Treating Infertility by Flushing the Tubes

It’s one of those interesting phenomena that most gynecologists have seen in their practice at least once. You do an HSG, and the woman with longstanding infertility becomes pregnant the very next cycle!

HSG – that’s short for hysterosalpingogram, a study in which dye is injected through the uterus into the fallopian tubes to see if they are blocked or open.

Post-HSG pregnancies happened often enough that we all thought thought it must be a real effect of the HSG. We theorized that the flushing of the tubes must be opening up a previously undiagnosed blockage of the tubes. But we secretly wondered whether what we were really doing was flushing out the bad humors.

As it turns out, our experiences were indicative of a real phenomenon, and our secret theory was not so crazy. In the past decade, several randomized studies have confirmed that doing nothing but performing an HSG increases pregnancy odds by as much as two to three times. (Cochrane review here). Studies have also confirmed that tubal flushing decreases the concentration of cytokines and other inflammatory proteins in the fallopian tube, and reduces sperm phagocytosis (ie, bad humors).

Now, some docs are wondering if flushing of the tubes could become more than just an observed phenomenon but a planned part of infertility treatment.

Researchers at the Karolinska Insitute in Stockholm have published a nice little study in which they randomized couples with unexplained infertility to one of two treatment arms – (a) Clomid (a drug that stimulates ovulation) plus intrauterine insemination or (b) the same plus pertubation (flushing) of the fallopian tubes with an anesthetic solution just prior to insemination.

Among the 67 patients whose tubes were flushed, there were 10 clinical pregnancies (15%) vs only 2 (3%) in the 63 women whose tubes were not flushed, a statistically significant difference.

But before you get yourself too worked up about these results, it’s worth noting that a fertility-expert friend of mine says that the pregnancy rate in the control group was unusually low, and suspects that this may make the intervention look better than it really is.

In addition, the authors point out that the overall pregnancy rates using this technique are significantly lower than the 30% pregnancy rate expected with IVF in the same population of patients. But their lower tech method is cheaper and faster, and they propose that it may be appropriate for couples who either don’t want IVF or want to do something while they are waiting for IVF.

It’s an interesting idea that needs a bit more study before implementing it outside a research setting. Stay tuned…
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Disclaimer – I am NOT a fertility expert, just a plain-old gynecologist reading the latest literature and doing a little wondering. My little musings should not be mistaken for medical advice. The best person to decide your teatment is your doctor, not me.

Living a Life After Cancer

I have some amazing patients.

Take Carrie Wells. Carrie’s a breast cancer survivor who has done so much more than survive – she’s moved beyond her diagnosis and used what she has learned to master the art of living a life.

If you do not let cancer dissolve your spirit, it will be the doorway to learning… I faced my long, losing battle to control change, to put reason to the cancer, and decided to heal.

Carrie credits her energy for life to her experiences at the Life Beyond Cancer Retreat in Arizona in 2004. It was there that she healed, de-stressed and discovered that she had the inner resources and energy to create and live a life after cancer.

Such retreats make so much sense. So many women with cancer get their diagnosis and then move through treatment while working either in or out of the home, leading busy lives and often caring for children and even parents while fighting the battle of their lives.

You know these women – heck, you may be one yourself. Fitting in radiation treatments before work or during lunch hours, heading back to work two weeks after surgery, popping chemo pills between meetings. Most barely take the time to heal physically, let alone emotionally and spiritually. Certainly few take the time to rejuvenate and regroup.

Carrie is determined to help other women heal the way she has. She has created a web portal called Survivor’s Retreat, where cancer survivors can search for retreats, workshops and other destinations that offer healing experiences, relaxation, exercise or just plain pampering – whatever you think you need to heal. You can search on Carrie’s site by location, cost and type of retreat to find just the right escape you need.

Do send a link to the site to a friend or loved one dealing with a cancer diagnosis. And if you know someone who sponsors a retreat, let Carrie know so she can include it on the site.

Carrie’s just been named as one of 25 Yoplait champions, an award that honors “ordinary women and men from across the country doing extraordinary things in their local communities to help in the fight against breast cancer”.

See? Amazing.

Mohs Nose – Part 3 or Okay, I’m Over Myself..

