Randi Hutter Epstein M.D. M.P.H.

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Payoffs of Snooping

The Birth of Forceps Offers Insight to Birth Today

There’s an upside to being a snooping guest—you could find a long-lost treasure as this nosey 19th century mother-in-law did.

In 1813, Dr. William Codd’s mother-in-law was poking around he and his wife’s home in Essex, England. She noticed a crack in the floorboard, pried it open, and hoisted a box of metal trinkets. She must have thought the stuff looked scientific because she ran the box over to her friend, a retired surgeon who lived nearby. He knew immediately that she found a medical treasure. One that had been missing for a hundred years.

Inside the box were the world’s first usable forceps. They were created in the 1500s by the Chamberlens, passed down from generation to generation until Peter Chamberlen retired and hid them in the floor of his estate.

The story of forceps is one of a huge medical advance. Before forceps, babies stuck in the birth canal died, and sometimes so did the expectant mother. But it’s so much more. It’s a story of fierce competition and bitter debates.

The Chamberlen men developed this lifesaving device and then refused to share the secret because they figured (rightly so) it would give them an edge in the childbirth business. They became the male-midwives to aristocrats and royalty. And to make sure no one stole their idea, they stored the forceps in box the size of a coffin (so there were no clues about its size or shape) and then blindfolded the laboring women so she couldn’t sneak a peak, either. (As if a woman about to deliver a baby is going to grab a pen and paper—or quill and parchment—and jot down notes).

Eventually in the mid 1700s, Peter Chamberlen, a great-great nephew of the inventor, realized he could make money selling the design. So he did so to Dutch and then British doctors. When he retired, he buried the original forceps in the floor of his house. And there they remained until the nosey mother-in-law of the next home’s owner happened upon them.

I was telling the tale of the eccentric Chamberlens this week when I was interviewed on KWMR radio by Christina Lucas, a nurse in Point Reyes, California about the history of childbirth. I thought I knew the story pretty well until she said, “Where are the forceps now?”

I was stumped during the show, but promised I’d do some searching afterwards. Like most things in life, the answer was one Google click away. The forceps are now on display at the museum of the Royal College of Obstetricians & Gynaecologists.

Since the Chamberlen days—or really starting with the Chamberlen’s, forceps have instigated some of the most contentious childbirth debates. Women worried about the safety of high-tech birth (forceps) versus natural birth (sans forceps). The concerns are reminiscent of the cesarean section versus no-cesarean section debates today.

Today forceps fit into the natural category and many obstetricians believe that the art of using them (it takes a bit of skill) needs to be re-introduced to minimize the high rates of c-sections. There are also initiatives to teach forceps skills to women in developing countries, where surgical births may not be an option.

In any event, if you’re as curious about childbirth history as I am—and if you happen to be in London—it’s worth a stop at the Royal College of Obstetricians and Gynaecologist’s museum. You have to make an appointment. The College is near Regent’s Park, a lovely part of town.

And if you’re really curious, you can hop on a train from Liverpool street to Hatfield Peverel in Essex and see the Chamberlen’s former home. It’s called Woodham Mortimer Hall. There’s a blue plaque on the door that rehashes the history in a few sentences. The Hall is now private, but you can see if from the outside and visit the cemetery nearby. (It’s also a lovely area of the English countryside…where I got my first puppy, a Golden Retriever.)

I’m glad that Christina pushed me to get to the end of the mystery. But the one thing we’ll never know is what Dr. Codd said when he got home that afternoon and found his mother-in-law dismantling his flooring.

 

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What We Don’t Know about Egg Donation

Should potential egg donors worry about potential dangers?

For anyone undergoing any kind of medical treatment, it’s always weighing the benefits of treatment (will this save my life? Cure my illness?) versus potential side effects (can I endure, say, the headaches or whatever comes with the drug?).

For women undergoing fertility treatments, there’s been a push in recent years to minimize the amount of hormones and the amount of cycles—that will lower any potential risks of drugs and also plummet the cost. (The drugs can costs hundreds of dollars).

The whole risk-benefit ratio is different when it comes to young women who are egg donors. The upshot isn’t making a family but making money. The downside is unknown. The sperm and egg industry have long been unregulated fields.

