills that were just introduced in this 3rd week of January. "Fetal Personhood" bills propose to accord a fertilized egg, an embryo, or a fetus the status of a person, with all the rights and privileges thereof. It is no secret that such legislation is an attempt to override Roe v. Wade and stop abortions of any kind. There are clearly medical and constitutional problems with giving a person status to a fetus, embryo or fertilized egg. This is a classical example of a powder keg of unintended consequences. I do respect people who oppose abortions but stay civil about it and maintain respect to people who support a woman's right to choose. Unfortunately, in their zeal to overturn Roe v. Wade, those who introduce or support Fetal Personhood laws ignore fundamental medical and constitutional principles, especially the compromise to women's rights that such status will undoubtedly create. By granting embryos equal protection of the laws, the state would be forced to deny the same to the woman. Medically, if the embryo is considered a person, the field of infertility, especially in vitro fertilization, would be severely compromised. Consider the laboratory person that drops a dish of embryos- would she be prosecuted for murder? Do spontaneous abortions require a death or birth certificate? Will I, an infertility specialist, be subject to prosecution if I render fertility treatment that results in a miscarriage? Will such laws deprive couples of the right of disposition of their embryos, creating adversarial relationship between the couple and their embryos? Will fetuses and embryos will have to be counted in the U.S. Census, mandated by the Constitution every 10 years, now that they are "persons" (including hundreds of thousands of frozen embryos in IVF programs such as ours)? As absurd as these examples sound, Personhood laws are fraught with multiple problems, many of which are difficult to anticipate at present. Wouldn't it be more honest on the part of anti-abortion organizations to introduce anti-abortion legislation rather than sink into a cesspool of medical and legal problems that ultimately will compromise Americans more than bolster their welfare? .

It took 12 years for the respectable medical journal the Lancet to retract a study published in 1998 by Dr. Andrew Wakefield linking vaccines to autism. Twelve years! It finally did so in early 2010. During these years, as a consequence of the Lancet's arrogance and an overzealous crock of a scientist (now widely regarded as a disgrace by the medical profession), hundreds of thousands, and possibly millions of children were not vaccinated against common infections such as mumps, measles, rubella, pertussis, diphtheria, and others. Nobody knows the extent of life lost and expenses incurred due to this travesty, not to mention hopes in parents of autistic children dashed. In an age of fantastic medical breakthroughs, what a pity that human arrogance and hubris does such a disservice to medical progress!

The other day, a 25 years-old patient walked into my office with the diagnosis of polycystic ovary syndrome (PCOS), depression, irritable bowel syndrome (IBS), hypertension, attention deficit disorder (ADD) and sleep apnea. This patient had a body mass index (BMI) of 45 (normal should be under 25), which constitutes morbid obesity. Upon further questioning, it turned out that PCOS, sleep apnea, ADD, and IBS were self-diagnosed, with a probable nod of "whatever" from her primary care physician. Additional inquiry revealed that she used on-line diagnostic tools for several of her conditions. So here is a young person, younger than my daughter, walking around with several medical labels and multiple medications. Common sense shows that her obesity, whether due to depression or heredity, is the primary cause of her absence of menstrual periods, hypertension, and sleep apnea. Where is she heading if she does not drastically change her eating and exercise habits? Towards infertility, diabetes, heart attacks, and a shortened life span.

As the end of the year approaches, many of us will make new year's resolutions. Weight loss is probably the most common one, and justifiably so. Few of us will persist and succeed in this endeavor. For some of us, a personal trauma provides the wake-up call to alter our lifestyle, whether a personal scare such as chest pain, or a family member who prematurely died. For others, there is an internal wake-up call, without external tragedy or trauma. No matter the cause, we should avoid the temptation to self-diagnose ourselves (often erroneously) with a medical condition in order to create a pretext to avoid dealing with a physical or psychological problem. It simply takes us down a self-destructive path. So this year, along with our new year's resolution, let's vow to stop self-diagnosing ourselves and get a hold of our physical and mental health, whether on our own, with the help of a caring and knowledgeable professional or a friend, or with faith, yoga, Pilates, acupuncture, massage, or whatever.

PLACE OKLAHOMA POLICY FOCUS WHERE IT BELONGS by Eli Reshef MD

Which will it be- legislative pillage, sack, and plunder, or a return to political sanity? After the U.S. victory in WWII, Japanese surrender led to reconstruction that eventually resulted in Japan emerging as an economical giant and one of America’s closest allies. Wisely, U.S. chose not to humiliate a defeated nation. In Oklahoma, the last elections solidified Republican control of the House, Senate, and the Governor’s mansion. The road was cleared to push the political agenda to the far right or, alternatively, to improve Oklahoma’s economical woes and its national image. We can do both, some may argue. But listen to well-respected conservative Republicans and you will hear otherwise.

Kris Steele (R- Shawnee), House speaker-elect, appears to be steering our political process in the correct direction when he recently said: “Given the current condition of the economy, people in Oklahoma want to make sure that they have adequate job opportunities.” Our new governor also emphasizes economic growth and job creation rather than pour salt in the wounds of her opposition by pushing controversial agenda. Thankfully, not much anti-Democrat bluster is expressed by the powers to be.

Other conservative politicians and pundits have added their weight to the call for emphasizing remediation of Oklahoma’s economic woes, including unemployment and a huge deficit, rather than pushing partisan extremist agenda such as anti-immigration, anti-abortion, and open-carry issues. “There are a handful of rednecks in the Republican party who are pushing for other, controversial and frivolous issues to be above job growth”, lamented a prominent conservative commentator recently.

Termed “silly season” by political mavens, the months of December and January are marked by the introduction of partisan bills that sap the political, financial, and physical energy out of our legislative process. This is when legislative travesties such as restricting horse teeth filing, banning payments to egg donors, and scaring the living daylight out of undocumented immigrants emerge. Add to that ballot initiatives such as the Sharia law prohibition, and our grand state is doubly punished: real issues such as economic growth and employment are shoved aside; and our state becomes the butt of national and international ridicule. How is that for soliciting businesses to relocate to Oklahoma, reducing our budget deficit, and creating a paycheck for the unemployed?

In every legislative session, some lawmakers decide to further their own agenda, or that of special interests, rather than represent the people that elected them or support issues that promote the welfare of society as a whole. Furthermore, critical issues change over time. In times of famine, people think about bread, not choice of music. In times of unemployment, Oklahomans prefer to have jobs rather than debate abortion or open-carry laws.

So as a physician, a small business owner who cares about his state, here are my simple wishes this December: if you are a state legislator, please place the welfare of Oklahoma first and don’t contribute to “silly season.” If you are a constituent, please remind your representatives of their priorities.

A TRIBUTE TO A PIONEER IN REPRODUCTION: DR. ROBERT EDWARDS AWARDED 2010 NOBEL PRIZE IN MEDICINE

In 1971, the British equivalent of the National Institutes of Health rejected a request for financial support for research in in vitro fertilization by a biologist, Dr. Robert Edwards, and his partner Dr. Patrick Steptoe, a gynecologist. The scientists persevered in their attempts to fertilize human eggs with sperm using private funds. In 1978, Louise Brown, the world's first in vitro fertilization (IVF) baby was born. Against objections by scientific and religious organizations, fearing unintended adverse medical and ethical consequences, IVF became a standard in the treatment of infertility. The dire predictions of naysayers did not materialize. To date, millions of children were conceived by IVF, fulfilling the dreams of millions of parents who could not conceive otherwise. Thirty-two years after the birth of Louise Brown, Dr. Edwards was awarded the Nobel Prize for Medicine and Physiology. Dr. Steptoe passed away some years ago.

The ultimate measure of the value of scientific innovation is its contribution to the advancement of humankind. Dr. Edwards clearly deserves the accolades and the award. Edwards and Steptoe persevered through adversity and gave humankind the ultimate gift through their relentless scientific endeavors. It is an honor and privilege for me to be able to apply their wisdom to helping childless couples realize their ultimate dream. Hats off to you, Edwards and Steptoe!

WHAT DO CONSISTENTLY HIGH-PERFORMING IN VITRO FERTILIZATION PROGRAMS IN THE U.S. DO?

In an effort to assist in vitro fertilization (IVF) programs in the U.S. to improve their results, VanVoorhis et al surveyed the 10 consistently best performing IVF programs in the U.S. about their clinical and laboratory practices. The programs were surveyed on every aspect of the IVF process, including patient selection criteria, stimulation protocols, laboratory procedures, and embryo transfer techniques. Our program, Bennett Fertility Institute, was one of the 10 programs included in this survey.

I was recently asked to comment on the "YAZ Controversy" by one of Oklahoma City's television channels. The reporter inquired about the multiple complaints launched against Bayer, the manufacturer of the oral contraceptive YAZ, by "thousands of pill users" about side effects allegedly attributed to this medication. Like other casual observers of television, I have seen numerous lawyer commercials soliciting lawsuits against Bayer. YAZ is purported to cause blood clots, strokes, and heart attacks at a far greater rate than other oral contraceptives. A thorough review of the available scientific literature, however, shows otherwise. I am not an apologist or defender of large pharmaceutical companies. As a caring physician who endeavors to make patient-friendly choices regarding medications, I abhor direct-to-consumer (DTC) advertising and the charm techniques these companies use to entice physicians to use their products. DTC advertising is, in principle, shallow and misleading. Bayer, the manufacturer of YAZ, was slapped on the wrist by the Food and Drug Administration (FDA) for misrepresenting YAZ's indications in their ads.

Along came the lawyers, like buzzards smelling demise in an injured animal, and are now frantically soliciting consumer complaints against YAZ for causing medical mayhem (sort of "kick them while they are down" tactic), despite scientific evidence that shows no difference between YAZ and other brands in causing adverse effects. True, several questionable studies in Europe showed slight increase in the incidence of blood clots with YAZ compared to several other low-dose oral contraceptive brands. This increase, however, was so minimal as to be clinically insignificant. Most of my patients (and even some of my colleagues) are unaware that pregnancy and delivery are far more dangerous than contraceptive pills. Willie Sutton, the famous bank robber in the 1930's, when asked about why he kept robbing banks, replied: ..."because this is where the money is!" Sutton's law, as it is now known, applies here so poignantly: Bayer (a large pharmaceutical company) is where the money is! How sick and twisted is a society where lawyers leverage public welfare for their own gain! This is where lawsuit reform should help the public, hopefully deterring buzzards from profiting at the expense of medically-needy individuals.

RISK-REDUCING SURGERY IS ASSOCIATED WITH DECREASE IN BREAST AND OVARIAN CANCER IN HIGH-RISK PATIENTS

Breast and ovarian cancer are common in women who test positive for BRCA1 or BRCA 2, genetic markers of mutations in certain genes. Lifetime risk of breast cancer in women who test positive is 56-84% and for ovarian cancer 36-63%. Ovarian cancer in particular is deadly. This prospective study of almost 2500 women in 20 centers showed that mastectomy (breast removal) or oophorectomy (ovarian removal) in high-risk patients significantly reduces the risk of developing breast or ovarian cancer.

