603463?1220630455
Elaine Brown, MD  
Female, 52
Billings, MT

Specialties: Pregnancy, Gynecology

Interests: obstetrics & gynecology, Gynecology
Elaine Brown, MD - BLOG
gynecology
(406) 252-0022
Billings, MT
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What's New in Infertility, a three part series

Dec 27, 2012 - 15 comments
Tags:

Infertility

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Pregnancy

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biological clock

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Female Infertility

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male and female infertility

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Male Infertility

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endometriosis

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antimullerian hormone level

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ovulation predictors

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ovulation trackers

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unexplained infertility

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HSG

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hysteroscopy

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laparoscopy

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pre



In the United States 1 in 8 couples has difficulty when they wish to start a family.

***What's new?  The birth rate in the US reached an all time low of 63.2 per 1000 in the US in 2011.

The majority of couples who visited their doctor for infertility issues wish they had visited sooner.

When should couples visit the doctor?

Most experts advise couples to begin with a visit to her doctor (ob/gynor family doctor)  if the couple has been trying unsuccessfully to conceive for over a year. If his age is over 55 or hers is over 35 the visit should happen sooner--after 6 months without success. Of course, same sex couples will need to begin with a visit to the doctor right away.

Causes of infertility are divided approximately equally between the sexes, with female factor infertility accounting for approximately one third of cases, male factor infertility accounting for approximately one third, and the final one third is composed of couples with both male and female factors.  For a significant percentage of couples, no obvious problem is found.  Those couples have traditionally been given the diagnosis of "unexplained infertility".

What are the causes of infertility in women?

In women, causes of infertility can be divided into two very broad catagories:
1) Hormonal problems such as abnormalities of the thyroid or pituitary gland, or problems with ovulation (releasing an egg from the ovary).
2) Physical problems such as blockage of the fallopian tubes, problems with the uterine lining (polyps or fibroids), and problems with the cervical
mucus.

***What's new? Many infertility doctors now believe that many of the cases of "unexplained infertility"  in women are actually cases of very early, mild, or atypical endometriosis
                                                                                                    
What are causes of infertility in men?

As in women, causes of infertility in men can be divided into two broad catagories
1) Hormonal problems such as abnormalities of the thyroid or pituitary, or problems with sperm production caused by low testosterone levels.
2) Physical problems such as blockage of the seminal vessicles, retrograde ejaculation, or failure to achieve or maintain an erection.

***What's new?  Recent studies suggest that a significant number of cases of  unexplained infertility in men are actually cases of excessive DNA fragmentation in the sperm. (DNA is the genetic material  carried by sperm.)  Excessive breakage of DNA strands has been linked to many factors, such as excessive exposure to stress, heat or environmental toxins.

***What else is new? Fertility specialists are investigating a third, controversial category known as Immunologic infertility.   A Malfunction in the body's immune system, which  normally protects against invasion by foreign agents, causes the body to attack itself interfering with  normal mechanisms of fertility.

How is infertility diagnosed?

Traditionally the infertility evaluation begins with the female partner.  An ob/gyn physician or general practitioner can perform the basic work up.  Most physicians will begin the evaluation by determining whether the female partner is ovulating regularly.  A progesterone level at the right time in the cycle(cycle day 21) can confirm ovulation.  Ovulation predictor test strips (which are similar to home pregnancy tests) and  Basal body temperature charting is also useful.

***What's new?  There are some convenient new apps for your laptop or cell phone that can be downloaded to help a woman monitor her cycle and determine her fertile days. Medhelp.org offers a nice tracker for signs and symptoms of ovulation.  http://www.medhelp.org/user_trackers/list/603463  New digital technology such as the The Clear Blue digital fertility monitor, can be used in conjunction with this app to determine the maximum number of fertile days and the optimum timing of intercourse.
  
If the woman is NOT ovulating regularly, the clinician will often evaluate thyroid hormone levels, prolactin levels, and FSH levels.Treatment of thryoid or pituitary abnormalities with appropriate medications can often help to re-establish regular menstrual cycles, and improve fertility.If the FSH level is elevated, this may mean that the ovarian reserve(the number of eggs remaining in the ovaries) is diminished.Older age (35 and up) is the most common reason for an elevated FSH.  Premature ovarian failure is a rare condition in which eggs are depleted before age 40.

