General Practitioners

• Arthritis
• Cryotherapy
  Endometriosis is a condition where endometrial cells (see glossary) are found outside of the uterine cavity. Retrograde menstruation (menstruating backwards out the tubes) is common in most women, but excessive dumping of menstrual debris into the pelvis, over time, may predispose to endometriosis. Women at risk for endometriosis are those with frequent or heavy menses, women with cervical stenosis (narrowing opening of the cervix), or women with congenital problems that makes it more difficult to get blood out of the uterus at the time of menstrual bleeding. Other causes are genetic, and in many cases we just don’t know the cause.  Perhaps performing operations on the cervix for abnormal pap smears (leeps, cold knife cones, cryotherapy) could contribute to cervical stenosis. A vaginal delivery, on the other hand, may open the cervix up and make it more likely for menstrual blood to leave the uterus and not come back. If this is true, it might account for our informal observations that the C-section is just not as good as vaginal delivery.
• Medical Weight Loss
  Which comes first, androgens or insulin? If you give insulin to a woman with PCOS the androgens go up. Administration of glucose makes both insulin and androgen levels rise. Weight loss will decrease androgens and insulin, and experimental reduction of insulin will lower androgen levels. Correction of androgen levels does not correct the high insulin levels. So it appears that hyperinsulinemia is the primary cause of PCOS in many women.
• Primary Care
  I saw an infertile couple today and the wife was mentioning the symptoms of stress she was having and also wondered if she was depressed.  If she is depressed, she is not alone. Depression is a frequent, unwelcomed guest in the lives of infertile couples. Major depressive disorders (MDD) and associated conditions such as anxiety are common in women with infertility and are often not adequately addressed by the primary care providers.  Depression is not well understood, nor is it known how infertility causes depression, but logically there are complex psycho-dynamics at play that might contribute to the onset and maintenance of MDD (1).
• Smoking Cessation
  The implications of this consensus statement are clear. Doctors treating PCOS women will need to carefully assess whether these risk factors exist in their PCOS patients. The risk for CVD may be present at a much younger age than other women without PCOS and these risk factors. Interventions including the use of insulin sensitizers, smoking cessation, anti-hypertensives, anti-obesity drugs, and statins will need to be considered along with diet and excercise modifications. For some bariatric surgery for weight loss may also be considered if other strategies fail.
• Erectile Dysfunction