Reshef's take: While removal of breasts or ovaries prior to the development of cancer may seem aggressive, it results in significant reduction of mortality from these deadly and relatively common cancers. This is a landmark study that confirms what we suspected for quite awhile- prevention of cancer and cancer mortality is possible in this particular case. Who is at high risk for breast or ovarian cancer? women whose first- and second-degree relatives (mother, sister, aunt) had breast or ovarian cancer. These women should be offered BRCA1 and BRCA2 blood tests. If positive, the appropriate management should be discussed with the doctor. If a young women tests positive for BRCA before completing her family, conception should be considered as early as possible so that the option of mastectomy or oophorectomy can be considered.

A list of 12 unsafe or outright dangerous supplements to avoid was just published by Consumer Reports. They are Aconite, Bitter Orange, Chaparral, Colloidal Silver, Coltsfoot, Comfrey, Country Mallow, Germanium, Greater Celandine, Kava, Lobelia, and Yohimbe. Also in the article are 11 supplements to consider, including calcium, cranberry, fish oil, glucosamine sulfate, lactase, lactobacillus, psyllium, pygeum, SAMe, St. John's Wort, and Vitamin D.

Reshef's take: I absolutely agree with the first list, even though it misses other dangerous substances like Ashwagonda and Gincko Biloba. I agree with most of the second list ingredients EXCEPT glucosamine sulfate and St. John's Wort. Recent well-designed studies have not shown any advantage to these supplements over placebo. I highly recommend this article, though even this reputable consumer protection publication occasionally fails to do its homework...

Please visit my Facebook page. I have a personal one and a professional one (which carries my photo). The professional one is where you should visit. Please also visit the Facebook page of Bennett Fertility Institute (BFI) and post positive comments about your experience there to assist and advise prospective patients who can be helped by BFI. Baby photos are also most welcome! If you have had negative experience with BFI or with me, please contact me directly (by phone or e-mail) so we can discuss it personally.

In food labeled "Sugar-free" or "No sugar added", sugar substitutes such as sugar alcohol (e.g. sorbitol, maltitol, xylitol) still contain sugar (approximately half of the calories of the equivalent in sugar, since half of these sweeteners does not get digested) and may raise blood sugar. People who count calories, as well as diabetics, SHOULD READ FOOD LABELS CAREFULLY!

New guidelines allowing more vaginal deliveries in women who had previous c-sections will be published by the American College of Obstetrics and Gynecology (ACOG) in the August issue of its journal Obstetrics and Gynecology. The percentage of VBACs has decreased significantly in the past 10 years because of fears of lawsuits following isolated cases of uterine rupture during labor. The risks to mother and baby are actually less following vaginal delivery compared with c-section but most OB/GYNs have stopped offering VBAC because of fears of lawsuits or forced to do so by their hospitals and malpractice insurance carriers. The new guidelines will potentially reduce the number of c-sections, approximately 1.4 million per year.

Reshef's take: This is a welcome change but the legal climate of today, which places the OB/GYN professional at a very high risk for multi-million dollar lawsuits, may result in a much smaller reduction in c-sections than hoped for. Let's face it: most OB/GYNs would rather do a c-section, regardless of its pure medical merits (or lack thereof), than risk being sued. The new generation of OB/GYNs has had little experience with forceps deliveries that often reduced the need for operative delivery. Give us national lawsuit reform first and lower c-section rate will follow!

(Labrie F. et al, Journal of the North American Menopause Society, 16 (5), 2009)

DHEA is a steroid hormone that is converted in the human body to testosterone and estrogen. A group of researchers from Canada and the U.S. studied a preparation of DHEA used intravaginally in postmenopausal women to see if it affects sexual dysfunction (problems with sexual desire and interest, arousal, and pain during intercourse). This was a well-designed study (prospective, randomized, double-blind, placebo-controlled) by respected researchers. It showed that DHEA administered vaginally had potent beneficial effect on all four aspects of sexual dysfunction without elevating blood levels of this hormone.

Reshef's take: This is a promising study for women after menopause who suffer from sexual dysfunction. Showing benefit without an increase in the blood level of this hormone (vaginal administration allows the hormone to go directly to the vaginal mucosa without entering the blood steam) raises hopes that treatment may be offered to postmenopausal women with moderate or severe vaginal atrophy and sexual problems without increasing risks of excess estrogen and testosterone (breast cancer risks, high cholesterol, etc). A word of caution, though: this treatment is not approved by the FDA and these are preliminary findings. Please consult with your doctor about this!

Disclosure: I am not associated with any pharmaceutical company, including the manufacturer of vaginal DHEA.

(Guallar E and Miller ER, "Vitamin D Supplementation in the Age of Lost Innocence", Annals of Internal Medicine, March 2010)

Media attention has recently surged about the health effects of Vitamin D deficiency. It was implicated in cardiovascular disease, hypertension, diabetes, cancer, autoimmune disorders, and even as a cause of early death. The claim that a large segment of the population is deficient in Vitamin D even prompted calls for supplementation and fortification of food stuff with Vitamin D. Two systematic reviews in the Annals of Internal Medicine on the role of Vitamin D in cardiovascular disease provide a sobering insight to the notion that Vitamin D supplementation may reduce or prevent such disease which is so prevalent in our country . The authors of the editorial in the Annals assert that "Despite the promise for disease prevention suggested by available studies, we believe that the evidence for wide-spread use of high-dose Vitamin D supplementation in the general population remains insufficient".

Reshef's take: Previous trials regarding the benefits of antioxidants, especially Vitamins C, A, and E, have yielded disappointing results. There is no firm scientific evidence that they provide any benefit for reducing disease or prolonging life. This is sobering but true. Will future studies also show that the current enthusiasm about Vitamin D is similarly exaggerated? Probably so, but let's wait awhile until data mature. There is no harm in taking Vitamin D in doses of 1000-2000 IU. The use of megadoses of 50,000 IU is probably an over-reaction and physicians should think long and hard before recommending it to their patients without firm scientific support.

As hard as I tried, I could not find anything exciting and educational to share with my patients on this Web site in June....

(Kaandorp, S et al. Aspirin plus Heparin or Aspirin Alone in Women with Recurrent Miscarriage. New England Journal of Medicine, 29 April, 2010)

In this randomized study, 3 groups of women with unexplained recurrent miscarriages were followed. One group took placebo; another took aspirin alone; and the third took aspirin and injectable heparin. There was no improvement compared to placebo in the live-birth rate with either aspirin alone or aspirin plus heparin. The patients with recurrent miscarriages had negative blood work for lupus anti-coagulant or any other blood factors associated with recurrent miscarriages.

Reshef's take: Approximately 1% of women have recurrent miscarriage, defined as three or more miscarriages. This proportion rises to 5% when two or more miscarriages are considered. Miscarriages lead to anguish and distress. The patient and her physician are often pushed to accept treatment options that have not been adequately studied, including heparin, aspirin, intravenous immunoglobulins (IVIG), and progesterone. Aspirin and progesterone are generally considered harmless and are accepted as empirical treatments (trial and error) for recurrent miscarriages. Heparin, on the other hand, carries with it increased risk of bleeding. A relatively small motor vehicle accident may develop into a major bleed in the brain after hitting a windshield. The physician must first ascertain that the treatment is not worse than the disease. The study above, well-designed and poignant, points to little or no benefit from heparin or aspirin for recurrent miscarriage. While it is difficult for physicians to deny treatment to women desperate to have a child, their first duty is to "do no harm."

I have an old Toyota truck. It smells, it leaks, it dies on occasion, but it is a joy to drive. It is doomed for slow demise but still a great source of enjoyment with its powerful Chevy 350, 8-cylinder engine that roars like a cranky rhinocerus and a standard gear shift that for the most part cooperates with the clutch. This old FJ40 Land Cruiser can usually take me from point A to point B. Such is my medical records system- the old-fashioned paper system with manila folders, colorful stickers, and transcribed notes alternating with actually hand-written notes. When Mrs. Scott asks me during her annual examination how much she weighed in 1999, I do not point and click- I leaf through her chart and in as much time that it takes to navigate through a top-of-the-line i-Pad, I come up with the answer. "How large was my ovarian cyst two months ago," you ask? Give me a second- three or four pages later, I find the answer. I still dictate notes and letters to be transcribed by a real person (often with correctable human mistakes- I check them diligently). I look at my patient and her significant other during the initial interview rather than input the data into a computer. A personalized narrative is then dictated few minutes later, to be transcribed to the chart the next day.

When I look at EMR's from other physicians, while I can usually read the content clearly (as opposed to deciphering handwriting), I am always suspicious of the genuine nature of the History and Physicals that are clearly pre-fabricated. Did this doctor really listen to this patient's heart? Did they truly percuss her chest? One can spend hours expounding on the benefits of EMR's. I know it by heart. But have EMR's truly improved health care? I am privileged to be in a special medical niche where I am not obligated to see scores of patients a day or deal with lengthy and complex medical records. My colleagues in Internal Medicine, Family Practice, and Geriatrics must be able to restore some order to their information overload. EMR's for them may be a solution. I asked a seasoned, well-respected senior nurse on the hospital ward one night whether patient nursing care has changed over the past 30 years. "It certainly has not improved," she answered. "We may be much better at recording vital signs and entering orders and medication data into the computer," she added, "but we spend much less time in direct patient care, actually touching and interacting with those who need human contact."

My old Toyota will die soon, but I will try to squeeze the last bit of smelly exhaust fume and rev up its old engine until it can no longer roar. Similarly, EMR's will enter my practice in the future. That's a near certainty. Until then, I will still look at my patient's face or gently touch her hand or hug her in grief or joy rather than point and click. The minutes or dollars that I may save with EMR's will never replace those genuine moments of human contact that are a central part of my practice.

("Promises the Pill Could Never Keep", Elaine Tyler May, New York Times, April 25, 2010)

In May 1960, the Food and Drug Administration (FDA) approved the pill as a contraceptive. Its original creators and supporters promised happiness and security for families and the easing of hunger and poverty. The pill, so claimed its enthusiastic supporters, will improve sex life and lower the divorce rate. If such promises are used as parameters of success of oral contraceptives, then the pill has clearly failed. Yet when one lowers the sights, the pill has had a significant impact on lowering unintended pregnancies (and with it the reduction in abortions and the many psychosocial complications of such pregnancies) and lowering gynecological complications such as painful or heavy periods, ovarian cysts, and the rate of uterine and ovarian cancer. The pill has clearly helped women deal successfully with the profound dilemma of choosing between family and career.

Has the pill fulfilled its promises, then? Well, if the promise is nirvana, the pill is a failure. If the promise, however, is reduction of pain and suffering and the advancement of humankind (especially women), then the pill is as successful as antibiotics. One should not measure the success of a medical procedure or medication by euphoric and unrealistic supporters (including, in the case of the pill, medical giants like Dr. John Rock of John Hopkins, one of the pill's original researchers), much like the success of a marriage should not be measured by what the enthusiastic pastor and family members uttered at the wedding ceremony. The title of Elaine May's Op-Ed in the NYT is rather provocative and misleading, then, but she also reminds us of the monumental role the pill had in reshaping society in 50 years of existence.