In today’s New York Times, Jane Brody writes about Jessica Grace Wing, a Stanford undergraduate who served as an egg donor three times. Then she got colon cancer and died at the age of 31. There is no proof that the hormones she took to make her spew lots of eggs in one cycle caused her colon cancer. But there aren’t studies proving the safety.

And that’s the issue. Wing was the perfect egg-donor-candidate. She went to a top college, was pretty, athletic, thin, and musical. The hope is that all of those positive things were tucked into the genes in her egg destined to be passed along to the offspring. The fee for her eggs helped pay for college. Where I teach, I hear my college students laughing about the alluring advertisements in the school newspaper. To them it all seems so silly that their genes (not their hard work,not their home environment) got them into college and into egg-donorable standing. It’s just always seemed crazy to me that this business has fallen more in line with the way we deal with any other commodity we want to sell rather than a medical procedure that needs to be tracked for safety.

Her mother, a physician, along with other doctors have been pushing for data bases that can keep track of the donors and their health. This is an idea that has been debated since the egg donor industry started. When I was working on my last book, Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank, I talked to sperm donors and egg donors and the folks who run the businesses. For the most part, the folks “donating” the eggs and sperm (they really sell them), do not want the hassle of the oversight or the bureaucracy of keeping some kind of national data base. The sperm concern isn’t about dangers of donating. Men don’t take hormones. They masturbate in a room. But there are concerns that some men who may be harboring genetic diseases are passing along those illnesses from one bank to another—perhaps unbeknownst to them. The issue for egg donors is their own health. We need to be able to tell these young women—offered thousands of dollars to take heavy doses of hormones that make their bodies release multiple eggs in one month—what the health risks are.

This fear isn’t new. It makes headlines each time there’s a death of a young woman. Today is was a New York Times piece. Two years ago, it was a New York Post piece that showed the photograph of a beautiful young egg-donor who got terminal cancer and had a starring role in a documentary, Eggsploitation. In this day and age, when data is easy to collect and analyze, it’s a shame that we are collecting all kinds of data on what brands of toilet paper people like and who is likely to buy this hat versus that coat, but we can’t collect and monitor data from women who may be risking their lives to help other women make babies.

References

Zarek SM1, Muasher, “Mild/minimal stimulation for in vitro fertilization: an old idea that needs to be revisited,”  SJ.Fertil Steril. 2011 Jun 30;95(8):2449-55. doi: 10.1016/j.fertnstert.2011.04.041. Epub 2011 May 7.

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The Accidental Activist: from Sperm to Politicians

When Dr. Stephanie Dahl returned to her native North Dakota after a fellowship in reproductive medicine further east, she imagined she would join the region’s only fertility clinic helping people make babies. Simple as that. In 2006, it was the only fertility clinic between Minneapolis and Seattle. She expected a flood of patients. What she never expected was a career transformation of sorts. This mild-mannered doctor turned into a political activist, thanks to all the renewed talk of Personhood. Personhood is an ancient term with a muddled definition. The word goes back to biblical times when philosophers tried to guess the moment a seed turns into a soul-filled being. The country thought the courts settled the debate with Roe v. Wade. That decision focused on viability, or the ability to survive independently outside the womb. But the word has crept back into political hallways. Lawmakers in several states have tried to pass bills that would give personhood a legal definition. And this is how some folks want it defined: Personhood starts the moment sperm meets egg. That means this single cell would the full rights of a U.S. citizen. So far, no bills have made it to law but the drawn-out process to block them seems to waste a lot of time and money that could be put to better use. To be sure, we know much more about  the innermost details of a growing embryo. But do these insights provide any information to help everyone agree on a revised personhood timeline? While most doctors perceive this as a threat to abortion rights—which  it is—the potential legislation also impacts the treatment of complicated pregnancies and limits infertility procedures. And that’s why fertility experts are worried. And that’s why Dr. Dahl has become an activist. And that’s why professional fertility associations have formed their own anti-personhood committees to defeat  potential legislation. If a person is a sperm-and-egg, you really can’t put them in freezers. That is what happens when doctors make extra embryos and freeze them for potential future use. And you certainly can’t discard them when they are no longer needed. At issue is not only the definition of personhood (At conception? At viability? At birth?) but who should be making the decision: scientists, courts or clergy. And if it is clergy, which religion? Beliefs on this issue vary as widely as the people who hold them. This past week, North Dakota senate passed two personhood bills, putting Dr. Dahl on guard once again.