The week went just fine. I wore the band aids on my nose, and the world did not come to an end. I made it a point to briefly explain and apologize for my appearance at the beginning of each patent’s visit so as to get it out of the way, but the truth is, they barely noticed. After all, it’s about them, not me, isn’t it? And that’s just the way it’s supposed to be..

At work, the staff I work directly with were great. My colleagues barely said a word, but after a meeting, one colleague did ask what happened, but very carefully. Compare that to my choral rehearsal, where the whole place went into the “Oh my god, what happened? Are you all right?” mode.

It’s funny – at work, we don’t talk about anyone’s health. The same colleague who asked me about my nose revealed in the same conversation that she had had a cancer last year. I had no idea. It could be because HIPAA has squelched all that conversation. But the truth is that few of us docs are really truly friends, and have little to no time to become friends. In addition, years of little battles over space and autonomy and time and money and workload have whittled away at what room we have in our hearts for each other. Those friendships that do form are often woven with shared dislikes and negative opinions about other colleagues. I’ve seen this in enough places I’ve worked to know it is not unique to my current place of employment. Academic medicine is just like that. It’s sad, really…

Anyway, the stitches are out and the steri-strips are on. Here’s a photo, but you really can’t see much because of the steri strips. I’ll post another next week when the steri-strips come off.

Thanks again to all of you, and to all my friends and family for their support this past week. It’s meant a lot to me.
______________________________

Part 4 here

Mohs Nose Woes – Part 2

Well, it’s done.

The dermatologist did the Mohs procedure on Thursday morning. It took 3 passes to get all the cancer out, and I was left with a defect about the size of a dime on the lower left part of my nose. Sort of like this –

Despite what was being done to me, I had a good time at my Moh’s surgeon’s office. We talked kids, and schools and family and money – and then I hung around his little back Mohs waiting room for a few hours till my plastics appointment, returning patient calls and checking labs on my laptop (one of the curses and advantages of an EMR). I left feeling relieved and upbeat.

Until I saw the plastic surgeon.

The Closure

Where my dermatologist is an upbeat, everything is going to be fine kind of guy, Dr Plastics is an empathetic, caring, almost rabbinical kind of guy who really understands how women feel about their faces. So when he entered the room and saw the size of my defect, he looked at me with those dog-eyes of his, looking so sorry for me that I started to cry. He told me the defect was larger than he had expected, and that he would not close it in the office, but under anesthesia at the surgi-center the next morning.

I walked home crushed, sure that I was going to be deformed for the rest of my life. And the fact that I had to spend the night with this hole in my face did not help. What if something happened and I couldn’t get to the surgery tomorrow? Suppose there was a fire, or I got hit by a car, or one of my kids got sick? I’d have to decide between them and closing the hole in my face.

Somehow I got through the night, and next morning went to the surgi-center. What a place – an Upper East Side townhouse that, when you enter, looks for all intents and purposes like a private mansion. Until you head into the back, where the place looks just like any recovery room and OR suite you’ve ever been to. Runs like a well-oiled machine, wonderfully friendly staff and anesthesia, high quality care. A real New York kind of place.

I waited for several hours in a gown on a gurney, listening mostly to my neighbors letting go of gas after colonoscopies while I finished almost all of the Friday NY Times crossword, a feat worth mentioning in any post. My nurse had had two surgeries similar to mine in the past, a fact I did not notice until she pointed out the faint scars. This made me feel hopeful.

Then my surgeon appeared, apologizing profusely for keeping me waiting due to his previous case that had gone longer than expected. I felt oddly reassured by this, figuring that he would take as long as he needed to give me the best cosmetic result he could.

So to sleep I went, the Fentanyl and Versed doing their job quite nicely, and awoke some 30 minutes later, finally done. Dr Plastics had performed a bi-lobed flap and used about 20 tiny stitches to close. So I have an incision running from near my inner eye down the side of my nose that looks like a half of a flower. Sort of like this –

Nice, Huh?

Post-Op

In addition to the incision, I have a black eye and my nose is swollen and red. The pain isn’t too bad during the day, but has kept me up a bit at night, and my stomach is a bit upset from the antibiotics.

Now I just have to wait. Wait for the sutures to come out next week. Wait for the swelling to go down and the scar to fade. It will be sometime before I know how I am going to look, but at least this thing is done.