OUR HOUSE LAID AN EGG- OUR SENATE COOKED IT SO NOTHING HATCHED (HOW TO DEFEAT A BAD BILL)

In February, Oklahoma House representative Rebecca Hamilton (D-Oklahoma City) introduced House Bill 3077 that would outlaw any compensation to egg donors in Oklahoma. This effectively would have shut down most egg donations in Oklahoma since very few, if any, women would be willing to donate their eggs without compensation for their time and trouble. Hamilton claimed that what spurred the bill was an ad from an egg donor agency from Dallas in the University of Oklahoma student newspaper (OU Daily) that offered $5000-40,000 compensation for the "right egg donors." She claimed that the bill would protect Oklahoma women, especially the poor and vulnerable, from predatory practices by fertility doctors (like myself). HB 3077 overwhelmingly passed the House by a vote of 85-7. In late March, the bill died after failure to be heard in a Senate committee. What happened? We defeated the bill.

"We" are physicians, patients, legislators (bipartisan), and caring citizens that realized the impact of such bad bill on health care in our state. My Op-Ed in the Oklahoman, Oklahoma's largest daily newspaper (see below) summarizes the issue. When I heard about the easy passage of Hamilton's bill in the House, I contacted my colleagues in Oklahoma City and Tulsa to map out a strategy to defeat the bill. The Oklahoma State Medical Association was made aware of the bill and issued a statement against it. Resolve, the national organization of infertile couples, issued a similar statement at our request, joined by the American College of OB/GYN and several other national organizations that were alerted by us. Next, networks of cancer survivors and infertility patients were hastily established to e-mail, fax, make phone calls, and write letters to legislators urging them to oppose the bill. We, the physicians, met with key senators to explain the real scenario in our state and the unintended consequences of Hamilton's bill. Once these key legislators realized that the egg donation issue has nothing to do with abortion, pro-choice, or pro-life issues, and that actually preventing a legitimate reproductive procedure is anti-family (the other side tried to portray their efforts and the bill as "pro-family"), the pendulum swung our way. Despite aggressive lobbying efforts by several organizations, including the Archbishop of Oklahoma, to convince the senate to hear the bill, it mercifully died in committee without a hearing.

There is still war out there, and we were promised a re-introduction of this bill next year. We won the battle but uncertainties still exist about future efforts by zealots like Hamilton to undermine legal, legitimate, and decent reproductive care in Oklahoma. In the future, however, we will be better prepared to handle such onerous bills that threaten to undermine good medical practice. It will be more difficult to "sneak" such bills through the legislature. Hamilton's personal religious agenda is the clear motivation to introduce HB 3077. Such agenda vehemently opposes any form of assisted reproduction (including inseminations and in vitro fertilization) and contraception. It ignores safe and legal health practices and the welfare of Hamilton's own constituents. Fortunately, reason still prevails in our state. Legislators such as Hamilton are advised to tend to the welfare of their own constituents rather to their own personal agenda. It is a blatant betrayal of public trust otherwise.

OUR HOUSE LAYS AN EGG
By Eli Reshef MD
A 19-year old woman undergoes surgery for ovarian cancer and loses both ovaries. A 32-year old woman suffers from premature menopause. A 28-year old woman has a genetic abnormality that may be passed on to her offspring. Since 1985, these women have had the opportunity to mother a healthy child by egg donation. Representative Rebecca Hamilton (D-Oklahoma City) wants to change that. She introduced HB 3077 making it illegal for an egg donor to be financially compensated. The bill passed by a wide margin in the Oklahoma House of Representatives and is due to be heard in the Senate in the next few weeks.
Forbidding financial compensation for egg donation will effectively eliminate this medical procedure in Oklahoma. No woman in her right mind would be willing to spend 7 weeks of tests, blood drawings, injections, and a surgical procedure to remove eggs without being compensated for her time and trouble. Sperm and plasma donors get compensated and lives would not be saved or children born without their services. In her zeal to “protect the ovarian health of Oklahoma women”, Hamilton has created a thoughtless and onerous bill that will accomplish just the opposite- deprive deserving Oklahoma women of a valuable and safe medical service.
“We are endangering our young women’s lives,” she said. “These girls are being injured. They are dying.” Are they? I have been personally supervising egg donation since 1994 without a single incident of severe injury or death. This is also the experience of the few other providers of this valuable service in our state. There is no scientific evidence for an increased risk to one’s fertility or health from donating eggs. Worldwide, more than 32 years of experience with IVF have shown no long-term adverse effect from ovarian stimulation or egg retrieval. Hamilton’s crusade is predicated on baseless science and a personal agenda with no grasp of reality.
Legislators are elected to represent their constituents rather than their own emotional agenda. The role of the Oklahoma House and Senate is to ascertain that a bill will result in an improvement in the welfare of Oklahoma citizens. The Oklahoma House of Representatives, by passing HB 3077, has thus failed in its duty to its constituency. It failed to get input from credible medical sources about a medical issue, thereby practicing medicine without a license. The emotional debate about abortion has now boiled over to consume other health issues in its path, regardless of their relevance to the life and health of Oklahomans. Egg donation is not about abortion, pro-choice, or pro-life- it is about the right of Oklahoma women to conceive and the right of righteous individuals to donate their eggs and to give hope to Oklahoma families with the promise of decent compensation for their time and trouble.
Cool heads should prevail in the Senate now that the House has succumbed to hysteria and misinformation and failed to protect Oklahoma women from a personal campaign. I urge the Senate leadership to do the right thing and reject HB 3077.
(Op-Ed in the Oklahoman, March 10, 2010)

The well-respected British journal Lancet, in its recent issue, published a retraction of a 1998 article by Dr. Andrew Wakefield that purported to show a connection between vaccinations and autism. While an inquiry about the validity of the study in 2004 revealed no wrong-doing, further investigation led to findings of inconsistencies and even outright unethical behavior by Dr. Wakefield and associates. Unfortunately, the damage was done-millions of parents throughout the world have consequently refused to vaccinate their children and as a result, outbreaks of measles, a viral disease almost eradicated by vaccination, caused illness and even deaths. Dr. Wakefield is part of a small but vocal group of physicians claiming connection between vaccines and autism, even though scientific evidence does not support any link. Certain celebrities joined the bandwagon by advocating against vaccinations. The tragedy is that the children who suffer as a result of their parents' ignorance are not only the unvaccinated innocent ones but those that they infect. Ignorance kills! Amazingly, SafeMinds, an organization of parents opposed to vaccines, attributes the retraction to an attack on a reputable scientist by the medical establishment. Autism is a tragic condition. The lack of treatment makes it even more tragic. But denial of good science in support of an attractive but nonviable medical hypothesis, the vaccine-autism connection, is not only doubly tragic but outright ignorant and selfish since it jeopardizes the health of many innocents.

A TALE OF QUACKERY, DIET, AND A FERTILITY MEDICATION
Eli Reshef MD
What died in the 1950’s, revived by a charlatan, landed Manny Ramirez in hot water, and is currently prescribed by healthcare professionals all over the U.S.? Human Chorionic Gonadotropin (HCG), a fertlity medication, and the HCG diet. HCG is prescribed for infertility treatment in women to promote ovulation and in men with low pituitary hormones to increase testosterone and sperm counts. It is also used illegally for doping in sports (increasing endogenous testosterone production) to avoid detection of synthetic androgenic steroids during urine drug testing. In 1954, Dr. ATW Simeons, a British enocrinologist, in a book called “Pounds and Inches,” described a semi-starvation 500 calories a day diet augmented by low-dose daily HCG injections. He claimed that the HCG helped specific fat tissue loss in the hips, abdomen, and thighs. Long after Simeons’ death, his pseudo-scientifc diet regimen became all the rage in the U.S., with at least 80 clinics in California alone treating thousands of patients. When reports that part-time doctors were offered as much as $100,000 to simply write HCG prescriptions, the medical profession finally took notice.
In 1962, the journal of American Medical Association warned against the potential hazards and lack of effect of the Simeons diet. In 1974, the Food and Drug Administration imposed a warning label on HCG against its use in diet plans. Canada went even farther by warning that HCG use in diets “borders with malpractice.” In 1976, the Federal Trade Commission ordered clinics and promoters of the Simeons Diet and hCG to cease making false claims about the effectiveness of HCG for weight loss, after several research trials disproved any benefit for HCG over placebo. Later studies further refuted any benefit to HCG. Case closed? Not so fast…
Enter Kevin Trudeau, an author, salesman, self-proclaimed alternative medicine advocate, and a felon. He is known for his many television infomercials as well as several best-seller books, including “Natural Cures “They” Don’t Want You to Know About” and “The Weight Loss Cure “They” Don’t Want You to Know About.” Convicted for fraud and larceny in the early 1990’s and as late as 2007, and repeatedly sued and fined by the FTC, Trudeau nevertheless revived the Simeons diet until it became a current rage.
I contacted several physicians and compounding pharmacies in Oklahoma about prescribing and distributing HCG for weight loss. All were dispensing HCG and none were aware of the origin and history of the diet. The Web is replete with testimonials about the wonders of the HCG diet and advice about obtaining the drug on the Internet.
What harm can the diet cause? HCG itself in such sub-therapeutic doses is unlikely to be effective or harmful. A 500-calories diet, especially if unmonitored, is essentially a starvation diet that may cause protein depletion from vital organs. Weight loss occurs, as it does with any calory-restriction diet, independent of HCG effect. Most patients are likely to gain weight back, as is the case with almost 90% of patients on any fad diet. While patients have the right to hurt themselves, health care professionals must not collaborate, knowingly or not, in such efforts. If we , as physicians, fail to educate ourselves about the treatments we prescribe, we are likely to repeat the mistakes of the past and violate the First Do No Harm principle that is central to our mission. Hiding behind statements like “Well, it is worthwhile for patients to lose weight even if the HCG acts merely as a placebo” is not good medicine. To be complicit with an unproven, expensive, and potentially dangerous therapy constitutes a violation of clinical and ethical principles and moves the health care profession in a downwards direction closer to Mr. Trudeau.

In 1798, Thomas Malthus, in his famous publication "Essay on the Principle of Population", predicted that population growth would outstrip the world's food supply. Fortunately, his idea was proven nonsense. When industrialization spread through the Western world and allowed people to become wealthier, the size of their family shrunk. And as families got smaller, people became richer. Now this process occurs in developing countries like Brazil, Indonesia, and parts of India: fertility is falling and families are shrinking. It is now predicted that the fertility rate of half the world is now 2.1 children per family or less. Somewhere between 2020 and 2050, the world's fertility rate will fall below the global replacement rate.

For clarification, the fall in fertility rate does not imply a corresponding increase in infertility. Despite industrialization and pollution, there is no appreciable increase in infertility. The fall in fertility rate is due to economic and social factors. While in China, the fall in fertility is coerced or imposed ("One child per family" policy), in most other countries, the decision to bear less children is voluntary. The dependence on children by subsistence farming is no longer a major determinant of family size. The world population is predicted to reach 9 billion by 2050 but is thereafter predicted to decline. Population control can be achieved by policy (usually an unsuccessful strategy); technology, and governance. The latter two factors are actually the more successful strategies. Smaller families are more economical, and allow families to acquire wealth more readily.

Reshef's take: the most dire predictions often succumb to reality. Among other strategies, easier access to contraception may assist humankind in limiting family size. This by no means is the main way to reduce family size. Opponents of contraception, nevertheless, must provide a better alternative to ease population explosion, which ultimately leads to further suffering and warfare. Food for thought...

