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Ask Stanford Med, Fertility, Men's Health, Pregnancy, Stanford News, Women's Health

Ask Stanford Med: Expert in reproductive medicine responds to questions on infertility

Ask Stanford Med: Expert in reproductive medicine responds to questions on infertility

couple sitting2Infertility is a reality faced by 10 to 15 percent of U.S. couples. For some, the topic is emotionally charged. And while many may have questions related to reproductive endocrinology, research and treatment options may not be favorite table topics for a night out with friends. So for this edition of Ask Stanford Med, we’ve asked Valerie Baker, MD, the division chief of reproductive endocrinology and infertility and director of Stanford’s Program for Primary Ovarian Insufficiency, to respond to such questions about infertility. Her answers appear below.

@giasison asks: Can you name the 3 top causes of #infertility in your current practice?

Age-related decline in fertility (particularly decline in egg quantity and egg quality with age), sperm problems, and lack of ovulation.

Charmaine asks: Is it true that infertility could be a side effect of vaccination? Why?

No, vaccinations do not cause infertility.

Michelle asks: How have treatments for infertility evolved over the last 10 years? And what might treatments look like 10 years from now?

The biggest advance since the mid-90s has been our ability to help couples with extremely poor sperm quality to conceive. I hope that 10 years from now we will have treatments that help couples where a woman is suffering from premature loss of her egg supply to conceive with her own eggs. Right now, the main choice for women with extremely low egg supply and low egg quality is oocyte donation, where the egg comes from a donor.

Shabba92 asks: What are the most common treatments in your clinic? What percentage of patients wind up undergoing IVF?

The most common treatments are intrauterine insemination (IUI) and in vitro fertilization (IVF). We also do ovulation induction for women who are not ovulating on their own and surgery if needed to correct certain problems. Many couples are able to conceive with simpler treatments and do not need IVF. Fewer than half need IVF.

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Men's Health, Public Health, Research, Rural Health, Stanford News

A guide to coping with a common male birth defect

A guide to coping with a common male birth defect

One of the most common birth defects in boys occurs when the urethral tube fails to completely close, leaving the urethral opening somewhere along the underside of the penis, rather than the tip. Approximately one in 200 males is born with the condition, but the cause is usually unknown. It’s been suggested that exposure to pesticides might be the culprit in some cases, but no definitive studies have been done.

A paper from Stanford researchers, which came out today in the journal Pediatrics, presents results of analyses they conducted of several hundred pesticides commonly used in commercial applications. They found weak links with 15 of the chemicals, but emphasize that further studies need to be done before anyone can say there’s a link between any of the chemicals and the condition, called hypospadias. You can read more of the details in our press release.

Causation aside, parents of a baby boy born with the condition have to make decisions about how to treat the condition.

“Any birth defect is concerning to parents, and a defect in the genital structure often causes special concern,” William Kennedy, MD, associate professor of urology at Stanford and associate chief of pediatric urology at Lucile Packard Children’s Hospital, told me.

Kennedy has been counseling parents and performing corrective surgeries for years and has seen the difficulty parents often have in dealing with the condition.

“Parents are often reluctant to talk to anyone — even medical professionals — about the baby’s condition,” Kennedy added. “Fortunately, most corrective surgeries have positive outcomes.”

Kennedy says a lot of parents first turn to the Internet for information and, as we all know, sometimes what we find there can be misleading. That prompted Kennedy and Suzan Carmichael, PhD, associate professor of pediatrics and lead author of the Pediatrics study, to join with Matt Dorow, who has a son born with the condition, to write a book on
the subject for parents.

“Hypospadias – A Guide to Treatment,” is a slender volume of just over 100 pages, containing information and guidance on every aspect of hypospadias. The recently published book presents information in a clear, organized fashion and includes short pieces written by a man born with the condition and Dorow. If you have a boy born with hypospadias, or know someone who does, it could be immensely helpful.

Health and Fitness, In the News, Men's Health, Mental Health

Story highlights need to change the way we view and diagnose eating disorders in men

Story highlights need to change the way we view and diagnose eating disorders in men

Previously on Scope, we’ve discussed how eating disorders, such as anorexia and binge eating, are increasingly being recognized in men. But why? As a story in today’s San Francisco Chronicle explains, this increase is probably due to a combination of factors.