Gynecologists

• Gynecology
  Bruce A. Lessey MD, PhD, is Medical Director of the Reproductive Endocrinology and Infertility Division of the Department of Obstetrics and Gynecology in Greenville, SC and Professor at the University of South Carolina School of Medicine. Dr. Lessey completed his doctoral in Zoology at Colorado State University in 1980 and his MD degree at the University of Colorado Health Sciences Center in 1984. He attended Duke University for his residency in Obstetrics and Gynecology and completed his fellowship training in Reproductive Endocrinology and Infertility at the University of Pennsylvania. Dr. Lessey was on the faculty at Penn but then joined the faculty at the University of North Carolina in 1993 where he became Professor of OBGYN and Adjunct Professor in the Departments of Pathology and Cell Biology. He was a member of the NIH U54 Specialized Centers Program in Reproduction and Infertility Research Grant. He is best known for his research on integrins and implantation and continues to study the effect of steroid hormones on the endometrium as head of the Fertility Center of the Carolinas, a practice of Greenville Hospital System.
• Female Infertility
• Obstetrics
  Paul B. Miller MD is the longest serving member of the Division of Reproductive Endocrinology and Infertility in Greenville, SC having started there in 1997 after finishing a fellowship at the University of Washington.  He currently is an associate clinical professor of Obstetrics and Gynecology at the University of South Carolina School of Medicine.  Before fellowship, Dr. Miller trained at some of America’s most prestigious research universities, including Johns Hopkins, where he received his Bachelor of Arts degree with honors, Columbia University College of Physicians and Surgeons, and Duke University Medical Center where he completed his Ob/Gyn residency. Dr. Miller utilizes his years of research and clinical expertise to aid women and couples in the treatment of endometriosis, hypothalamic dysfunction, infertility, and difficult hormone problems.  As the Director of In Vitro Fertilization, he has led his assisted reproductive technologies team to exceed the national average in pregnancy rates every year he has been in Greenville.
• Endometriosis
  We have perhaps the most experience with Femara for ovulation induction of anyone in the United States. Several years ago, I urged colleagues on the Reproductive Sciences Network to do the randomized control trial comparing Femara (Letrozole) with clomiphene citrate for the treatment of PCOS. This drug is an aromatase inhibitor made by Novartis for the treatment of breast cancer. It’s use for fertility and PCOS was  first introduced by Dr. Robert Casper from Toronto, Canada and we’ve been using it for the past 9 years in both PCOS and endometriosis patients. Femara suppresses the activity of the aromatase enzyme and thus blocks the production of estrogen by cells that express this enzyme. If a cancer or endometriosis expresses aromatase then the local production of estrogen can give that cell a strategic advantage, allowing it to grow without waiting for estrogen produced by the ovaries. In PCOS, there is a plethora of estrogen by local production in fat cells using the aromatase enzyme that converts circulating androgens to estrogen, leading to endometrial problems including hyperplasia. When we give Femara to PCOS women, we find a very high percentage will ovulate and most will also conceive (quickly). My current record is a woman with 15 years of infertility who achieved a pregnancy taking Femara. When I moved to Greenville, I had 20 patients within the first 6 months with PCOS that had failed clomiphene citrate (didn’t ovulate) and 80% ovulated and nearly that many conceived. In intrauterine insemination cycles we see higher success rates using Femara compared to clomiphene citrate and have started using it during IVF as well.
• Pelvic Pain
• Pregnancy
• Labor and Delivery
  In many ways the work up for secondary infertility is similar to that of primary infertility (see Infertility Workup 101).  In cases where couples have been successful before at establishing a pregnancy, we often ask “what has changed”?  Is the partner the same one from before?  Did the woman have surgery or illness since the last pregnancy? Did anything happen in childbirth that might have altered the woman’s fertility? Did the patient gain or lose weight?  If the first pregnancy occurred only after many months, there may have been a problem that is antecedent to the first pregnancy.

Internists

• Ovarian Cancer
  Other talks of the day included discussion of T-regulatory cells in endometriosis by Andrea Braundmeier, discussions of a mouse model of endometriosis and ovarian cancer by Steve Charnock-Jones, and a wonderful talk by Serdar Bulun from Northwestern University about the role of progesterone action and endometriosis.
• Cervical Cancer
  STDs: sexually transmitted disease such as chlamydia or gonorrhea that can cause fallopian tube damage or human papilloma virus (HPV) that can lead to cervical cancer
• Prostate Cancer
  4) Based on a study prospective Prostate Cancer Prevention trial, men were followed after age 55 and evaluated for ED and CVS. The relationship was so high that the authors concluded that developing ED was greater to equal to the effects of family history of MI, cigarette smoking, or hyperlipidemia.

Neurologists

• Autism
  In some cases, genetic testing is either redundant or simply not useful. For example, there is no reason to do genetic testing for type two diabetes when the fasting blood sugar is already abnormal and is a more useful marker. There is no reason to do genetic testing for famiial hypercholesterolemia when the routine lipid panel provides this information. Likewise, there is no reason to do genetic testing to determine eye color or hair color when a simple examination provides this obvious information. Very soon, the cost for routine whole human genome sequencing will become cheaper, and some day will be offered during routine clinical testing along with the CBC, blood count and chemistry panel. Many health issues have environmental causes with no clear genetic markers. Autism may ultimately fall in this category.

Psychiatrists

• Depression
• Mental Health
  The initial evaluation should be scheduled with Cynthia Whitaker at The Center for Women’s Medicine (864-455-1600). The initial evaluation session must be scheduled prior to the 10-week program. The discharge session will also be with Ms. Whitaker and will be scheduled at the end of the 10-week program. In most cases, if your insurance provides mental health coverage, the charges will only involve your co pay.
• Insomnia
• Anxiety