This is an editorial in one of the most respected OB/GYN journals (the "Green Journal") about some of the myths regarding blood clotting abnormalities from birth and pregnancy complications. Assisted by 2 studies in the January issue, Dr. Branch emphasizes that the "usual suspects" in causing pregnancy complications such as recurrent miscarriages, fetal growth restriction, severe pre-eclampsia, and stillbirths, namely abnormalities in the MTHFR, Leiden Factor V, and Prothrombin genes, actually ARE NOT associated with pregnancy complications. Such genetic abnormalities are very common in the general population (for example, MTHFR abnormalities occur in more than 50% of all women) and should not be perceived as associated with disease. In fact, some MTHFR abnormalities are actually PROTECTIVE against certain pregnancy complications.

Reshef's take: Oh, finally the voice of reason arising from the multitudes of junky medical advices on the Web! Desperate patients, especially those with recurrent miscarriages without viable medical explanation, inundate their physicians with desperate pleas to be treated with low-molecular weight heparin (LMWH), a blood thinner, or with intravenous immunoglobulin (IVIG). Apart from being very expensive and often outright dangerous, such treatments have no medical or scientific justification. The only condition that merits LMWH to prevent pregnancy complication is the ANTI-PHOSPHOLIPID SYNDROME. If you test positive for ANA, MTHFR, Leiden Factor V, or prothrombin defects, your physician must think long and hard before prescribing an injectable blood thinner. The risks of taking a blood thinner is high (think of a minor fender-bender where your head hits the windshield and your blood has little ability to clot!) and it should only be given in cases where clinical evidence justifies its use.

OCTOBER 2009 NEWS

THE FLU- QUESTIONS AND ANSWERS
(Tara Parker-Pope, New York Times, October 9, 2009)

Bill Maher, comedian/politico, recently called people who took flu shots "idiots" on Twitter. Only one third of parents surveyed would have their children vaccinated. So far, 76 children have died from H1N1 flu in the U.S., a number rapidly approaching the total number of child deaths from the common flu during the entire 2007-2008 flu season. So who do you listen to? Your fears as a parent? an idiot comedian? the Centers for Disease Control? Here are some facts to consider:

- The Swine Flu (H1N1) differs from the regular flu in compromising young and healthy people (including pregnant women) rather than mostly immune compromised individuals and the elderly. Most people who get H1N1 recover in 3-4 days. Among those with H1N1 that need hospitalization, especially in intensive care units, the death rate is higher than the common flu.
- The regular flu vaccine, which changes every year according to the anticipated flu strains, does not protect against H1N1 and vice versa.
- The regular flu kills 30,000 people in America annually. It is estimated that H1N1 is at least as deadly
- The new H1N1 vaccine is made by the same methods as the regular flu vaccine, whose safety record is excellent.
- The nasal spray vaccine uses a weakened live virus while the injection contains dead virus. Therefore, people with compromised immune system (including women, asthmatics, diabetics) SHOULD NOT take the nasal spray, only the injectable form
- The body develops immunity to H1N1 within 7-8 days after administration. Kids should get 2 doses a month apart since their immune system does not respond as rapidly as adults to vaccination.
- If you already had the flu this year, unless the type was confirmed by lab tests, you should consider taking both vaccines if you are likely to be exposed (unless you live in a lighthouse in New England, you are vulnerable to infection.)
- If you have flu symptoms, DO NOT take the flu vaccine until the symptoms subside.
- Does the mercury in the preservative thimerosal pose a health risk? The amount of mercury in one dose of vaccine is less than in one tuna sandwich. Studies have not shown health problems from such low dose. If you are concerned about mercury, ask your physician for the individually-packed vaccination that contains no thimerosal (and stop eating tuna sandwiches...)
- If you think you might have H1N!, see your doctor only if you are a high risk individual or if your symptoms do not improve or worsen after 3-4 days. Tamiflu should be given to high risk patients within 36 hours of exposure to other sick individuals or as soon as symptoms appear.

BOTTOM LINE: No need to panic. Don't listen to celebrities about medical issues (be it Suzan Sommers, Jenny McCarthy, or Bill Maher). Most people with H1N1 will recover uneventfully. Use common sense- handwashing, avoidance of contact with infected individuals, Tamiflu when indicated. If sick, DO NOT make an appointment with your physician (thus infecting everybody in the office) unless complications arise (shortness of breath, dehydration, inability to eat or drink, etc.)

HABITS HELP IN AVOIDING BREAST CANCER

(RC Rabin, New York Times, September 8, 2009)

A reduction in the risk of breast cancer can be achieved by women by watching their weight, daily exercise, breast feeding, and limiting alcohol intake, reports the American Institute for Cancer Research. More than 800 studies on breast cancer and nutrition were reviewed by the Institute, showing reduction in risk in women exercising for at least 30 minutes a day, breast feeding, and drinking no more than one alcoholic drink a day. The Institute recommends plant-based diet and reduction in red meat consumption. The Institute's review estimates that approximately 70,000 new cases of breast cancer (40%) can be prevented by following these recommendations.

PLASTIC SURGERY MAY EASE MIGRAINES

(C. Saint Louis, New York Times, September 3, 2009)

A new study published in the journal Plastic and Reconstructive Surgery showed that more than 80% of patients who underwent forehead lift involving one of three "trigger points" experienced reduction in migraine headaches. More than half of them experienced complete elimination of headaches.

Reshef's take: A promising remedy for some of the 30 million Americans suffering from migraines. Sounds a bit extreme and in need of confirmation, this surgical solution should only be offered by plastic surgeons experienced in a particular type of forehead lift. Proceed with caution, migraine sufferers!

CHRONIC FATIGUE SYNDROME VIRUS DETECTED
(Science, October 8, 2009)

A group of American researchers from the National Cancer Institute identified high prevalence of the retrovirus XMRV in patients with Chronic Fatigue Syndrome (CFS). Approximately 17 million people worldwide suffer from CFS (including 1 million Americans), a debilitating condition characterized by fatigue not relieved by sleep, body aches, and compromised immune system. XMRV is a retrovirus, a family of viruses that include HIV, which causes AIDS.

Reshef's take: While this study does not establish that XMRV causes CFS, it is a promising discovery in an elusive and controversial disease that is very disabling. If you feel that you might suffer from CFS, you should see a qualified specialist (rheumatologist, internist). There are specific criteria that establish the condition. Many modern ailments (e.g. low thyroid, depression, stress, cancer) are often misdiagnosed as CFS.

Due to technical difficulties, February through August News and Musings are not available.

SEPTEMBER 2009 NEWS

UNIVERSAL COVERAGE KEY TO EQUITABLE SYSTEM
Point of View: Health Care Reform

Eli Reshef MD

The proverbial 10 blind men who were asked to describe an elephant gave 10 accurate but incomplete descriptions of the beast, depending on the body part they touched. Similarly, when asked to describe the root of our health care crisis and a solution, different pundits give a multitude of correct but incomplete answers. A comprehensive solution should come from multiple sources rather than being borne in haste from a partisan political cause. After all, the health of Republicans, Democrats, wealthy or poor is at stake, not the next elections, or the fulfillment of campaign promises.

Several basic premises must be considered: First, Americans are not Canadians or British. We have a strong predisposition for individuality and for a decentralized government. This is how the West was won, after all… Second, any sweeping changes in the health care system must be slowly and patiently implemented, like taming a wild mustang. Third, we all must sacrifice for the sake of a more equitable health care delivery. Fourth, the system must be changed. Maintaining the status quo isn’t an option.

Much like we mandate car insurance for every driver, all Americans must carry health insurance. Universal insurance coverage is the cornerstone of a more equitable system. How do we finance such a massive undertaking? We implement “sin tax” on tobacco, alcohol, high-fat food and high-sugar drinks. Preposterous? Not really. These, after all, are some of the major sources of burden on the medical system. We should also gradually reduce the income tax exclusion for expenditure on employer-sponsored health insurance. This is a source of significant revenue but we must do so carefully so that employees in lower income levels can still afford the premiums. Tax the wealthy? This French Revolution vengeance will unfairly compromise the top 5% of earners, who contribute more than 60% of our tax revenues.

We must have a substantial national lawsuit reform. The cost of “defensive medicine” to reduce the likelihood of being sued clearly adds to the escalating cost of medical care. Lawsuit reform may serve to appease physicians, whose income is likely to decline under any comprehensive health care reform. It may also draw Republicans to the negotiating table.

Health insurance must be meaningful, not just a plastic card. Insurers should thrive only if they improve their subscribers’ health. They must compete on value, not “cherry pick” healthy subscribers and discriminate against the sick, the poor, and the elderly. Large statewide or multi-state insurance pools with emphasis on measured outcome, prevention and wellness will allow broader coverage with less inequity. A value-based system where achievement and maintenance of good health is the cornerstone is less costly than dealing with poor health in the emergency room.

We may choose to be blind to the health crisis, that pesky elephant in the room. We will then continue to deny ourselves, especially the uninsured, better health outcome and longer life expectancy. Alternatively, we can choose to marry our innovative spirit with our resources and in a bipartisan fashion create the most technologically advanced AND equitable health delivery system in the world.

(Published in the Oklahoman as an Op-Ed on August 3, 2009)

JANUARY 2009 NEWS

THE SIX HABITS OF HIGHLY RESPECTFUL PHYSICIANS

(Michael Kahn, MD. New York Times, December 2, 2008)

Dr. Kahn, a psychiatrist, proposes a simple six-step checklist for doctors when meeting a hospitalized patient for the first time:

* Ask permission to enter the room

* Introduce yourself (show your ID badge)

* Shake hands

* Sit down. Smile if appropriate.

* Explain your role on the health care team.

* Ask how the patient feels about being in the hospital.

Reshef's take: A very poignant reminder to us to act human and respectful. We often forget.

DO PATIENTS TRUST DOCTORS TOO MUCH?

(Pauline Chen, MD, New York Times, December 19, 2008)

Dr. Pauline Chen, a regular contributor to the Health section of the New York Times, ponders about the criteria used to evaluate doctors on Angie's List, an opinion resource about performance of professionals in the service, business, and health industry. Professionals (including doctors, plumbers, dog-walkers, childcare providers) are graded on 5 categories: price, quality, responsiveness, punctuality, and professionalism. Interestingly, there are no comments about the doctor's actual medical skills. In contrast, comments about roofers were very specific about their quality of work. Beyond the overall grade for physicians, there were no detailed descriptions of medical skills. Dr. Chen is baffled about the degree of trust that patients have in their doctors that allows them to ignore one of the most fundamental issues when seeking a doctor- his or her actual medical and surgical talent. The American College of Surgeons conducted a nationwide survey that found that the average patient spends less than one hour researching his or her surgery or surgeon. Patients are more likely to spend time researching a new car (8 hours) or a new job (10 hours) than about the surgical skills of their doctor or his/her credentials. According to Dr. Chen, doctor-patient relationship does not simply entail good bedside manners and responsible office management. Patients must be better educated about their doctor and about their illness.

