Medical Mysteries!

I admit it…sometimes I do watch “real life” medical shows on television. Last year I was watching “Medical Mysteries” on Discovery (I think) and the show presented a young woman who wanted to conceive but had not resumed menstruating after stopping oral contraceptives. She noted that her doctor prescribed “pills” to induce ovulation but when she failed to bleed the doctor ordered additional tests to evaluate if she could be in “early menopause.” Although not exactly correct the story seemed appropriate thus far. Then the doctor called her and gave her the good news that she was not menopausal. Great, I thought, so what did the MRI show?

The woman was then told to just keep trying and see what happened….not a great plan. A few months later she was in the movies and when she stood up she couldn’t see her feet! WARNING, WARNING, THIS IS A BAD SIGN! “So what did the MRI show!” I yelled at the TV (freaking out my wife, I must add who was quietly reading). The woman said that she thought that was weird but it wasn’t until she had a seizure 2-3 months later that her doctor was smart enough to order an MRI. “My doctor was so smart to think of doing that test,” she told the interviewer. Duh!

So the MRI showed a large benign brain tumor (meningioma). After it was removed her periods returned and she went on to have 2 kids….hooray. Happy ending but as you can read below the “smart” doctor was several months late in ordering that MRI! This whole mess could have ended up on the “Medical Malpractice Hour” if the patient hadn’t had such fondness for her doctor.

So here is today’s Question of the Day (which is not a daily feature…shame on DrG) from the book that was not on sale at the MIT Coop when I was in Boston last weekend, 100 Questions & Answers About Infertility.

26. If I don’t have either PCOS or POF, then what is my problem and why am I not ovulating?


Hormone abnormalities other than PCOS can also lead to irregular menstrual cycles. Such abnormalities include problems with the thyroid gland (which produces a hormone that controls metabolism), abnormal levels of prolactin (a hormone that induces breast milk production), and a lack of pituitary stimulation to the ovary known as functional hypothalamic amenorrhea (FHA).

The pituitary gland has been called the master gland of the body; it secretes hormones that control a wide range of functions, including reproduction, metabolism, response to stress, water balance, and growth. Women with irregular cycles should have their thyroid hormone and prolactin levels measured, because problems with the thyroid gland can indirectly lead to elevations in prolactin. Low levels of thyroid hormone (hypothyroidism) and elevations in prolactin (hyperprolactinemia) can be readily treated with medication. In fact, treatment of hypothyroidism with oral thyroid hormone (levothyroxine) can promptly restore normal menstruation. Similarly, hyperprolactinemia usually responds quickly to bromocriptine therapy, often promptly restoring normal cycles.

An elevation of prolactin in the absence of any thyroid disease requires magnetic resonance imaging (MRI) of the brain to evaluate its cause. In such cases, hyperprolactinemia usually results from an increased growth of the prolactin-secreting cells in the pituitary gland that forms a small tumor. If the prolactin-secreting tumor is less than 1 cm in diameter, then
it is called a microadenoma. A macroadenoma is greater than 1 cm in diameter.

Women without thyroid or prolactin issues who fail to have menstrual periods following treatment with progesterone are usually referred to as having functional hypothalamic amenorrhea (FHA). These women fail to produce normal levels of estrogen despite an appropriate complement of ovarian follicles. Women who are below ideal body weight and who exercise frequently and vigorously are particularly prone to developing this problem. Women with FHA are at risk for osteoporosis and should discuss with their physician the benefits of hormone therapy (such as oral contraceptives) when not attempting pregnancy. They should also undergo an MRI of the brain to rule out any structural etiology for their condition. Women who are below ideal body weight may resume normal menstrual cycles when they gain weight or decrease their exercise frequency and duration.

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Do I need a Laparoscopy?

As the son and brother of general surgeons I am often put in the position of defending the low volume of surgery that I perform as a reproductive endocrinologist. In years past, fertility physicians were often in the operating room spending hours repairing damaged fallopian tubes in an attempt to improve a patient’s fertility. However, as IVF technology has improved the need for laparoscopy has dwindled. I explain it to patients in this fashion: If I do a laparoscopy and find significant adhesions (scar tissue) and endomteriosis then IVF is your best option. And if I find minimal endometrosis and minimal scar tissue then IVF is your best option. And if I find that everything is normal then IVF is your best option.

So almost all roads lead to IVF so why do the laparoscopy? Well, not all patients can afford IVF or wish to try IVF. They may be afraid of the drugs, of OHSS, of multiples and I agree that those are good things to fear….and yet IVF really works better than our other options. Natural cycle IVF can remove some risk is more acceptable to some patients but it doesn’t work as well as stimulated cycle IVF. So do I need a laparoscopy? That is the topic of today’s question from 100 Questions and Answers about Infertility. So to honor my general surgeon father in light of the rapid approach of Father’s Day…here is my response…and it pretty much proves that I am not a “real” doctor in his eyes…

11. What is a laparoscopy, and do I need one?

A laparoscopy is an outpatient surgery usually performed under general anesthesia. Most laparoscopies are completed in a hospital, but some physicians utilize freestanding outpatient surgery centers. During a laparoscopy, the physician inserts a small fiber-optic telescope into the abdominal cavity through an incision made in the patient’s umbilical area (belly button). Most physicians initially distend the abdomen using carbon dioxide gas with a needle (Veres needle) to create what is called a pneumoperitoneum. A trocar—an instrument with a diameter similar to that of a pencil—is then passed through the umbilicus, allowing for introduction of the telescope (called a laparoscope) into the abdomen.

Using the laparoscope, a gynecologic surgeon can inspect the uterus, fallopian tubes, and ovaries. The appendix and upper abdomen are carefully inspected as well. Additional instruments may be inserted into the abdomen through incisions (ports) made along the hairline above the pubic bone. For example, the physician may use graspers, scissors, or suction irrigators to rinse the tissue and remove blood and fluids as needed. Some physicians insert a slightly larger telescope through the umbilical port, which allows them to use a carbon dioxide laser to cut scar tissue or destroy implants of endometriosis. Besides the laser, other instruments can be used to cut or burn abnormalities such as endometriosis or scar tissue.

During a laparoscopy, the physician typically introduces a blue dye into the uterine cavity while directly visualizing the fallopian tubes. If the fallopian tubes are patent (open) but are located in an abnormal location because of scar tissue, then the surgeon may try to free the fallopian tubes to improve the patient’s fertility. If abnormal ovarian cysts such as endometriomas are present, then the physician may remove them during the course of the laparoscopy or, if necessary, perform a laparotomy.

A laparotomy is a surgery performed through a larger incision, usually made along the bikini line. It may require the patient to stay 1 to 3 days in the hospital following the surgery. In addition, a laparotomy requires a longer recovery period and may create more new scar tissue than laparoscopic surgery. Certain abnormalities cannot be easily treated through laparoscopy, including exceedingly large ovarian cysts, ovarian cysts that are suspicious for cancer, and fibroids that are deeply embedded in the wall of the uterus. Patients with these problems are probably better served by a laparotomy.

For many years, all women who were seeking fertility care underwent laparoscopy as part of the initial evaluation. In recent times, this practice has faded with increased utilization of IVF. Although IVF has essentially replaced tubal surgery in patients with tubal factor infertility, laparoscopy is still used to correct certain problems in patients prior to undergoing IVF. Complications of laparoscopy are rare but can include injury to the bowel, bladder, and blood vessels; a need for laparotomy; and even death.

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