I find myself embarrassed thinking about having to see patients over the next few weeks with a big bandage on my nose. I wish I had taken off a little more time from work, but everyone said I could go back pretty much right away, so I’m going back on Tuesday. But I feel like it’s all going to be about the nose for sometime. And I am anxious for the point when I can cover the incision with some makeup until the scar starts to fade.

Most people I talk to are remarkably supportive and no one seems particularly worried about how I’m going to look. But somehow their comments haven’t helped. They only make me feel as if I am over-reacting.

And in some respects, I am. I think about Patrick Swayze and know that I am so, so lucky that this is all I have to deal with. And truth be told, I haven’t thought about my nose too, too much today, as we are now on the 7th episode of the first season on The Wire.

But then, I look at myself in the mirror, and get upset all over again. It makes no sense, I know, but this thing has really hit me hard. I think it was the combo of the big hole, the unexpected wait and and then the Frankenstein sutures, and I expect I’ll feel much better about things in a week or so. But right now I’m feeling pretty darned sorry for myself.

After all, it is my Nose.
_________________________________________________

If you want to see photos, go here. I’ll be posting updates periodically as I heal. I warn you, it’s not pretty……

Part 3 here

Mohs Nose Woes – Part 2

Well, it’s done.

The dermatologist did the Mohs procedure on Thursday morning. It took 3 passes to get all the cancer out, and I was left with a defect about the size of a dime on the lower left part of my nose. Sort of like this –

Despite what was being done to me, I had a good time at my Moh’s surgeon’s office. We talked kids, and schools and family and money – and then I hung around his little back Mohs waiting room for a few hours till my plastics appointment, returning patient calls and checking labs on my laptop (one of the curses and advantages of an EMR). I left feeling relieved and upbeat.

Until I saw the plastic surgeon.

The Closure

Where my dermatologist is an upbeat, everything is going to be fine kind of guy, Dr Plastics is an empathetic, caring, almost rabbinical kind of guy who really understands how women feel about their faces. So when he entered the room and saw the size of my defect, he looked at me with those dog-eyes of his, looking so sorry for me that I started to cry. He told me the defect was larger than he had expected, and that he would not close it in the office, but under anesthesia at the surgi-center the next morning.

I walked home crushed, sure that I was going to be deformed for the rest of my life. And the fact that I had to spend the night with this hole in my face did not help. What if something happened and I couldn’t get to the surgery tomorrow? Suppose there was a fire, or I got hit by a car, or one of my kids got sick? I’d have to decide between them and closing the hole in my face.

Somehow I got through the night, and next morning went to the surgi-center. What a place – an Upper East Side townhouse that, when you enter, looks for all intents and purposes like a private mansion. Until you head into the back, where the place looks just like any recovery room and OR suite you’ve ever been to. Runs like a well-oiled machine, wonderfully friendly staff and anesthesia, high quality care. A real New York kind of place.

I waited for several hours in a gown on a gurney, listening mostly to my neighbors letting go of gas after colonoscopies while I finished almost all of the Friday NY Times crossword, a feat worth mentioning in any post. My nurse had had two surgeries similar to mine in the past, a fact I did not notice until she pointed out the faint scars. This made me feel hopeful.

Then my surgeon appeared, apologizing profusely for keeping me waiting due to his previous case that had gone longer than expected. I felt oddly reassured by this, figuring that he would take as long as he needed to give me the best cosmetic result he could.

So to sleep I went, the Fentanyl and Versed doing their job quite nicely, and awoke some 30 minutes later, finally done. Dr Plastics had performed a bi-lobed flap and used about 20 tiny stitches to close. So I have an incision running from near my inner eye down the side of my nose that looks like a half of a flower. Sort of like this –

Nice, Huh?

Post-Op

In addition to the incision, I have a black eye and my nose is swollen and red. The pain isn’t too bad during the day, but has kept me up a bit at night, and my stomach is a bit upset from the antibiotics.

Now I just have to wait. Wait for the sutures to come out next week. Wait for the swelling to go down and the scar to fade. It will be sometime before I know how I am going to look, but at least this thing is done.