The story tells how two men grapple with anorexia and highlights two Stanford researchers who study eating disorders in men and women. Though their collective experiences, we learn how the notion that eating disorders are a “female problem” could predispose family members, medical professionals, and even people with eating disorders to overlook the disease in men. From the piece:

“Even males with eating disorders think of anorexia as a female problem in which the main goal is to be thinner,” said Alison Darcy, a psychiatry research associate at Stanford who has been among those leading a charge to gain greater recognition for male disorders.

Darcy recently led a study of adolescent boys with eating disorders at Stanford’s Eating Disorder Program. As the article explains, Darcy found that many young boys with eating disorders want a lean and muscular physique, rather than just weight loss.

One important aspect of Darcy’s study is simply that it focuses on eating disorders in young boys. Research on eating disorders tends to be “gender-biased, with many studies still focusing exclusively on women and girls,” according to the piece.

“If we continue to act as though eating disorders do not occur in men, we are missing a vast population of need,” Athena Robinson, PhD, a Stanford psychologist, commented.

Previously: KQED health program examines causes and effects of disordered eatingWhat a teenager wishes her parents knew about eating disorders and Stanford’s eating disorder program owes its success to holistic treatment

Ask Stanford Med, Fertility, Men's Health, Pregnancy, Stanford News, Women's Health

Ask Stanford Med: Expert in reproductive medicine taking questions on infertility

Ask Stanford Med: Expert in reproductive medicine taking questions on infertility

4223909842_e028c12f28An estimated 10 to 15 percent of couples in the United States are infertile. One or a number of factors may render a couple unable to conceive, including hormone imbalances or blockages of sperm movement in men, and ovulation problems arising from a variety of causes in women. Those who turn to fertility treatments, a recent study showed, can expect to pay more than $5,000 out of pocket on average, or upwards of $19,000 for in vitro fertilization (IVF).

Strides in research to overcome barriers to conception have included a recent Stanford-developed technique to promote egg growth in infertile women who have experienced early menopause. Senior author Aaron Hsueh, PhD, professor of obstetrics and gynecology at Stanford, collaborated with scientists here and at the St. Marianna University School of Medicine in Kawasaki, Japan on a procedure known as “in virto activation,” in which a portion of a woman’s ovary is removed, treated outside the body, and then returned near her fallopian tubes. Through this specialized structure, a participant in the study recently gave birth.

For this edition of Ask Stanford Med, we’ve asked Valerie Baker, MD, to respond to your questions about infertility. Baker, who offered insights on Hsueh’s study and its possible implications for patients in a video and article last month, is division chief of reproductive endocrinology and infertility and director of Stanford’s Program for Primary Ovarian Insufficiency. Her research and clinical interests include primary ovarian insufficiency, and assisted reproductive technology and hormone therapy for fertility and reproduction.

Questions can be submitted to Baker by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Monday, October 21 at 5 PM.

When submitting questions, please abide by the following ground rules:

  • Stay on topic
  • Be respectful to the person answering your questions
  • Be respectful to one another in submitting questions
  • Do not monopolize the conversation or post the same question repeatedly
  • Kindly ignore disrespectful or off topic comments
  • Know that Twitter handles and/or names may be used in the responses
  • Baker will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: Researchers describe procedure that induces egg growth in infertile womenOh, baby! Infertile woman gives birth through Stanford-developed technique and Sex without babies, and vice versa: Stanford panel explores issues surrounding reproductive technologies
Photo by Dylan Luder

Ask Stanford Med, Cancer, Men's Health, Stanford News

Six questions about prostate cancer screening

Prostate cancer is the second leading cause of cancer death among men, and it’s something of an enigma. Unlike cancer in most other sites, tumors aren’t surgically extracted from the prostate. Instead, the entire prostate is removed, leading to short- and long-term side effects in patients. Also, it may be the only type of cancer that is diagnosed via blind biopsy – the urologist never actually sees the tumor and must resort to taking multiple needle-stick samples from throughout the prostate. Even when the presence of cancer is confirmed, there’s still a great amount of inaccuracy in determining its stage (or relative aggressiveness).