Reshef's take: Excellent commentary by a reputable physician about the fact that good consumerism virtually disappears when it comes to selecting a doctor. It is not that patients trust doctors too much nowadays- the days of Dr. Marcus Welby are long gone. Patients simply do not always have adequate resources or motivation to check on their doctor's skills. Where would you go to check on me? At the numerous websites with information about doctors? NO! These sites simply check (for a fee) hospital privileges, board certification, and possibly disciplinary actions, as well as other patients' opinions. Not very different than Angie's list. Very few areas in medicine have outcome-based information about doctors. With regards to IVF results, however, you can simply go to www.sart.org to check on your doctor's performance. With regards to surgery, however, word of mouth is still the most common resource, as inaccurate as it is. If I were to pick a surgeon, I would ask nurses in his/her operating room about their performance. This is even more reliable information than from physicians. The average patient, however, does not have access to "inside information" about their physician. To answer Chen's question- patients do not trust doctors too much, but are unable or unwilling to find adequate information about them.

MEDICAL MYTHS DEBUNKED

(BBC News, January 28, 2009)

Researchers from Indiana University looked in vain for support for common myths. Here are some:

* Drinking 8 glasses of water a day: Not true. Adequate hydration can be achieved with any drinks. Excess water may be dangerous.
* We only use 10% of our brain: Not true. Damage to almost any area of the brain may lead to significant, long-lasting deficits.
* Hair and fingernails continue to grow after death: Not true.
* Shaving hair makes it grow faster: Not true. The stubble resulting from shaving gives false impression of thickness and coarseness.
* Dim light damages vision: No evidence.
* Mobile phones create electromagnetic interference and should not be used in hospitals: Not true.
* Eating turkey makes people sleepy because of tryptophan: Not true. Turkey, chicken, and beef contain the same concentration of tryptophan. Any large meal may induce drowsiness.

DECEMBER 2008 NEWS

DO FERTILITY MEDICATIONS INCREASE THE RISK OF CANCER? (DOES CLOMIPHENE INCREASE THE RISK OF UTERINE OR BREAST CANCER?)

(Calderon-Margalit R. et al., American Journal of Epidemiology, November 2008)

The buzzword in the British media, now spreading like wildfire across the Atlantic in the U.S., is that clomiphene (a fertility pill known as Clomid or Serophene) is associated with an increase risk of cancer. A recent article by Ronit Calderon-Margalit from Hadassah-Hebrew University in Israel claims that clomiphene increases the risk of breast cancer, malignant melanoma, and non-Hodgkins lymphoma. An article in the same scientific journal in 2005 claimed a connection between clomiphene and uterine cancer. What is an infertility patient to do? Should we stop the use of a medication that has been around since the 1960's for ovulatory infertility?

The obvious answer is a resounding NO. We should continue using clomiphene appropriately and carefully for ovulation induction in the appropriate patient for the right indications.

The word CANCER generates immediate panic. Combine that with the media's thirst for sensational news, and here is an appetizing story that generates immediate interest. Fortunately, much like the National Enquirer, a large proportion of sensational medical news is hype, doomed to fade away like an Oklahoma May storm. But not without leaving behind a trail of damage, much like spring tornados in the red-earth state. Fertility pills and injections have been used for over 40 years throughout the world. We simply have not seen a surge or an epidemic of cancers in former infertility patients (ovarian, uterine, cervical, breast or others). One must remember a very important fact: INFERTILITY PATIENTS HAVE AN INCREASE RISK OF REPRODUCIVE CANCERS, WHETHER TREATED WITH MEDICATIONS OR NOT. Any scientific study attempting to relate infertility treatment to cancer must compare infertility patients under this treatment to infertility patients without such treatment. A common error is to compare infertility patients to the GENERAL population, a scientifically invalid exercise.

Calderon-Margalit's article surveyed 15,000 women who delivered babies in Jerusalem in 1974-76. Of those, 567 women used fertility drugs. An increased risk of uterine cancer and a borderline increase in breast cancer were detected in the fertility medication users. No increase in ovarian cancer was seen. Increased risk of malignant melanoma (skin cancer) and non-Hodgkin's lymphoma (blood cancer) was also seen.

Reshef's take: A poorly constructed study that will have 15 minutes of fame, scare millions of current and former infertility patients, and fade into oblivion. I have no special interest in defending clomiphene. I use it frequently but only for a short course (usually less than 6 cycles) and mostly in patients who do not ovulate. One should not panic when a study comparing cancer rates in clomiphene users with the general population has unfavorable results. It is simply an invalid comparison. It is a well-known medical fact that patients who do not ovulate (usually overweight patients with polycystic ovary syndrome, PCOS) have an increase risk of uterine and breast cancer, whether treated or not. Such patients must be followed closely throughout their lifetime, whether they were treated for infertility or not. If you are a current or past infertility patient with concerns after hearing about this study, please contact your doctor to discuss it or simply e-mail me a note.

NOVEMBER 2008 NEWS

Bennett Fertility Institute (BFI) 2007 IVF Success Statistics

In several months, the Society of Assisted Reproductive Technology (SART) will publish IVF statistics for 2007 from clinics in the U.S. Each year, IVF clinics are obligated to report their results to either SART or to the Centers for Disease Control (CDC). The majority of IVF programs report to SART. The deadline for submission of 2007 statistics is December 2008.

Bennett Fertility Institute's 2007 statistics are now available for our patients. They are briefly summarized below:

The live birth per IVF retrieval procedure for women under age 35 in 2007 was 60.1%. For women ages 35-37, it was 57.9%. For women ages 38-40, it was 21.7%. For women ages 41-42, it was 33.3%. Nationwide for 2006, the corresponding rates were 42%, 34.6%, 24.1%, and 13.2%. We do not yet have the national 2007 statistics but they have varied little from year to year in the past several years. Our twin pregnancy rate for women under age 35 was 34.4%, and triplet rate for that group 1%. In egg donation, our livebirth per procedure was 60% in 2007.

For comparison, in 2006, the national livebirth per retrieval, all ages combined, was 34% compared with 52% at BFI. That rate was 55% for 2007 at BFI.

Statistics may be helpful or misleading. Pregnancy rates in IVF must be interpreted with caution. Patients who seek IVF treatment should ask about live births per procedure, not clinical pregnancy rate or positive pregnancy test rate. The infertile couple is interested in the probability of having a child, not a positive pregnancy test. In addition, comparisons between programs may not be valid due to different patient mix, different selection criteria for IVF, the number of embryos transferred in each program, and other variables. We publish our statistics here and with SART to give our patients (current and future) a frame of reference as to our own performance from year to year and to instill confidence in those seeking treatment with us (an expensive and emotionally draining as it is) that we are a good program. As a patient, these statistics are and will be available for scrutiny but you must always ask yourself and your doctor: "what are my chances of conceiving successfully at my age in a particular program?"

So what should an infertile couple who seeks IVF treatment look at when reading SART statistics (www.SART.org)? Make sure that you look at the appropriate age bracket for the female partner. Make sure that the multiple birth risk (mainly twins and triplets) is acceptable to you. Look also at the cancellation rate for the appropriate age bracket. Some programs are very selective about who is allowed to qualify and complete the procedure. High cancellation rate (compared to the national average) may imply a very selective program that only allows good prognosis patients to proceed with retrieval and transfer after initiating the cycle. Look at the number of embryos transferred per procedure- a low number of embryos per transfer in a program with good live birth rates imply high implantation rates and a good IVF laboratory. Most importantly, ask questions!

OCTOBER 2008 NEWS

The Impact of Male Obesity on Infertility

(Hammoud AO, et al, Fertility Sterility, October 2008)

This is a critical review of the current literature linking male obesity to infertility. While the negative impact of male obesity on fertility has been known for 2000 years, the recent obesity epidemic has increased our awareness that obesity in males is associated with impaired semen and with sexual dysfunction. Male obesity decreases testosterone and increases estrogen, both of which have negative impact on the frequency of intercourse and on sperm performance. Erectile dysfunction (ED) is more common in obese males. There is scientific evidence that weight reduction can correct the hormonal imbalance and improve fertility. It is also well known that female obesity reduces fertility. When these male and female factors are combined, the reduction in fertility may be even more pronounced.

Soy-Rich Foods are Associated with Lower Sperm Count
("Men- easy on the tofu?")

(Chavarro JE et al, Human Reproduction, November 2008)

High intake of isoflavones (plant-derived estrogens) found in soy-based foods, is associated with lower sperm count but did not affect sperm motility or morphology.

Reshef's take: While we must view such observational studies with caution, the health food craze must be moderated by a balanced diet. Male obesity and high isoflavone intake, both of which increase exposure of males to estrogen, may be associated with reduced sperm performance and reduced fertility. Until better studies are performed, go easy on the tofu, men, and get slim!

Female Obesity and Cancer
(What you don't know CAN hurt you!)

(Soliman, PT et al, Obstetrics and Gynecology, October 2008)

A survey of 1545 women in Houston showed that there is limited knowledge that obesity is associated with an increase in cancer incidence, especially cancer of the uterus, breast, and colon.

Reshef's take: As health care professionals, we must do a better job at educating our patients about the connection between obesity and certain cancers. While cardiovascular disease is a well-known consequence of obesity, the fear of cancer may be a far greater motivator for women to lose weight.

SEPTEMBER 2008 NEWS

DEADLY MEDICINE AND THE GRAY LINE

Eli Reshef MD

What do Jorge Berges, Karl Brandt, Radovan Karadzic, Shiro Ishii, and Bilal Abdullah have in common? Upon graduation from medical school, they all probably recited the Hippocratic oath, or some version thereof, then proceeded to mastermind or participate in some of the most horrid atrocities or terror acts in human history.

Jorge Berges was an Argentinean physician who tortured and abused pregnant women and was selling babies during Argentina’s infamous “dirty war” in the 1970’s. Karl Brandt was Hitler’s personal physician, who, as the Reich’s Commissioner for Health and Hygiene, personally participated in “high altitude” experiments in Dachau that maimed and killed scores of prisoners. Radovan Karadzic, a psychiatrist, was recently caught and charged with genocide and crimes against humanity for masterminding the slaughter of 8000 Bosnian Muslims in Srebrenica in 1995. Shiro Ichii, MD, PhD, was in charge of unspeakable horrors against Chinese prisoners in Area 731 in Japan in World War II, subjecting them to chemical warfare agents. Bilal Abdullah, an Iraqi physician, was one of two doctors implicated in failed terror attacks in London and Glasgow in 2007.

It is tempting to dismiss these cases as an anomaly reserved for psychopaths or sociopaths, a rare perversion of our profession’s hallowed mission of healing. Unfortunately, not only will each generation create its own medical monsters, but also the boundaries of medical ethics will repeatedly blur with transgressions of commission and omission. The thick gray line between the ethical and unethical contains multiple instances in which we, as stewards of health, may be uncertain as to how to act if we were in a medico-ethical quandary, or even become unsuspecting participants in violations of medical ethics. In retrospect, the Tuskegee syphilis study (1932-1972) was an egregious violation of current ethical standards. In this infamous study, poor and mostly illiterate African-American sharecroppers were studied, without informed consent, to observe the natural progression of the disease without treatment. When the study started, penicillin was not available and treatments for syphilis were very toxic. The treatment, one may have argued, was worse than the disease. Yet when penicillin became widely available, the study was not halted.