***What's new?  Antimullerian hormone level(AMH) is a new blood test that is believed by many doctors to more accurately reflect the number of follicles or eggs remaining in the woman's ovaries than the traditional FSH test. The AMH level can help to estimate the chances that a woman can conceive with her own eggs versus the need for donor eggs.

If it seems that the mom-to-be IS consistently ovulating each month, the problem may lie with a blockage of the fallopian tubes. A hysterosalpingogram (hsg) can be performed. A traditional HSG is an x ray procedure during which dye is injected into the uterus and spills out into the abdomen through the fallopian tubes.  If the dye fails to spill from one or other of the tubes, a blockage is diagnosed.

***What's New?  Selective salpingography is a cutting edge technique in which a tiny cather(tube) is placed inside the hsg catheter and directed into the opening of the tube itself. In this way it is possible to determine whether a tube which might appear blocked on hsg is actually open, but might have spasmed due to the dye.
It is also possible to measure the pressure inside the fallopian tube.  In some cases of endometriosis, the pressure can be elevated causing reduced pregnancy rates.

If the female partner is BOTH ovulating regularly AND her tubes are not blocked, the next step is to investigate the uterus. Ultrasound can be used to evaluate the patient for problems such as cysts or fibroids. Historically, the next step was surgery in which either one of two or both a laparoscopy and hysteroscopy were performed  A hysteroscopy is an evaluation of the lining of the uterus, in which a scope is placed into the uterus through the cervix. Laparoscopy, a minor surgical procedure in which a small scope is placed into the abdominal cavity  is employed at times to evaluate the patient for evidence of endometriosis or other abnormalities of the pelvis such as adhesions which may not be detectable with ultrasound.

***What's new?  Recently, the trend has been toward a less invasive office procedure known as Saline Sonogram--Sterile saline solution is injected into the uterus while the doctor watches with transvaginal ultrasound.  Less expensive, less invasive and less painful, the saline sonogram can disclose a lot about the lining of the uterus, as well as having all of the advantages of traditional transvaginal ultrasound.

The least common abnormality, and usually the last to be investigated,  is a problem with the amount or quality of the cervical mucus.  The sperm must swim through the mucus to reach the egg. Normal mucus is nourishing to the sperm, allowing them to survive for 3-6 days.  Cervical conization or LEEP procedure can cause scarring of the cervix which can contribute to problems with the scanty or hostile cervical mucous.

If the evaluation of the female partner is normal, attention is then focused on the male.

Part two in this three part series will be devoted to diagnosis of fertility problems in the male partner, and treatment of infertility.

Part three will go into more depth on some of today's most relevant topics such as Polycystic Ovary Syndrome and new technologies which are making the biological clock obsolete.

Preterm Labor--Advances in Dagnosis, Management and Prevention Srategies

Nov 27, 2012 - 3 comments
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preterm

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preterm labor

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labor

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management

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Prevention

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early labor

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ruptured membranes

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Osteopenia - premature infants

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false labor

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17 alpha hydroxyprogesterone

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progesterone suppositories

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progesterone

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terbutaline

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magnesium sulfate



What is preterm labor?
Preterm labor is labor and before 37 completed weeks of pregnancy (normally pregnancy is 40 weeks long).

Why is preterm labor undesireable?
Infants born prematurely(especially before 32 weeks)  are more likely to suffer complications such as cerebral palsy, chronic lung disease, visual disturbances, and hearing impairment.

What are the symptoms of preterm labor?
Symptoms of preterm labor include:
• more than 4-6 contractions per hour for several hours in a row
• vaginal bleeding
• ruptured membranes (“broken water”)
• cervical dilation of more than 3 cm or effacement (thinning) of greater than 80%

What causes preterm labor?
There are four major pathways that lead to preterm birth:
1.     over-distension of the uterus such as is caused by a multiple pregnancy (twins or more)
2.      vaginal bleeding or hemorrhage between the placenta and uterine wall
3.     premature activation of the pathways that lead to term labor, activation might be caused by infection.
4.      the strongest risk factor for premterm labor, is a history of a previous preterm birth

What tests are used to determine whether early contractions are "false labor" or true preterm labor?