I find myself embarrassed thinking about having to see patients over the next few weeks with a big bandage on my nose. I wish I had taken off a little more time from work, but everyone said I could go back pretty much right away, so I’m going back on Tuesday. But I feel like it’s all going to be about the nose for sometime. And I am anxious for the point when I can cover the incision with some makeup until the scar starts to fade.

Most people I talk to are remarkably supportive and no one seems particularly worried about how I’m going to look. But somehow their comments haven’t helped. They only make me feel as if I am over-reacting.

And in some respects, I am. I think about Patrick Swayze and know that I am so, so lucky that this is all I have to deal with. And truth be told, I haven’t thought about my nose too, too much today, as we are now on the 7th episode of the first season on The Wire.

But then, I look at myself in the mirror, and get upset all over again. It makes no sense, I know, but this thing has really hit me hard. I think it was the combo of the big hole, the unexpected wait and and then the Frankenstein sutures, and I expect I’ll feel much better about things in a week or so. But right now I’m feeling pretty darned sorry for myself.

After all, it is my Nose.
_________________________________________________

If you want to see photos, go here. I’ll be posting updates periodically as I heal. I warn you, it’s not pretty……

Part 3 here

Mohs Nose Woes – Part 1

It all started sometime this summer when the skin on the side of my nose bled spontaneously as I was drying off after a shower. I looked – nothing there, just a spot of blood. I figured I scratched myself and didn’t give it much more thought.

Till it happened again a few months later in the exact same spot. Still nothing to see, but on careful palpation, I noticed the skin there felt just a little raised and irregular.

Now, I’m a girl with my Mom’s Irish skin and a baby oil adolescence who has had four basal cells on my back scraped off in the past 5 years. So I knew before I even saw the dermatologist that this was another basal cell.

But this is not just another basal cell. This one’s different.

This is my Nose.

And that means I need Mohs.

What is Mohs?

Mohs surgery is a special procedure designed to remove skin cancer with the least chance of recurrence and the least removal of healthy tissue.

Skin cancer can grow along the planes under the top layer of skin, so the cancer is often larger than it initially appears on the surface. So when the cancer is removed, the dermatologist will want to take a wide margin of healthy-appearing tissue around the edges of the visible lesion to be sure the cancer is all out.

But on the face, there is not the luxury of wide open space for big margins. And so the procedure of choice is Mohs surgery.

Here’s how Mohs works – The dermatologist shaves off what he thinks is all the cancer, then you go into the waiting room and he goes into the lab and looks at the specimen to see if all of it was removed. If the cancer is growing all the way to the edge of any part of the specimen, that means there’s probably some more still back there on your face. So back you go into surgery to have a little more removed – but just in the spots where the margins are positive. Then it’s back to the lab to see if that’s enough, and so one, till the whole lesion and every last bit of cancer is removed. Each subsequent specimen is smaller and smaller, leaving healthy tissue where it is and just going after the “legs” of the cancer, till finally it’s all out and you’ve got the smallest defect to repair that you can possible have.

But now you have a hole in your face, and it’s got to get closed up somehow.

Closing the skin after removal of skin cancer

After a skin cancer is removed, one can leave the defect to fill in itself. This is how the cancers on my back were treated – They were scraped off, then left to fill in on their own, and in a few weeks, I was left with red round scars that fade with time.

On the face, if the lesion is small, you can do the same thing.

But for the cancer on my nose, this method will not work. That’s because this kind of healing is accompanied by contraction of the skin, which in my case would lead to the nostril pulling up and out on one side.

So I need to have a flap, wherein the skin above the defect is rotated downward to cover it.

But it’s my Nose!

Mr TBAM had a similar surgery this past summer for a small cancer on the tip of his nose – a Mohs procedure followed by a flap. Now he has a sort of Raggedy Andy patch there that you don’t notice unless he points it out to you, at which point you can’t not see it, until you forget about it again.

Now that I am having to have the same procedure, all I can do is stare at Mr. TBTAM’s schnoz and worry about my own. I mean, he looks fine for a guy, but I’m sorry, I don’t want that scar on my nose.

So I asked my dermatologist if plastics could do my closure. He said of course, but that in fact he’s done many more of these than they have. His nurse confirmed that he does 90% of his own closures, and that other dermatologists send their difficult ones to him for that very reason. At that point, what I really wanted to say was “If I was Julia Roberts, would you do the closure or call in plastics?” but that seemed rather rude. So instead I just said that he could do the closure.