In 2004, the New England Journal of Medicine published an article by Dr. Robert Lifton from the Department of Psychiatry at Harvard about complicity of American medical doctors in torture of prisoners in Abu Ghraib, Iraq. “Medical personnel have failed to report to higher authorities wounds that were clearly caused by torture and that they have neglected to take steps to interrupt this torture. In addition, they have turned over prisoners' medical records to interrogators who could use them to exploit the prisoners' weaknesses or vulnerabilities.” To most of us, the breach of medical ethical standards here is obvious, and goes beyond the political arguments surrounding the conflict in Iraq. Unfortunately, to some of us, physician complicity with torture may seem as a necessary evil to accomplish political or military goals.

In a September Op-Ed in the Oklahoman, I mentioned two gynecologists who joined a high-ranking clergy in publicly burning condoms in Kenya in 1996 to protest the immorality of sex before marriage and the sexual promiscuity that they allegedly promote. It was well known at the time that condoms reduce the incidence of HIV/AIDS, which then and now is responsible for momentous suffering and mortality in Africa. This is a blatant case of sacrifice of fiduciary obligations to health and healing for the sake of faith and spirituality. The thick gray line also contains instances in which doctors publicly advocate against the use of any contraception, in the spirit of a certain religious agenda that clearly ignores the benefits to society from reduction of unplanned pregnancies (and with it the reduction of abortions) and sexually transmitted diseases.

From March 30^th to July 5^th, 2009, a traveling exhibit from the United States Holocaust Memorial Museum (USHMM) called “Deadly Medicine: Creating the Master Race” will be displayed at the Science Museum Oklahoma in Oklahoma City. In its introduction to the exhibit, the USHMM writes: “From 1933 to 1945, Nazi Germany carried out a campaign to “cleanse” German society of individuals viewed as biological threats to the nation’s “health.” Enlisting the help of physicians and medically trained geneticists, psychiatrists, and anthropologists, the Nazis developed racial health policies that began with the mass sterilization of “genetically diseased” persons and ended with the near annihilation of European Jewry.” This unique exhibit must not be missed by members of our profession in Oklahoma. We must constantly remind ourselves that medical atrocities occurred, and are still occurring. We must not dismiss them as oddities or occasional idiosyncrasies, but as extreme examples in a continuum of medico-ethical breaches, some egregious, some so subtle as to draw even well meaning and compassionate health care professionals to their midst.

(Submitted for publication in a regional medical journal)

SELF-RIGHTEOUSNESS MAY BE HARMFUL TO YOUR HEALTH

Eli Reshef MD

In September 1996, Cardinal Maurice Otunga of Nairobi, the highest-ranking Catholic bishop in Kenya, and two gynecologists prayed and sang before setting fire to several boxes of condoms and pamphlets promoting condom use to fight the spread of AIDS. Meanwhile, millions in Africa were dying of AIDS. And while Alaska Governor Sarah Palin, the new political luminary, was staunchly expounding on the merits of abstinence-only education, her 17-year-old daughter Bristol became pregnant outside wedlock.

I like Sarah Palin for the same reason people like Obama- fresh face, youthful exuberance, clarity of vision, hope… Regardless of our political predisposition, many of us will embrace change if it brings hope, or hope if it brings change. But nobody, not even a well-meaning clergy or a vice-presidential candidate, can excuse or justify ignorance. Ignorance in Africa leads to death. In the U.S., it leads to unintended pregnancies, sexually-transmitted diseases (STD’s), and dashed hopes. The Palin family will deal with the crisis appropriately, no doubt. But let’s remind ourselves, Palins included, that in the words of Ben Franklin, “an ounce of prevention is worth a pound of cure.”

As a physician and educator, I teach seventh and eighth-graders about STDs and contraception. You may call my lectures “explicit” since I graphically describe STDs and their consequences and how contraceptive methods work. Explicit or not, if a single young individual is spared embarrassment, pain, unintended pregnancy, or death by listening to me, I have fulfilled my duty. I also always emphasize to my students that the most effective method to prevent pregnancy and STD is abstinence.

When asked in 2006 about supporting funding for abstinence-until-marriage education instead of explicit sex-education programs, Sarah Palin replied: “Yes, the explicit sex-ed programs will not find my support…Parents should have the ultimate control over what their children are taught.” Really, Sarah? Most parents do not even have a clue that nearly half of all 15-19-year-olds in the United States have had sex at least once, and that abstinence-only programs have failed miserably in reducing sexual activity, teenage pregnancy, or STDs.

Regrettably, it is not only in Africa but also here in our fair state and our enlightened country that so-called “health care professionals” place their spiritual agenda ahead of their patients’ welfare. And while they don’t burn condoms in Alaska, their teenage pregnancy rate was worse than 22 other states. The good news is that in the past 10 years, teenage pregnancy rate has declined. Abstinence-only advocates will immediately attribute this to their government-supported agenda, clearly ignoring scientific studies that indicate otherwise.

As the general elections approach, rhetoric will temporarily prevail over common sense. But when the dust settles after the campaigning hurricane, well after the placards and signs are stowed in the trash, public welfare should be the first to benefit from the new political reality. And while we roll our eyes to the old cliché of “Practice what you preach,” it is a principle that should supercede self-righteousness and any spiritual or political agenda.

(Published in the Daily Oklahoman, Sunday September 7, 2008)

(To read a response to my Op-Ed, Published September 14, 2008, link to http://newsok.com/abstinence-is-best-practices/article/3297044)

AUGUST 2008 NEWS

New Ovarian Cancer Test- Is it Ready for Prime Time?

(Andrew Pollack, New York Times, August 26, 2008)

Ovarian cancer detection is very elusive. While early ovarian cancer confined to the ovaries has a high survival rate after treatment (90% in 5 years), most ovarian cancers are detected when the disease has already spread beyond the ovaries, with survival rate of only 30% in 5 years. Each year, more than 15,000 American women will die of the disease, with over 21,000 new cases diagnosed per year. LabCorp, one of the nation's largest laboratory companies, is now marketing Ovasure, a test for detection of ovarian cancer developed at Yale University. LabCorp claims a high degree of accuracy for detection of this deadly cancer. The test, however, has not been approved by the Food and Drug Administration (FDA) and even the Society of Gynecologic Oncologist, the premier organization of female cancer doctors, has stated that the test has not yet been validated or adequately tested. Many cancer experts claim that marketing the test is premature.

So what is a concerned patient to do? The cost of the test is approximately $230. Many patients will be willing to make a financial sacrifice and take the test. But what do you do with the results? Positive results can not be ignored but may not necessarily indicate cancer. They will then lead to greater anxiety and further actions, including unnecessary surgery. Negative results may lead to a false sense of security that there is no cancer, while ovarian cancer may be insidiously spreading anyway.

Bottom line: Wait for the verdict. As a physician, don't adopt this test yet for every patient concerned with ovarian cancer but be willing to test your high-risk patients, especially when they request it. These are patients with family history of ovarian cancer, as well as cancer of the uterus, colon, or breast. As a concerned patient, only do this test if you are willing to bear the consequences of false negative or false positive results. If you are a patient at high risk for ovarian cancer, make sure that your physician uses other methods to detect cancer such as the physical examination, mammograms or breast ultrasound or MRI, or pelvic ultrasound. Ask yourself:"will it help me sleep better at night if I have the test?" If you are unsure, consult with your physician.

The Billings Ovulation Method- Does it Work?

John Billings, an Australian physician who developed a natural contraception method endorsed by the Catholic church, died last year at age 89. At the request of the Catholic Marriage Guidance Bureau in Melbourne, he developed a method in the 1950's to predict ovulation by relying on cervical mucus self-assessment by women during the menstrual cycle. This method can be used to assist conception as well as to prevent it. Its main advantage is the avoidance of contraceptives in couples not wishing to conceive, and in avoidance of modern aids such as the ovulation predictor kit (OPK) or blood hormone levels or ultrasound to predict ovulation. How effective is the Billings Ovulation Method (BOM) in preventing undesired pregnancy? It depends on who you read. Most studies on BOM were performed by individuals or institutions with a vested interest in promoting it to certain populations with certain religious beliefs. According to the Australian Medical Association, the failure rate of BOM is 3 in 100 (3% of couples using it for contraception will get pregnant unintentionally in one year of use). According to the Centers for Disease Control (CDC), the failure rate is 1-25%. In comparison, the failure rate of the birth control pill is 1-8%, condoms 2-15%, IUD or tubal sterilization less than 1% (CDC data).

The success rate for BOM in assisting conception is difficult to assess. There are simply no reliable side-by-side, scientifically reliable studies comparing BOM to spontaneous conception rates and to conventional infertility treatments. As with the contraceptive efficacy of BOM, most studies on BOM as a method to promote conception were performed by people with vested interest in promoting the method for religious reasons. Most of those studies support the method as a viable option to assist conception. There is no evidence that BOM improves the chance of pregnancy over the natural human conception rate of 20-25% per month. This method, however, can assist couples not wishing to use standard modern methods to predict ovulation (such as OPK) in conceiving faster. The main problem with BOM is compliance. Checking one's own cervical mucus is not complicated but requires discipline and some observation skills. Even in study populations (who are more compliant than real life populations), only 88% will use BOM after 6 months and less than 50% will use it after 2 years. It is much like a diet plan, which in most cases will help its users lose weight but is very demanding in terms of cost and discipline and many people will abandon it after several months or years

Bottom line- does the Billings Ovulation Method work? as a method of pregnancy prevention (contraception), it works for some but requires self-discipline for compliance, which many of us do not have. In addition, it does not protect against sexually-transmitted diseases (STD's), which are devastating and often deadly (as in the case of HIV/AIDS), especially in third-world countries in which BOM is promoted. The irony is that STD's may not only kill or hurt but also lead to infertility, an unintended consequence of a the life-long work of a well-meaning scientist like John Billings. As a method to promote pregnancy, BOM is a good alternative to modern ovulation-detection methods for women with normal ovulation who have strong religious beliefs or those not wishing to use modern methods. BOM is not more effective than the OPK or other methods in promoting pregnancy. In certain situations, successful conception may be delayed if couples are taught that BOM or Natural Family Planning (NFP) are the only alternatives for conception. BOM does not work in couples with severe sperm problems, tubal disease (including blockage), severe endometriosis or scar tissue, or lack of ovulation. Most infertility problems are due to these factors.

Trick or Treatment

("Trick or Treatment" by Simon Singh and Edzard Ernst MD. Reviewed by Scott Gottlieb,Wall Street Journal, August 19, 2008)

This new book by an English expert on complementary (alternative) medicine is an eye-opener. Dr. Ernst and his group of serious medical researchers at the University of Exeter in England spent 15 years studying alternative medicine. In his book, he points to the ineffectiveness of some commonly-used alternative treatments and to the actual dangers associated with some of them. An epidemic of liver damage among Chinese immigrants in New York led to the discovery of potential life-threatening dangers of some popular Chinese herbs, including Aristocholia Fangchi and Licorice. Ginseng has been shown to be ineffective in treating or curing any medical conditions. Shiatsu massage is a "waste of efforts and expense". Chelation therapy is "disproven, expensive, and dangerous". Patient safety may be compromised by chiropracters whose neck manipulation may cause strokes. Homeopathic medicine is not only ineffective but may be outright dangerous by leading to delay in initiating true medical treatment. Dr. Ernst calls homeopathy "the worst therapy encountered so far- it is an implausible therapy that has failed to prove itself after two centuries and some 200 clinical studies". The book also discusses practitioner-patient relationship. Some alternative-medicine practitioners may accomplish great success in enhancing the placebo effect of their treatment by developing close rapport with their patients. Conversely, some conventional doctors may engender frustration among their patients by creating poor rapport, thereby driving these patients to seek alternative medicine.