Judging prostate cancer’s aggressiveness is very important because despite the number of men it kills, the vast majority of cases are not life threatening. Most affected men have very slow-growing tumors that they will die with rather than from. And because the side effects of treatment – including urinary and sexual dysfunction – can greatly affect men’s quality of life, the medical challenge is to correctly assess which men require treatment and which do not.

James Brooks, MD, is a professor of urology and a member of the Stanford Cancer Institute. He has been caring for prostate cancer patients and conducting laboratory and clinical research at Stanford for more than 16 years, and he recently answered some basic questions about prostate cancer screening for me.

What is the PSA test?

PSA stands for “prostate specific antigen,” referring to a protein made exclusively in the prostate. We measure the relative level of PSA as an indication that cancer might be present. To be clear, though, the PSA test is not a cancer test. Lots of different things can make PSA level go up, including infections, enlarging of the prostate – which happens as we age – and other things that have nothing to do with cancer.

Who should get a PSA test, and how often?

Recently released guidelines from the American Urological Association advise that for men at an average risk for prostate cancer, they should get a PSA test every other year beginning at age 55 and stop at age 69. If a man has a family history of prostate cancer, or is of African American descent, it is probably better to begin at age 40 or 45, and if their first score is very low he can wait up to five years to get another test.

What has been the impact of the PSA test?

I think it is pretty clear that screening has made a difference in survival rates. Prostate cancer death rates were slowly rising for many years. Then in the late 1980s we started screening with the PSA test. Deaths from prostate cancer peaked in 1994, and they are now 40 percent lower than they were at that peak. Two things changed since 1994: aggressive screening and aggressive treatment of prostate cancer.

All of this screening has in a sense changed prostate cancer. It used to be that men presented with more advanced prostate cancer. For example, in 1990, one in five men who walked into my office had prostate cancer that had already spread outside the prostate. Now only one in 25 men has metastatic disease.

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Cancer, Dermatology, Men's Health, Research, Stanford News

Stanford study: Young men more likely to succumb to melanoma

Stanford study: Young men more likely to succumb to melanoma

Young white men with melanoma have a 55 percent higher risk of death from the disease than their female counterparts, suggesting biological sex differences may play a role in outcomes in this deadly cancer, a new Stanford study shows. Though other studies have found that older men tend to fare worse when it comes to melanoma – the most serious form of skin cancer – this is one of the first to compare survival between men and women in a younger population.

The study focused on adolescent and young adults between the ages of 15 and 39 years, who were diagnosed between 1989 and 2009. Among the more than 26,000 patients studied, 1,561 died of the disease. Though males accounted for fewer cases overall (40 percent), they accounted for 64 percent of the deaths. Susan Swetter, MD, a professor of dermatology and the study’s senior author, said:

Studies worldwide have demonstrated that women diagnosed with melanoma tend to fare better than men in terms of improved survival, and this has mostly been attributed to better screening practices and behaviors in women that result in thinner, more curable tumors, and/or more frequent physician visits in older individuals that result in earlier detection. Our study focused on survival differences between young men and women diagnosed with cutaneous (skin) melanoma, who constitute a generally healthy population compared to the older adults who have primarily been studied.

The researchers found that the young men were significantly more likely to die of melanoma than young women their age, even taking into account factors typically related to poor prognosis, such as the tumor’s thickness, its location, histologic subtype and whether or not it had spread to other parts of the body.

“Our results present further evidence that a biologic mechanism may contribute to the sex disparity in melanoma survival, particularly since adolescent and young adults see physicians less frequently and are less likely to have sex-related behavior differences in skin cancer screening practices than older individuals,” said Swetter, who directs the Stanford Pigmented Lesion and Melanoma Program.

The results follow a previous analysis in Europe in 2012 which found that women with melanoma have a 30 percent survival advantage compared to men, despite similar follow-up and treatment, she said. And a more recent study out of Europe showed that even women with advanced melanoma do better in terms of survival.

Christina Gamba, MD, who recently graduated from Stanford’s medical school, was the study’s first author. She told me, “We feel that our study in a largely healthy, young population adds further evidence that a biological mechanism may be at play. Several theories for the survival disparity include differences in sex hormones, vitamin D metabolism, and immune regulation, but further investigation is needed to explore these proposed mechanisms.”