Many doctors give their patients a single injection of terbutaline when the patient presents to the hospital with contractions. If labor stops completely, it was probably a false alarm.
Additional diagnostic tests that are used to help sort out true from false labor are:
transvaginal ultrasound--cervical length of greater than 3 cm. effectively rules out preterm labor, while a cervix which is shorter than 2 cm is concerning.                                                                        
A negative fetal fibronectin test is also quite helpful (fibronectin is a protein which glues the membranes to the uterine wall it is not present unless the membranes are loosening.)  if the test is negative a doctor can send a patient home with confidence that she is unlikely to deliver.

What is done if true preterm labor is diagnosed?

If it appears that delivery may be imminent, magnesium sulfate is typically begun.  Magnesium sulfate is given by IV in the attempt to stop true preterm labor long enough to transfer a mother to a tertiary care hospital with a NICU that is capable of caring for premature infants. Recent studies have indicated that magnesium sulfate has a protective effect of stabilizing delicate fetal blood vessels especially those in the brain--It reduces the risk of cerebral palsy and necrotizing enterocolitis.
During this time period corticosteroids are administered. Corticosteroids such as beta methasone help the fetal lungs to mature quickly--reducing the newborn's need for oxygen. Oxygen delivered in high concentrations for prolonged periods of time is associated with vision problems and hearing impairment

Who is at highest risk for preterm delivery:
• mothers with twins or higher order multiples--61% of multiple pregnancies deliver before 37 weeks.
• mothers with bacterial vaginosis have traditionally been thought to have an increased risk, but recent studies have had conflicting results—suggesting that this may not be a risk factor after all.
• mothers with a history of premature delivery in a previous pregnancy are at very high risk.
• mothers with a short cervical length--measurement of the cervix is now a standard part of an ultrasound mothers with a cervical length of less than 2 cm measured by transvaginal ultrasound are at significant risk. Mothers who have undergone treatment for cervical dysplasia such as conization or LEEP procedures are more likely to have a short cervix
• Finally, other factors associated with preterm delivery are vaginal bleeding, urinary tract infection in the current pregnancy, sexually transmitted diseases, smoking and periodontal disease

Can preterm labor be predicted and prevented before it begins?

Recent studies have shown that administration of 17 alpha hydroxyprogesterone caproate (typically used for mothers with a history of preterm birth in a previous pregnancy) statistically reduces the preterm labor.
Cervical cerclage (a suture similar to a purse string which is placed around the cervix) has also been demonstrated to reduce the number of preterm births.  A cerclage can be used for women who have a history of preterm delivery and have not responded to progesterones.

The incidence of preterm birth in the United States actually increased by 20% between 1990 and 2006,  (largely due to an increase in multiple gestations resulting from Assisted Reproductive Techonologies--multiple pregnancies increased by 22% over approximately the same time period) so newer and more effective strategies are needed to address preterm labor and birth.

Current research is increasing  our understanding of the mechanisms that cause preterm birth. As this knowledge increases, our ability to diagnose, treat, and prevent preterm birth should improve substantially.

Additionally our ability to care for premature infants, even extremely premature infants has resulted increased survival of preterm infants and fewer disabilities.





What Do I Need to Know About Group B Strep?

Sep 22, 2012 - 1 comments
Tags:

Group B Strep

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Pregnancy

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infections in pregnant women

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infections in newborns

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diseases in pregnancy



Prior to the mid 1960's Group B streptococcal (GBS) infections in humans were almost unheard of.
By the mid 1970's there had been a meteoric increase in the number of infections.
Worst of all, the infections were occurring in pregnant women and their newborns, with case fatality rates
of 20-50%.

Group B Streptococcus is a type of bacteria which typically colonizes the vagina and lower gastrointestinal tract of women. It is likely that virtually every woman is colonized by GBS at some point in their lifetime.  Approximately 20-30% of  all pregnant women are current carriers.  Colonization (meaning that the bacteria is detectable in the vagina or GI tract) can be transient, it can be intermittent or it can be chronic.  Carrier status can change from one pregnancy to the next. Carrier status is different from infection because a carrier has no symptoms.