JULY 2008 NEWS

8-Year-Olds on Statins?

(New York Times, July 8, 2008)

Cholesterol drugs for 8-year-0lds? The America Academy of Pediatrics (AAP) recently issued aggressive new recommendation to use cholesterol-lowering drugs in some children to prevent heart disease. It applies to children as young as 8 with high "bad cholesterol" (LDL), positive family history of heart disease, and/or diabetes. The AAP also recommended that children with family history of heart disease be screened as early as age 2 and no later than age 10 for cholesterol and other lipids.

Reshef's comments: This new recommendation ignited a firestorm of criticism by outraged health care professionals. Is there any evidence that such practice can prevent heart attacks? Not much. What about the side effects of cholesterol-lowering medications (statins) in children? Not much information about that either. Will parents and pediatricians resort to medications instead of diet and exercise? Very likely in our heavily-medicated society (see attention deficit disorders, ADD). Will it open the door for pharmaceutical companies to heavily advertise the use of statins in young children without evidence of long-term effectiveness and safety? Probably. While childhood obesity has reached epidemic proportions in our society, resulting in an increase in childhood diabetes, the incidence of heart attack has actually decreased in adults. For now, let's concentrate on aggressive education regarding diet and exercise rather than on medicating young America. Let's do no harm first, before we harm our kids!

Herbal products tied to high lead blood levels

(Buettner, C. Annual Meeting of the Society of General Internal Medicine, 2008)

In a study of 12,807 women of child-bearing age, herbal supplements such as some preparations of echinacea, ginkgo, ginseng, and St. John's wort often contained excess lead. Cases of lead toxicity were reported with these supplements.

Reshef's comments: Since the health benefits of these supplements are largely unproven, they may cause more harm than good, especially in pregnant women. Lead poisoning may lead to serious adverse effects on the fetus and serious illness in adults. Ayurvedic medicine and traditional Chinese medicine use herbal supplements. Such supplements are very popular among patients, who do not always disclose their use to their physicians. A patient of mine had to be admitted to a hospital in another state for severe bleeding requiring blood transfusions. Only after a careful and persistent inquiry by a medical resident did she disclose the use of several herbs, all of which prevented blood from clotting. While the herbs in your local health food store may seem enticing and harmless, especially if your own physician may not help you much with your problem, you must be aware of their potential for harm. One of them, Aristocholia Fangchi, may actually cause severe kidney damage. Herbal supplements are poorly regulated and their dose is often inconsistent. They are often not tested for heavy metal contamination and other hazardous "hitch-hikers". Moreover, your physician, even a very good one, and even your pharmacist, may not know what your supplement contains, since it may arrive unaltered from another country. Most of us are quite careful about washing fruit and checking the expiration date on milk, but let down our guard when it comes to alternative supplements. Please weigh the cost and benefit before biting into the unknown!

What next for pre-implantation genetic screening (PGS)?

(Jansen RPS et al, Human Reproduction, July 2008)

This was a randomized clinical trial of blastocyst (day 5 embryo) biopsy from Australia. The authors attempted to determine the health of the embryo by testing for common chromosomes. The trial was terminated early because of inability to show any advantage for PGS.

Reshef's comments: Here is another example of a promising technique (PGS), in which a cell from the embryo is analyzed for chromosomes and only "healthy" embryos (with normal chromosomes) are subsequently transferred into the uterus in IVF. Yet this technique in this particular study did not result in any benefit in terms of improving pregnancy rates or reducing miscarriages. Why? Testing an embryo at an advanced stage (approximately 128 cells) by analyzing one or two cells may not account for mosaicism, a common phenomenon in which cells are actually different from one another and testing one may not reflect on the health of the entire embryo. In addition, the actual technique of PGS may decrease the ability of the embryo to implant. So what now? Let's proceed with caution. PGS is a very promising technique but let's not rush and apply it or adopt it wholeheartedly until well-designed studies show a definite benefit (like the electric car- exciting concept that is not yet practical...)

IVF/ICSI outcome in women operated on for bilateral endometriomas

(Somigliana E et al, Human Reproduction, July 2008)

Women who had surgery for ovarian endometriomas (endometriosis cysts) were compared to women who had not had ovarian surgery in terms of IVF/ICSI results. IVF/ICSI outcome was significantly impaired in women operated on for bilateral endometriomas.

Reshef's comments: This study indicates that women with bilateral endometriomas have reduced success in IVF/ICSI either because of their severe endometriosis, affecting both ovaries, or because of the surgery to remove endometriomas. In analyzing our own IVF data, we found that patients with severe endometriosis do not exhibit lower pregnancy rates in IVF/ICSI. I suspect, then, that aggressive ovarian surgery may be the culprit. It is well known that ovarian surgery may reduce ovarian responsiveness to fertility medications in IVF. It is advisable to defer aggressive ovarian surgery for endometriosis if the patient is relatively asymptomatic and her main concern is to conceive. In the case of ovarian endometriomas, it may be preferable to treat the patient with Depo-Lupron, then do IVF without major ovarian surgery.

Success rates and cost of IVF in women aged 45 and older

(Sullivan E et al, Human Reproduction, July 2008)

This is a study from Australia of 2339 IVF cycles on women aged 45 or older. The live birth rate was 0.5% per cycle. The average cost of a live birth was $753,107 (Australian).

Reshef's comments: Is it worthwhile to do IVF in women 45 or older? Is it worthwhile to climb Mount Everest? In our IVF program, in existence for 23 years, we have not seen a single viable pregnancy after age 44 when using the patients' own eggs. We therefore highly discourage IVF (except egg donation) at that age. Patients often are misled by the media, which depicts celebrities who conceive at an older age. What is often painfully missing there is information on how they conceived. Many of those used alternate forms of conception, including third-party reproductive procedures such as egg or embryo donation. Sort of "I made it to the top of Everest- I flew in an airplane..." Women who consider using their own eggs in assisted reproduction over age 40 should consider 3 tall barriers: the "getting pregnant" one, the "staying pregnant", and the "having a healthy baby" one. Most people at that age do not get pregnant regardless of technology. Most that do get pregnant will miscarry (nature's way of saying: "this pregnancy was not meant to survive to begin with"). The few that will not miscarry still have a high chance of having a child with chromosomal abnormalities. Is it worthwhile? I leave it to the patient's discretion. Most people will make the right decision for themselves, even the very few that will decide to climb Everest...

JUNE 2008 NEWS

China

In April 2008, I visited China for the first time. I was invited to lecture at Lanzhou University by Dr. Zhang Xuehong, a reproductive specialist and the director of the in-vitro fertilization program at Lanzhou University First Hospital. Dr. Zhang was a guest at my private practice as well as at the Bennett Fertility Institute for 6 months last year. She graciously invited me to give 3 lectures to physicians and medical students at her university in Lanzhou, the largest city in the province of Gansu in northwest China. When I was a child, legend had it that if you dig a hole through the earth, you will end up in China. During this trip, I learned from my Chinese colleagues that they were told the same story in reverse when they were growing up... This story underscores the similarities between us, which, I discovered, readily overwhelm our differences. China, a mystery to me before, unfolded elegantly during the trip to reveal a wealth of past and a promising future. It was, in a word, enchanting. The secret in visiting China is to seek the positives rather than dwell on negative stereotypes that haunt all of us when devoid of adequate information. China clearly has its demons: pollution, crowding, human right issues. Nevertheless, China appears to improve its economical and political status with such vigor that it has made staggering progress after almost a century of stagnation. My Chinese friends in the cities of Lanzhou and Chonqing provided unbelievable hospitality that left me speechless at times. Elsewhere, my interactions with the Chinese were very cordial and pleasant. I hope that the Chinese, in their quest to emulate the West in some areas, do not lose their kindness and patience when interacting with foreigners. I was most impressed with their tolerance and discipline, stemming, I presume, from generations of authoritarian regimes and respect for ancestors and elders.

China has a mix of traditional and Western medicine. Traditional Chinese medicine (TCM) combines herbal medications, acupuncture, and other non-Western practices that evolved over almost 5000 years. I had the opportunity to visit a village clinic and a township hospital in Lintao County of Gansu Province. In their pharmacies, alongside antibiotics and aspirin, there were drawers of herbs designed to cure various ailments. Do they work? An integral part of medical treatment and its success is trust in its efficacy. Without the patient believing that a certain treatment is effective, a treatment is doomed to fail. A great example is the efficacy of Chinese herbs on hot flashes. It is much greater in Chinese women than in Western women, in part because the Chinese have greater belief and trust and less skepticism about their efficacy. TCM works quite well in China, whether by true or placebo effect. After all, regardless of the underlying cause, it is hard to argue with success. What china is lacking in technology and education, it makes up with an impressive thirst for knowledge. The Chinese are devouring medical knowledge at a rate similar to the increase in the number of cars on the road and new construction. From my observation, it appears that they are indeed capable of catching up with the West in a decade or so. While some of us view China's progress with suspicion or even as a threat, I see it as a blessing. With more than 4 Chinese for every American, China has the kind of population capable of producing great basic scientists, and patient population that can generate a treasure trove of clinical studies. In the West, we are great producers of scientific knowledge. The Chinese are currently hungry consumers for such assets. Collaboration and reciprocation, as I was fortunate enough to be part of, are essential for all of us, East or West.

Accepting China as a partner does not mean accepting its shortcomings. When it comes to human rights, we have obvious disagreements. Nevertheless, just as the Chinese are acquiring Western knowledge, their awareness of the importance of human rights is increasing. While China is awash with environmental woes, it has an emerging Green movements that is often supported by the government. China is trying to reconcile its drive for progress with the resulting damage to its environment. This is an incredibly daunting task, but trying hard they do. Will Beijing clean up its act before 08/08/08? Time will tell. Will China make meaningful strides in human rights and environmental issues? I am optimistic that they will after witnessing their resolve first-hand.

Contrary to Western perception, China does not have socialized medicine. In fact, most Chinese, including those in major metropolitan areas, do not carry medical insurance. Such insurance is a luxury reserved for the wealthy or for those fortunate enough to work for major corporations. Consequently, most people see physicians only with significant health issues. Preventive medical and dental care, therefore, is severely lacking in China. Interestingly and ironically, basic health care is sometimes more available to people in the country than those in the city. In Lintao County, for example, for only 10 RMB per year (less than $2), one can participate in heath care programs where the local government contributes additional money so low cost, basic health care can be administered. Vaginal delivery, for example, is almost fully subsidized but the patient has to pay extra for a c-section.

One of the smartest things I did before and during my trip was to study Chinese history. Knowledge of basic history in a country so proud of its rich heritage opens hearts and doors. My hosts viewed it as a compliment that their guest was adequately proficient in the knowledge of their dynasties and historical milestones. They obviously interpreted (correctly) my natural curiousity as a sign of respect. I even struggled with a bit of Mandarin which also helped break the ice on several occasions. I avoided the common error of Americans to become too contrivingly Chinese or exhibit our typical exuberant Western confidence that is often misinterpreted as arrogance. Consequently, I had an immensely positive experience in that formerly strange land. And I did not have to dig a hole in the ground to get there and find that, despite obvious cultural differences, our goals and hopes are very similar...