And then I spent the rest of the week silently freaking out. And staring at Mr TBAM”s nose.

Three days before my procedure, I happened to mention this to a nurse I work with, who was shocked that there was even a dilemma. Why wouldn’t I want plastics? She then regaled me with stories of deformed faces she’d seen on the subway, wondered how those poor people got through the day, and reminded me how in America appearance is everything. I then called a female colleague who I’d seen as a patient several times. “What, are you nuts? Of course, plastics is closing you! This is your nose, for gods sake! You’re seeing the best Mos dermatologist I know, but he’s a dermatologist, for god sakes! Of course he’s going to tell you you’ll look fine – He’s a guy, they don’t even notice when we get our hair cut half the time! End of discussion. Here’s the name of the plastic surgeon who’s going to do your closure…”

I made the call, dropped my name and I was in.

I have no idea if using plastics for the closure is going to make any real difference in how I look after my Mohs procedure. I adore my dermatologist, and he really is the go-to man for this surgery. But suddenly I’m calm. Not because I don’t think I’ll have a scar, but because I know I will have done everything I can to be sure it’s the best scar I can get.

After all, this is my Nose.
__________________________________________

Part 2 here

Pastry Politics

In my last post, we discussed whether or not Obama was like a popover and why. (Hat tip to Valentine Bonnair for the comparison.) Of course, one must now ask – If Obama is a popover, what are the other presidential candidates?


Obama = Popover.Very quick to make, fast rise in a hot oven; be careful not to take it out before it is done or it will collapse. Delicious flavor alone, but really needs a little butter and jam to make it perfect. Everyone loves popovers.


Hillary = Sourdough bread. Needs a starter from a previously made bread to get going. Slow rise, punched down halfway and risen again. Has a wonderfully complex flavor, but can be a little tough and chewy. Not everyone likes sourdough bread, but those who do adore it.


McCain = Biscotti. Dry, hard, slowly baked and twice-cooked. Will keep for long periods of time in a can without losing flavor, making biscotti a favorite among soldiers and sailors. If a biscotti loses crispness, it can be put toasted in a low oven until crunchy again. Best eaten dunked in wine or strong coffee to soften.


Nader = Fruitcake. Has lots of fruits and nuts, all of which are good for you, and yet for some reason not many people like it. Can keep for years in a tightly closed tin. The same unopened fruitcake will get recycled year after year with no one ever eating it. Europeans appreciate fruitcake more than Americans do.

Discuss.

Pretty Near Perfect Popovers

I figured that if I was going to criticize the popovers at Popover Cafe, I’d better be able to make a pretty darned perfect one myself.

Given that I’d never done it before, I was a little nervous, so I scoured the web for recipes and advice before starting. And thanks to the Joy of Cooking, Mark Bittman, Ina Garten and all the great food bloggers out there who have preceded me on this adventure (see links at the end of this post), my popovers turned out to be pretty near perfect, and to my mouth, at least, much tastier than the ones at Popover’s Cafe.

Pretty Near Perfect Popovers

1 cup flour
1/2 tsp salt
1 cup whole milk (I used lowfat mixed with a little half and half)
2 large eggs
1 tbsp melted butter, plus another tbsp to grease the pan
A little flour or sugar to dust the pan

Preheat oven to 450 degrees Fahrenheit. Heat popover pan on a baking sheet in the oven for 5 minutes or so while combining the ingredients.

Make sure the milk, eggs and butter are at 70 degrees. (I heated the milk in the microwave then cooled in to around 70 or so degrees Fahrenheit).

Whisk flour and salt together in a bowl.

Whisk milk, butter and eggs together in a larger bowl.


Add flour to wet ingredients, whisking just enough to combine. It should be thin like cream and small lumps are okay.


Take popover pan out of oven and brush inside of cups with melter butter. Sprinkle a little sugar or flour on the cup inside walls. Pour in batter to 3/4 full. Place in oven so that the tops of the popovers will end up in the middle of the oven (My gas oven has the heat on the bottom).

Bake at 450 for 20 minutes. Do not open the oven door to peek (But if you have a glass door and a light, do look through the window and watch them pop!)

Lower heat to 350 and bake another 20 minutes. Remember, no peeking except through the glass!