Whether a mother is a carrier is usually determined by obtaining a swab from the vagina and/or rectum of the pregnant mother.

Infections caused by Group B Strep

In newborns, GBS infections are divided into two groups--early onset and late onset.

Early onset cases occur within the first week of life with most cases diagnosed on the day of birth or within 72 hours.
GBS causes infection in the blood, lungs, brain and spinal fluid, or other milder infections, of the skin for example.

Late onset cases occur after the first week of life. Meningitis (infection of the spinal fluid) is diagnosed in up to one third of late onset cases and permanent neurologic injury can follow.

In mothers, GBS causes urinary tract infections, infection of the placenta and membranes during labor, infection of the uterus after delivery and infection of the blood known as bacteremia.

Group B strep infections can be very successfully treated with antibiotics, especially penicillin or ampicillin.
Prevention of the infection is preferable however, and several strategies have been developed in an attempt to eradicate colonization and infection.  The current strategy is to identify colonized mothers and treat them with antibiotics while they are  in labor.

In 2002 the CDC, AAP, and ACOG recommended screening (obtaining a recto-vaginal swab from) all expectant
mothers between 35-37 weeks of their pregnancy. Antibiotics are then given to those who were culture positive at the time of the test.

Data from 2003 (one year after the guideline was issued) showed a 34% decline in early-onset disease.

In the future, hospitals may switch to a rapid test for group B strep that can be obtained from the woman when she is in labor. Tests for GBS that give immediate results are in the pipeline and already in use in some institutions.
Rapid tests would be superior to the current strategy because carrier status can change in the interval between 35-37 weeks and delivery.

Another exciting development is a vaccine against GBS, which may soon be used in young teens to immunize them against GBS ( similar to the HPV vaccine, Gardasil).

Continued efforts are being made to protect women and children from the devastating effects of Group B Strep.
There is very real hope that in the future, the disease will be a thing of the past.


Pap Smears and Hpv:  New Guidelines from the American Society for Colposcopy and Cervical Pathology

Sep 07, 2012 - 4 comments
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pap smears

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HPV

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Cervical dysplasia

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Cervical Cancer

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new guidelines for pap smears

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pap smear and hpv testing

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hpv and cervical cancer

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hpv causes cervical cancer



The pap smear was introduced in the 1960's in the United States, and since that time, the rate of cervical cancer has decreased dramatically.
Last year in the US there were only 12710 new cases. Most new cases now are diagnosed in women who have not had recommended screening
either because of lack of access or personal preference.

At the time pap smears were introduced, the decision to perform them annually was completely arbitrary.  Because it was a new test, no one knew
how often it should be done.  Since that time, much has been learned about what causes cervical cancer. We now know that ninety-nine percent of
cervical cancers are caused by high risk types of the human papilloma virus.  We have also learned a lot about the natural history of the human papilloma virus.
In fact, the majority of cases of hpv will be transient, in other words the patient's own immune system will successfully fight the virus so that the infections remain insignificant
and never lead to precancerous or cancerous disease.   In fact if we test too often, we will end up doing unnecessary procedures on women who will "get well"
on their own without intervention.

In addition, we now have  new medical technology that allows testing of cervical samples for the presence
of the hpv virus.  Using the two tests (pap and hpv) together permits earlier diagnosis of precancerous conditions in women with positive tests, and in turn, permits
women with negative test results to go longer in between screenings.

Because of all this new knowledge and insight, the American Society for Colposcopy and Cervical Pathology now recommends the following screening:

For Women under 21:  No testing
For Women aged 21-29: testing with cytology (pap smear) only, every 3 years
For Women aged 30-65: Co testing with cytology(pap smear) and hpv testing every 5 years
For Women aged 65 and above, or after hysterectomy for benign (non cancerous) disease:  discontinue testing

These recommendations are quite a radical departure from the previous yearly pap smears that many women were used to do, but the science indicates that
this testing will be frequent enough to permit detection of cervical cancers and pre cancers, but not enough to result in unnecessary procedures that can lead
to other complications.
The new guidelines are sure to come as a surprise (and probably a pleasant one) to many women.

For more information go to www.asccp.org