Here’s a snippet of my recent conversation with Dr. Dahl:

RHE: Can you explain these bills?

SD: The first bill that passed the North Dakota senate would amend the N.D. constitution to read: “The inalienable right to life of every human being at any stage of development must be recognized and protected.” The vague language could lead to devastating unintended consequences for pregnant women and woman who’d like to become pregnant. The second bill limits some types of in vitro fertilization, criminalizes doctors, outlaws abortion with no exemptions for victims of rape or incest, and makes it difficult to treat ectopic pregnancies.

RHE: In your blog you mention cancer, what does that have to do with fertility?

SD: Chemotherapy and radiation therapy, which are used to treat cancer, can adversely affect the ovaries and destroy a woman’s ability to become pregnant in the future. The best option to preserve future fertility for women with cancer is to perform in vitro fertilization and freeze the resulting embryos. Some centers freeze eggs, however, that technology is not as successful as IVF and is not yet available at our center. Another bill introduced in the senate would have prohibited embryo freezing (for all families including infertility patients and cancer patients), limited the number of eggs we could attempt to fertilize (either one or two), and banned some forms of birth control. Luckily, that bill did not pass. Our cancer patients have enough to worry about with their diagnosis and treatment. They shouldn’t have to forfeit their chances of becoming a mother in the future as well.

RHE: Do you ever think it would be easier to move to a state with more progressive attitudes about fertility so you can just do what you do best?

SD: I have thought about leaving the state, but I want the people in North Dakota to have this care available locally. I think what we do is important. I love my job. When patients bring their newborns for me to snuggle, it’s the best part of my day. So I try to push the politics to the background. I’m here to give patients quality care. We now have thousands of babies across North Dakota that would not have been possible without interventions like IVF. But I hear comments from senators that you wouldn’t believe. Just the other day, one told me that if God decided a woman’s womb should not bear children, doctors should not intervene. And I said, “Does that mean if God decides you should have a heart attack, doctors shouldn’t intervene either?”

 

For further reading as well as thorough history of the personhood debates, check out 102-year-old Howard Jones’s latest book, Personhood Revisited: Reproductive Technology, Bioethics, Religion and the Law. Dr. Jones, sharp as ever, along with his late wife, Georgeanna Seegar Jones, created America’s first test tube baby and has been in thick of the fertility debates since  day one.

 

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The Autopsy Business

On October 27, 1883, about a dozen men, armed with spades and shovels, snuck into Mount Olivet Cemetery in Baltimore, hoping to dig up a body. Their efforts were to no avail. The cemetery’s keeper fired shots, startling the vandals, who ran away. An hour later, pistols sent another group running from the very same grave.

There was a thriving business in dead bodies back then. Medical schools relied on body snatchers for a steady supply of cadavers for research and to lure prospective students. As John Harley Warner wrote in Dissection: Photographs of a Rite of Passage in American Medicine 1880—1930, cadavers gave doctors-in-training rare hands-on experience and gave schools an edge over competitors that taught by textbook only. The bodies—supplied through the black market—also helped doctors figure out why things went wrong, perhaps shedding light on how we die—or how we can postpone it.

The autopsy business isn’t what it used to be. For one, the body-snatcher industry has been replaced by a legitimate process that includes, among other things, obtaining permission from family members. And yet, the notion of learning from autopsies is a dying industry. It shouldn’t be.

In this week’s New York Times, Dr. Sandeep Juahar makes a good point. He notes that fifty years ago, autopsies were done on half the people who died in hospitals. Today it’s about one in ten. You may think—as lots of doctors do—that autopsies are no longer necessary, what with all the imaging tools and lab tests available. But they are. Jauhar notes that hospitals that do the most autopsies also make the fewest diagnostic mistakes. It’s not quite cause and effect, but does suggest that we may be learning a thing or two from the autopsies that are preventing further mistakes. “Despite the emphasis on metrics and data in medicine today, we ignore perhaps the most important information of all: what we can see for ourselves,” he writes.