Remove from oven and immediately from pan. Insert a sharp knife into popover to let the steam escape (And don’t worry – if they are done, they won’t collapse).

Serve warm with butter and jam.

Popover Thoughts and Questions

1. Should my popovers have popped a bit more? The little dent in the middle makes me think so, but my god, they were delicious!

2. I think may have over-filled the cups, since I ran out of batter before the last cup. That may be why I didn’t get that last “pop” on my popovers.

3. Does the manner of combination of ingredients matter? For instance, Joy of Cooking has you combine everything but the eggs and then beat in the eggs. Another recipe has you beating the eggs first till they are a light color and then adding the milk and melted butter. I wonder if it makes a difference…

4. I’ve read that sifting the flour makes for a better pop. Some recipes call for bread flour instead of all purpose. (Don’t use cake flour, though – it won’t make enough strong gluten to keep the popover risen.)

5. Most commercial popover recipes (Such as those from Jordon Pond Restaurant and Nieman Marcus) rely on baking powder, probably so they have a guaranteed pop. I think that’s contrary to the magic of popovers – the fact that they rise without leavening. The rise comes from the steam produced by the high proportion of liquid ingredients in the batter, supported by a sidewall strengthened by gluten.

6. This recipe from Apartment Therapy uses 1/4 cup more milk than mine, and what a gorgeous pop they got! It makes sense that more liquid might just help. So next time I will be sifting the flour, filling the cups only a little more than halfway and using a bit more milk (whole milk this time). Will post the results.

Popover Links

  • The Perfect Popover by Lynn Bonnett– Everything you need to know is here.
  • Joy of Baking – This apple popover looks delish!
  • Christy at All Recipes– Nice photos and great comments
  • Chowhound– Nice discussion on technique in the comments section
  • One More Moore— Another blogger inspired by Popovers Restaurant. Gorgeous popovers!
  • Popover Science– Answered a lot of my questions.
  • Popover variations – Try Lemon-Scented, Cheese, and Gluten-free.
  • Michael Pollen uses whole wheat + white flour, and still gets a pop.
  • Obama is like a popover. Discuss.

    Of course, since this is an election year, I can’t ignore this post from Valentine Bonnaire comparing Obama to a Popover…

    That thin crispy shell on the outside and nothing but a cavern of hot air inside. Popovers — another example of something with all of the audacity of nothingness. They taste good while you are consuming them, but there just isn’t a whole lot there is there?

    I beg to differ. A popover is not a lot of nothingness – it has lots and lots of delicious flavor. And if Obama is like a popover, well, then it’s because he is taking politics to a higher level. A popover has to have a strong crust to hold itself up there, and he’s got that. And if he needs a little butter and jam to make him perfect, well that’s just fine with me. We’ve got plenty of that.

Blogroll Update

I’ve cleaned out the blogroll, removing some links to blogs that sadly, have closed, and added some links to new blogs I have recently discovered. It’s bittersweet to say goodbye at last to those who have already left the blogosphere (but hopefully are still lurking), and always fun to make new friends. Here are some new blogs I’ve discovered.

Just Up the Dose – A fascinating blog from a female doc South Africa, where it’s still bit like the Wild West when it comes to healthcare.

Anatomy on the Beach – I’ve taken to reading med student blogs lately, and am starting a category for them over on the sidebar. I find it’s always good to go back to your roots once in awhile and remember what it was like and why you got into this business in the first place. Not to mention this one’s a singer as well, a man after my own heart…

Dose of Reality – The University of Michigan is sponsoring these medical student blogs. I think that’s great – I wish our place would do the same for employee blogs. I might actually come “out of the closet” from my anonymity.

The Accidental Scientist – A food blog from a scientist “noshing and fumbling her way through the food world.” Substitute “doctor” for “scientist” and that pretty much describes me, too.

If I accidentally deleted you active blog, drop me a line.

Vote for Your Favorite Female Blogger

Women’s Voices, Women’s Votes is an organization whose goal is to increase participation in the political process by unmarried women, a group historically under-represented among voters.

WVWV is honoring female bloggers and is asking you to nominate your faves by March 21st for inclusiion in their top 10 bloggers list.

To nominate your favorite female blogger, go here. (Hat tip to the Well Timed Period for the link)