The research appears online today in JAMA Dermatology.

Previously: New research shows aspirin may cut melanoma risk, New skin cancer target identified by Stanford researchers, How ultraviolet radiation changes the protective functions of human skin and Working to prevent melanoma

Cancer, Fertility, Men's Health, Research, Sexual Health, Stanford News

Low sperm count can mean increased cancer risk

Low sperm count can mean increased cancer risk

Men who are diagnosed as azoospermic , or infertile due to an absence of sperm in their semen, are at higher risk of developing cancer than the general population, Stanford urologist Mike Eisenberg, MD, PhD, has found. A diagnosis of azoospermia before age 30 carries an eight-fold cancer risk.

Eisenberg, who is director of male reproductive medicine and surgery at Stanford Hospital & Clinics, is lead author of a just-published study in Fertility and Sterility concluding that an azoospermic man’s risk for developing cancer is similar to that for a typical man 10 years older.

(Eisenberg is the same physician/scientist who discovered, a few years ago, that childless men are at higher cardiovascular risk than their counterparts with kids.)

About 4 million American men – 15 percent of those ages 15-45 – are infertile. Of these, some 600,000 (an estimated 15 percent) are azoospermic, usually because their testes don’t produce enough sperm for any to reach their ejaculate – most likely, Eisenberg says, because of genetic deficiencies of one sort or another.

That may explain the azoospermia/cancer link. As I wrote in my news release on this study, fully one-fourth of all the genes in the human genome play some role in reproduction:

The findings suggest that genetic defects that result in azoospermia may… broadly increase a man’s vulnerability to cancer, Eisenberg said, supporting the notion that azoospermia and cancer vulnerability may share common genetic causes.

Although men diagnosed as azoospermic before age 30 appear to have a particularly pronounced cancer risk compared with their same-age peers, Eisenberg notes that the absolute cancer risk for any apparently healthy man under age 30, regardless of whether or not he is azoospermic, nevertheless remain very small. Still, he advises young men who’ve been diagnosed as azoospermic to be aware of their heightened risk and make sure to get periodic checkups with that in mind.

“Most reproductive aged men (20s-40s) don’t have primary care doctors or really ever see the doctor,” Eisenberg says.

Previously: Men with kids are at lower risk of dying from cardiovascular disease than their childless counterparts

Health Policy, Men's Health, Orthopedics, Research

Report deals another blow to synthetic bone growth product

Report deals another blow to synthetic bone growth product

An independent group at Yale University has dealt another blow to a bioengineered protein that was once commonly used in spinal fusion surgery. The Yale University Open Data Access Project found that the human recombinant bone morphogenetic protein-2 (rhBMP-2) “provided little or no benefit compared to bone graft and may be associated with more harms, possibly including cancer.”

The findings, published in the June 18 issue of the Annals of Internal Medicine, confirm a 2011 review of the product by the editors of the Spine Journal, led by Eugene Carragee, MD, professor of orthopedics at Stanford.

What is most troubling, Carragee says, is that the Yale group found that surgeons who received millions of dollars from Medtronic Inc., the maker of the protein, misrepresented its efficacy and underreported complications. Carragee and his colleagues had previously reported in the Spine Journal that the product, marketed as Infuse, carried a range of side-effects, including male sterility, urinary problems, infection, nerve and bone injury and possible cancer risk. Carragee said in a statement released by the journal:

To put the YODA findings in perspective, one must understand the carnival-like promotion that preceded BMP-2’s fall from grace. Market boosters advised that the BMP-2 product went beyond all other medical innovations. Perhaps confusing Infuse with penicillin or the polio vaccine, one zealot proclaimed: ‘Infuse, the single most successful biologic product ever launched in orthopedics and possibly ever in medicine.’

In a triumph of understatement, the YODA group informs us that ten years after its development, ‘it is difficult to identify a clear indication for BMP-2 use in spinal fusion.’ Ten years after penicillin was developed, people were saying it had saved a quarter million lives in World War II. Ten years after the polio vaccine, braces had disappeared from grammar schools. Ten years after BMP-2’s introduction, the YODA group could not identify a single compelling indication for use – but we know it can kill you in the cervical spine and probably can promote cancer, which can then kill you.