As for that coveted dead body of 1887? That was poor Blanche Gray, a Fat Lady in the circus who died at the young age of 27. Her death was just as much of a show as her life, with hordes of neighbors ogling at the crane that needed to lift all 500 pounds of her from her room in the Freak Show museum all the way to the cemetery.

During those fledgling days of endocrinology, doctors were eager to learn more about the glands that secreted the juices (soon to be named hormones) that control our bodies and behavior. Blanche, well, she stayed dead and buried, never to be exhumed to a Baltimore lab—despite several attempts. But the field of endocrinology would blossom without her.

 

John Warner:

http://www.amazon.com/gp/product/0922233349?keywords=dissection%20john%20harley%20warner&qid=1457120412&ref_=sr_1_1&sr=8-1

 

NYTIMES link:
http://www.nytimes.com/2016/03/03/opinion/bring-back-the-autopsy.html?_r=0

 

Sandeep jauhar

Sandeep Jauhar

Sandeep Jauhar became a contributing opinion writer for The New York Times in March 2015. A practicing cardiologist, he earned a Ph.D. in experimental physics at U.C. Berkeley before going on to study medicine at Washington University in St Louis. He has been writing regularly about medicine for the Times since 1998.

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Thanks to Rosalyn Yalow

Last April the Endocrine Society hosted a meeting in Washington D.C. to discuss, what they considered, is the shoddy state of hormone testing.

I was reading about the hormone-measuring dilemma in the recent issue of Endocrine News (the Endocrine Society’s newsletter) and it got me thinking that it wasn’t too long ago that doctors considered the amount of hormones in the blood too small to quantify at all.

The ability to be measure hormones—that came about in the late 1950s—is in many way thanks to the Nobel Prize-winning Rosalyn Yalow.

Had she lived, Yalow would be celebrating her 95th birthday this week on July 19th. When she graduated from college and told her teachers that she wanted to be a scientist, they suggested she become a secretary for one. Good thing she didn’t listen. She only got into graduate school because so many men were off fighting in World War II, a few spots opened. As she would say later, “They had to have a war so I could get a PhD and a job in physics.”

She had trouble finding work even after graduating tops in her class but landed a position at the Bronx V.A. As legend has it, her first tiny laboratory had been a janitor’s closet.

It was at the V.A., where Yalow joined forces with Dr. Solomon Berson, and developed the radioimmunoassay, or RIA for short. RIA measures hormone concentrations down to the billionth of a gram. As Yalow’s biographer put it, that’s like measuring a teaspoon of salt tossed into the ocean. It’s also used to measure other things in the blood that had been considered unmeasureable, such as viruses and some kinds of drugs. (Berson didn’t get the Nobel because he had already died by the time it was awarded and Nobels are not given posthumously.)

These days we know that RIA works well for hormones that fall into a certain range, but it isn’t as good for hormones that are really scarce. The results also vary according to which brand is used. It’s like scales—we all know that some make us seem thinner than others.

For hormones, it wouldn’t matter so much each if each clinician relied on their own company’s standards for normal. But all too often, there’s one general chart with the window of normal values.

That means that a hormone test may suggest you are deficient in a hormone when you’re really not. And then you’ll be taking unnecessary treatment. And vice versa. You could think you have enough of a hormone when you could benefit from therapy.

For now, the Endocrine Society has gathered experts and formed PATH, which stands for Partnership for the Accurate Testing of Hormones. Their goal, as they put it, is to “advance the development of standardized hormone assays and advocate for the universal adoption of these assays in medical practice and research.” Which sounds like a sound idea.

I don’t think they intentionally announced their aims around Yalow’s birthday, but it seems to be good karma. A good time to remember a woman who fought against the odds to break down the all-male barriers—and at the same time revolutionize the field of endocrinology. I often loathe the overused word “revolutionize” when it comes to scientific achievements, but Yalow’s really was.

When she received her Nobel Prize in 1977, the committee said, “We are witnessing the birth of a new era of endocrinology, one that started with Yalow.”