Endocrinologist

• Diabetes Care
• Endocrinology
  A new consensus statement on the risks of heart attack and stroke for women with PCOS, in the online version of Journal of Clinical Endocrinology and Infertility.
• Hypothyroidism
  In women who breast feed their baby, activation of a prolactin secreting pituitary adenoma may occur. I’ve seen pituitary tumors result in secondary infertility (see this blog for hyperprolactinemia). Hyper and hypothyroidism can develop between pregnancies. A Cesarean section (C-section) might rarely cause intrauterine scarring or adenomyosis. Fibroids can develop over time and definitely enlarge during pregnancy. Pregnancy can result in Asherman’s syndrome (scarring of the uterine cavity) especially if the woman had a dilation and curettage (D&C).  Ovulation might be sub-optimal after pregnancy since it sometimes takes awhile to reestablish menstrual cyclicity. In cases where uterine hemorrhage occurred during delivery, there can be pituitary insufficiency (Sheehan’s syndrome).
• Thyroid
  7) Hormonal – this is the most common and perhaps the most controversial cause of pregnancy loss. Diabetes mellitus or hyperprolactinemia (high prolactin levels) are treatable causes of pregnancy loss. Thyroid disease (hypo- or hyperthyroidism) should be ruled out. Luteal phase defect (LPD) is designated by a shorted menstrual cycle, when the time after ovulation is shortened. A timed endometrial biopsy or serum progesterone level has been suggested in the workup of this condition, but each have been shown to be invalid recently by prospective studies that examined LPD in fertile controls. Extra progesterone or hCG support is indicated in LPD, because they do no harm and for hCG at least, it appears to help prevent losses.

Radiologist

• Ultrasound
  Antral follicle count: The number of follicles that can be counted by ultrasound on day 2 or 3 of the cycle during an ultrasound can help determine how many eggs are left
• MRI
  Case: 34 year old with lack of periods and clinical signs of hypothroidism. Breast discharge had started up again, after she had stopped breast feeding her last child. A serum prolactin level of 89 was found (normal < 20 ng/ml).   A test for hypothyroidism was low (TSH) but so was her free T3 and T4 (measures of thyroid hormones). An MRI was performed and the following picture was taken.  The pituitary in the middle of the brain has a tumor in it, surrounded by compressed (white) pituitary tissue.
• X-Rays
• Chemotherapy
  The 4th talk showed that while radiation and chemotherapy to treat cancer can wipe out the ovarian function by killing off the eggs (oocytes), the process for this reduction in eggs was discovered and found to involve a pairing with a protein called Cables1. By blocking the interactions of Cables1 and another protein P63, the investigators showed that the oocytes of treated animals could be protected from this cell death. These are very interesting data for any young woman who might be treated for cancer but who desires to protect her fertility.

Surgeons

• Vasectomy
  With advances in reproductive technologies it seems that there is no shortage of things we can do to (for) infertile couples trying to start or extend their family. Nothing seems to be out of reach anymore. We have an alphabet soup of procedures including IUI, HSGs, L/S and H/S, SOIUI, IVF, ICSI, GIFT, ZIFT, PGD, etc., etc. If a woman doesn’t have eggs, we can get some from someone else. If a man doesn’t have sperm, ditto. Testicular biopsy or epididymal aspiration with intracytoplasmic sperm injection (ICSI) has changed the outcomes for men with azospermia or after vasectomy. Women without a uterus can find a gestational carrier. Serious gene defects can be weeded out and eliminated from the gene pool of the next generation using preimplantation genetic diagnosis (PGD).  The number of things we can do is astounding, but so is the cost.
• Laparoscopy
  At the heart of the episode on unexplained infertility were several women that have separate stories to tell. Michelle conceived in the past after endometriosis was diagnosed. Kate was part of a study on endometrial integrins and based on a positive test (the lack of the alpha v/beta 3 integrin – ETEGRITY TEST), she had endometriosis diagnosed and treated and now is pregnant for the second time. Wilma failed IVF 4 times and had never had a laparoscopy. After her endometriosis was treated her LAST 2 frozen embryos were put back and she conceived with twins. Just think about the heartache and expense of having a correctable condition that went undiagnosed for so long. After holding those children (at the time of transfer and again when they were over 1 year old) I was struck by how important it is to test for uterine receptivity, especially in IVF failure cases where a good explanation is not forthcoming.

Plastic Surgeons

• Breast Augmentation
• Laparoscopic Surgery
  2) MARCOUX S, MAHEUX R, BERUBE S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med 1997;337:217-22.
• Bariatric Surgery

Dermatologists

• Acne Treatment
• Cyst