In 2012, the U.S. Senate Finance Committee conducted an investigation into the marketing of the product, as well as into physician/industry relationships and the scientific publishing process. It named three surgeons who had particularly lucrative financial ties with Medtronic, ranging from $10 million to $35 million each. These physicians had authored some of the early studies on BMP-2 that framed it in a positive light and helped launch it into general use by orthopedic surgeons.

Carragee says it’s unfortunate that after years of this “self-congratulatory research,” physicians still have a poor understanding of the protein:

At present these ‘concerns’ regarding higher rates of cancer, sterility, wound problems and nerve injury remain poorly described. The suggested reason for this gap in our understanding, if true, is simply appalling: these complications were systemically ‘misrepresented,’ ‘underreported,’ or just “missing’ from the first decade of publications. The research to better understand those complications and risks is still before us.

To its credit, Medtronic financed the $2.5 million YODA project.

Previously: For the record: Carragee on Medtronic spine stories, Stanford-led study on Medtronic bone product dominates the headlines, Stanford orthopedist reveals problems with Medtronic spinal fusion product, and Stanford study links spine product to male infertility

Men's Health, Research, Women's Health

Paper highlights major differences in disease between men and women

Paper highlights major differences in disease between men and women

In light of the recent launch of the Stanford Center for Health Research on Women and Sex Differences in Medicine (WSDM), I couldn’t help but take notice of a new paper on the topic. In an article in the journal Clinical Chemistry and Laboratory Medicine, Italian researchers have highlighted the “crucial differences between men and women” in five areas: cardiovascular disease, cancer, liver diseases, osteoporosis, and pharmacology.

Arecent journal release provides some examples of the differences:

Typically perceived as a male illness, cardiovascular disease often displays markedly different symptoms among women. While a constricted chest and pain that radiates through the left arm are standard signs of heart attack in men, in women the usual symptoms are nausea and lower abdominal pain. Although heart attacks in women are more severe and complicated, when complaining of these non-specific symptoms women often do not receive the necessary examination procedures, such as an ECG , enzyme diagnostic tests or coronary angiography.

Colon cancer is the second most common form of cancer among men and women. However, women suffer this illness at a later stage in life. Furthermore, colon tumors typically have a different location in women, and they respond better to specific chemical treatments. Gender also has an impact on the patient’s responsiveness to chemotherapy administered to treat cancer, such as colon, lung, or skin cancer. In this way, gender impacts the course of the disease and the patient’s chances for survival.

…While typically viewed as a female disease because of the much higher rate of female patients, osteoporosis also strikes men. The study contends that osteoporosis is too often overlooked in male patients, and it documents a higher mortality rate among men suffering bone fractures.

The authors conclude that “more far-reaching clinical investigations of gender differences are needed in order to eliminate fundamental inequalities between men and women in the treatment of disease.”

Previously: Exploring sex differences in the brain

In the News, Men's Health, Research, Stanford News, Women's Health

A call to advance research on women’s health issues

A call to advance research on women's health issues

An article in the San Francisco Chronicle today discusses the need to include more females in scientific research and mentions efforts being taken at Stanford to fix the problem. Erin Allday writes:

…[T]here have been tremendous advances in studying women’s health issues and including women in drug trials and clinical studies. Most of those changes  followed a 1993 mandate by the  National Institutes of Health that women be included in  such studies.

But when it comes to basic science – studying the molecular mechanics of  diseases in cells and tissues and in mice and rats – almost all of the work is on subjects with the male XY chromosome pairing.

Stanford, at least, is aiming to dig into that problem with the creation of a  new center focused on sex and gender in health. The Stanford Center for Health Research on Women and Sex Differences in Medicine officially opens Wednesday with a conference on sex, gender and the brain, at which [Louann Brizendine], now a UCSF psychiatrist who has written two books on the male and female brain, is speaking.

“For just about everything in medical science, we’re still very male-focused,” said Marcia Stefanick, an obstetrics and gynecology professor at Stanford who is co-director of the new center. “Our basic understanding is missing a key ingredient, and that is the sex difference.”

Previously: Exploring sex differences in the brain and Women underrepresented in heart studies

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