Dr. Reshef and his wife Edie at Xindian Township Hospital in Lintao County, Gansu Province, China. Mr. Fan, Director of Lintao County Health Bureau, is holding scales for weighing medicinal herbs, an integral part of Traditional Chinese Medicine (TCM).

JANUARY 2008 NEWS

The Politics of Adoption

(National Geographic, January 2008)

The U.S. adopts the largest number of children in the world (approx. 20,000 per year). This year, the U.S. will join the Hague Convention on Intercountry Adoption, designed to ban child buying. This could present a problem for Guatemala, a major source of adopted children for the U.S., which has been accused of child trafficking. Overall, the number of adopted children has been declining, reaching a peak of 23,000 in 2004. Countries like China, Russia, and South Korea have been tightening their policies and are making adoptions less available.

Reshef's comments:

A sizable number of my patients are choosing the international adoption route. Interestingly, while one may expect greater cost and hassle with such adoptions, many have had positive experiences, especially with China. In my practice, several patients serve as a resource for other patients who are just starting to explore this option. They provide valuable information and shorten the search for resources, an often daunting task for beginners (just try to Google "Adoption"...) Unfortunately, the situation with adoptions and availability of children changes constantly. A couple seeking adoption must be familiar with this change, as this National Geographic article implies.

Role of Professional Organizations in Regulating Physician Expert Witness Testimony

(Journal of American Medical Association, December 26, 2007)

In medical malpractice litigations, physicians often serve as expert witnesses for either the plaintiff or defendant. The role of the physician as an expert witness has been controversial, since not infrequently there is testimony that is not well grounded in prevailing clinical standards or science. Studies of physician expert witnesses have shown that those who testify for the plaintiff are older than those who testify for the defendant, have less publications in the medical literature, and are less likely to have board certification. A relatively small number of physicians, especially plaintiff experts, do most of the testimony in malpractice cases. The authors, from Harvard and University of Melboune, recommend regulation of physician expert witnesses to ensure that they accurately present specialty knowledge and practice. A legally trained panel members with no direct ties to medical or legal professional organizations may be best suited to supervise expert witnesses. Such panel should be part of a state government or state medical licensure boards, with power to regulate and discipline expert witnesses.

Reshef's comments:

There is a very handsome financial reward by serving as a physician expert witness. Not infrequently, physicians who serve as expert witnesses, especially for plaintiffs, can scale down or quit their clinical practice and solely rely on income from legal testimony. It is not uncommon for older physicians to do so. It is not uncommon for physicians who either do not have subspecialty training or have not kept up with the current standards of care to serve as expert witnesses. Currently, regulation of expert witnesses is severely deficient. One of the concerns for professional medical organizations assuming a regulatory role on expert witnesses is the real or perceived bias against such physicians, as well as the inability to punish "stray" witnesses. A body such as a state medical licensure board may possess the ability to discipline, as well as the credibility and legal knowledge that is required to control this unregulated medicolegal "Wild West".

Treatment of self-diagnosed vaginal yeast infections

(Bachman et al, The Female Patient, December 2007)

This study shows that, contrary to previous studies, women that self-diagnose vaginal yeast infections and use over-the-counter (OTC) treatments experience a high degree of symptom relief and satisfaction.

Reshef's comments:

The accepted view in gynecology regarding one of the most common diseases of women, vaginal yeast infections, is that self-diagnosis by the patient is often inaccurate and that the patient should seek the advice of her physician when symptoms of vaginal itching and irritation occur. This requires a phone call or an office visit, often a costly inconvenience. This study contradicts the conventional wisdom that physician intervention is necessary. While vaginal irritation or itching is often not due to a yeast infection, OTC treatment should be attempted by the patient. If the symptoms persist or recur, or accompanied by vaginal lesions, however, medical advice is necessary.

Pseudoephedrine sale restrictions and methamphetamine use- a premature celebration?

(Brandenburg et al, Oklahoma State Medical Association journal, November 2007)

In 2004, the State of Oklahoma became the first to restrict the sales of pseudoephedrine, a common ingredient in cold medicines and also a basic ingredient in the manufacture of the illicit drug methamphetamine (METH). Subsequently, Oklahoma experienced significant decline in home METH labs. this study tested the assumption that this reduction in home METH manufacturing resulted in a decrease in METH use as well. Emergency room patients were urine tested for amphetamines at a large medical center in Tulsa. The results show that the percent of urine tested positive for METH actually increased in the years following pseudoephedrine sales restriction.

Reshef's comments:
I chose this study as an example of a well-intended legal action designed to protect the health and welfare of society that actually resulted in the opposite effect. If you try to solve illicit drug use and distribution, addressing only one issue (manufacturing of METH) may not only fail to solve the problem of drug use, but may rapidly lead to alternative routes of distribution and use. While the problem of dangerous home METH labs in Oklahoma has been successfully addressed, resulting in loud sighs of relief and congratulatory back slapping among lawmakers and law enforcers, Oklahomans simply import METH from elsewhere. Another glaring example of a legal action with adverse medical consequences is the case of Theresa Hernandez, a METH addict who delivered a stillborn at 32 weeks. The Oklahoma County District Attorney brought first-degree murder charges against her for killing her own baby. She recently pleaded guilty to a lesser offense, a second-degree murder, and sentenced to 25 years in jail. While politicians and law enforcement agents feel that society was justly served by bringing a criminal to justice, pregnant women who use drugs may now avoid seeking prenatal care for fear of prosecution. The medical consequences of absent prenatal care, or failure to disclose drug use in pregnancy, are far more disasterous than the damage that METH causes to a baby. Ironically, very few scientific studies show any adverse effect on the baby by METH. Obesity, cigarettes, and alcohol cause far more damage to the baby in pregnancy. Should we criminalize them as well ?

Prenatal screening for chromosomal abnormalities- when and how to screen? Who should be offered amniocentesis?

(American college of Obstetrics and gynecology Practice Bulletins #77, January 2007, #88 December 2007)

Here are some of the new recommendations for screening pregnant women for chromosomal abnormalities:

1. First-trimester (up to 13 weeks of pregnancy) screening with ultrasound (looking for neck skin thickness) and specific blood tests is an effective screening for Down syndrome in the general population (these should be offered to every pregnant woman before 20 weeks of pregnancy, not just to those over age 35)

2. If the above screening is positive, women should be offered genetic counseling and second-trimester amniocentesis or first-trimester CVS (both are invasive tests). Amniocentesis after 15 weeks is safe. It should not be performed before 15 weeks because of the risk of pregnancy loss. CVS is safe only if performed by experienced physicians.

3. Screening in the first and second-trimester ("integrated screening") is more sensitive than first-trimester screening alone.

4. Invasive tests for chromosomal abnormalities (amniocentesis, CVS) should be available to all women, regardless of age.

5. Patients with increased risk for a baby with chromosomal abnormalities include women with a previous baby with chromosomal abnormalities; a fetus with birth defects seen by ultrasound; or a parent with chromosomal abnormalities.

Reshef's comments:

The decision to screen or not to screen a fetus in early pregnancy should be earnestly discussed with your physician. Screening does not imply that if an abnormality is detected, pregnancy termination must be considered. Some parents would like to learn about abnormalities early, so they can be physically and emotionally prepared for the outcome, or at least obtain reassurance of normality. If pregnancy termination is not an option for the couple, screening is questionable but should still be offered. The above recommendations are a departure from previous ones in that screening is now offered for every pregnant woman rather than just for older ones.

Bottom line? Make sure that your physician is aware of these new recommendations, and that screening (especially high-resolution ultrasound) and invasive tests are performed by an experienced physician.

NOVEMBER 2007 NEWS

Should we use pre-implantation screening (PGS) in IVF?
(Munne s., et al. Substandard application of PGS may interfere with its clinical success. Fertil Steril 88(4):781, October 2007)

A recent article in the New England Journal of Medicine by Masterbroek et al. from the Netherlands suggested that pre-implantation genetic screening (PGS) actually reduces pregnancy rates in IVF and should therefore be re-evaluated as a viable technique. Munne et al., in their rebuttal article, point out that poor methodology is responsible for the reduction in pregnancy rates in Masterbroek’s study. They suggest that in inexperienced hands, PGS can be detrimental.

Reshef’s comments:
Hysteria exists also in medicine, not only in Hollywood. The physician is typically bombarded with mountains of conflicting scientific information from which he must conclude what first may not harm his patients, and what then constitutes good medical advice. Since the indications for PGS have not yet been fully established, it is tempting to dismiss PGS as a viable technique to diagnose problems in the embryo prior to its transfer into the uterus based on the alarming results of the Masterbroek study. While PGS has not yet shown to improve pregnancy rates in IVF, it may decrease miscarriage rates in habitual aborters. Munne’s article emphasizes the need to critically look at the utility of PGS but avoid hasty conclusions about this promising technique based on one questionable study. Let cool heads prevail!

Limiting access to letrozole- is it justified?
(Tulandi and DeCherney, Fertl Steril 88(4):779, October 2007)

In this opinion article, the authors assert that letrozole (aka Femara) is an effective drug for ovulation induction and limiting access of patients to it is a disservice.

Reshef’s comments:
Another example of unwarranted medical hysteria. In November 2005, an abstract (short summary) of an unpublished small study was presented at our national meeting that showed an increase in birth defects in patients using letrozole as a fertility medication. The media, patients, and doctors were abuzz. The maker of letrozole immediately issued a warning for doctors to use letrozole only for its FDA-approve indication, the treatment of breast cancer. Letrozole has been studied extensively, primarily in Canada. It has been used off-label (without FDA approval) by many fertility specialists in the U.S. instead of clomiphene, the older standard. It has less side effects and adverse effects and better pregnancy rates than clomiphene. Larger studies, much better constructed, showed no ill effect of letrozole on the rate of birth defects but the damage was already done. I agree with Drs. Tulandi and DeCherney. Letrozole should be used for ovulation induction. The makers of this drug should be more concerned with their patients’ welfare than with legal risks based on a poorly constructed, unpublished study.

Colorectal cancer screening for women over 50
(Ob Gyn, 110(5): 1199, November 2007)

A committee opinion paper was just published by the American College of Obstetricians and Gynecologists (ACOG) regarding colon cancer screening. In women over 50 with average risk for such cancer, the preferred method is a colonoscopy every 10 years. Other appropriate methods include annual test for blood in the stool. This test requires 2 or 3 stool samples collected by the patient at home and returned to her physician for analysis. A single stool samples obtained during rectal examination at the physician’s office is not adequate for the detection of colon cancer.

Reshef’s comments:
While collecting a stool sample at home sounds repulsive and colonoscopy a pain, neither is actually a hassle. Please make sure that your physician is up-to-date on these new recommendations. The digital rectal examination is still recommended during the female examination, especially in women over 50 or those who are younger but with special risk factors or complaints.

Should I get a flu vaccine in pregnancy?

Yes. The flu shot (not the nasal spray) is recommended for pregnant women. Getting the flu in pregnancy is far worse than getting the vaccine. Influenza (the flu) kills 36,000 Americans a year. GET THE FLU SHOT! (www.cdc.gov)