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The Infertility Conundrum

Posted by MDViews on March 25, 2014

Tears spilled on my desk as she described her four-year trial with infertility. Married for six years, she and husband actively tried to achieve pregnancy for four years prior to her visit with me. After one year of no success, she saw her OB/GYN doctor. After testing, her doctor determined her to have open tubes, normal labs and a fertile husband. Try another year, she was told. After no success, her doctor tried her on Clomid, a medicine that caused ovulation2, even though she ovulated every month. After six cycles of that without success, she visited a Reproductive Endocrinologist (RE), a doctor who finished an OB/GYN residency and an additional two years of training in Reproductive Endocrinology. The RE recommended Clomid and intrauterine insemination or IUI3. If no success after three cycles, she recommended Follistim shots4 and IUI for three cycles. If that failed, she recommended in vitro fertilization.

My patient and her husband tried the Clomid and IUI, but couldn’t afford the Follistim and IUI or the in vitro fertilization.

She returned to her OB/GYN doctor and received more Clomid, again, without success. She and her husband, both Catholic, lived with the guilt of trying IUI, a fertility procedure not approved by the Catholic Church. Her complaints of severe pain with her periods and pain in her pelvic area fell on deaf ears as her OB/GYN told her in vitro fertilization was the most effective way to achieve pregnancy, and recommended a return to the in vitro clinic.

Pregnancy rates after an in vitro cycle average 30%. I checked three fertility clinics in the Twin Cities and found one charged $16,500 for each in vitro cycle, another $22,000 and a third clinic $23,000 per cycle.

Pregnancy rates after one cycle of a fertile couple who has unprotected intercourse are 25 to 30%. Last I checked, the cost was $0. Pregnancy rates after one cycle for a couple with endometriosis5 is lower than that, often around 5% to 10%. As excellent medical studies have shown, however, surgical treatment of endometriosis and pelvic scarring improves pregnancy rates, often greatly. Not only that, surgical treatment constitutes a one-time event that often relieves pain and increases pregnancy success for many cycles.

If a woman has a 20% success rate per cycle after surgical treatment of endometriosis, her chances of pregnancy at the end of one year are much higher than the 30% chance after one in vitro cycle, or the slightly higher chance after two in vitro cycles. I rarely find a patient who has tried three or more in vitro cycles.

She heard about our clinic and underwent surgery at which time I discovered and surgically treated her severe endometriosis by careful handling of tissues, thorough treatment of endometriosis and placement of adhesion barriers to prevent recurrent scarring.

The surgery brought relief of her pain.

She conceived on her own the next month.

She is now on baby number two since the surgery.

In order to understand the tragedy this represents, you need some history. Back when I did my residency in OB/GYN, the Reproductive Endocrinologists were the best surgeons in the department, often the entire hospital. They performed difficult endometriosis surgery, tubal reconstruction and treated scarred tubes, which often required the operating microscope. Now, RE’s in my area do not come to the hospital, much less perform surgery. At the two hospitals where I work, not one Reproductive Endocrinologist performs surgery in spite of in vitro clinics in our service area.

In the last five to ten years, in vitro procedures for infertility have become the default treatment to the elimination of all other treatments. General OB/GYN doctors in my community have a laissez-faire attitude toward the surgical treatment of endometriosis and make little effort to treat the disease thoroughly surgically even if they find it at laparoscopy6. This, in spite of good data on the effectiveness of surgical treatment to improve fertility and relieve pain7.

1) Fallopian tubes – tubes that carry the egg to the uterus from the ovary. Fertilization actually happens in the tube.
2) Ovulation – When the egg pops out of the ovary and can be fertilized.
3) Intrauterine insemination (IUI) - A procedure in which a semen sample is specially prepared for safe insertion into the womb, or uterine cavity itself.
4) Follistim – A hormone given in daily injections to cause the ovaries to make eggs, sometimes several eggs.
5) Endometriosis - A female condition in which uterine lining cells implant in the pelvis and cause pain, scarring and infertility.
6) Laparoscopy - A minimally invasive surgery to look inside the abdomen in order to diagnose and treat a condition, often endometriosis or infertility.
7) UpToDate states in the section Reproductive surgery for female infertility, "laparoscopic surgical treatment was associated with a significant increase in the ongoing pregnancy/live birth rate..." October 2013.

Posted in Doctoring, Family, Medical Issues | 1 Comment »

Christian Doctors Digest

Posted by MDViews on September 24, 2013

To any of you who are interested, David Stevens, MD of the Christian Medical Dental Association interviewed me on my dismissal from Fairview Health Services three years ago. I’ve much of the story here in my blog for anyone who wants to read about it, including the talk which my former employer found so offensive.

The link of the interview is here.

Hope you enjoy the interview.

Matt Anderson

Posted in Doctoring, Faith and the Glory of God, Personal | 2 Comments »

Protestant OB/GYN and Birth Control

Posted by MDViews on April 15, 2013

Is artificial birth control moral for protestants? If it’s moral, why oppose the contraceptive mandate of the Affordable Care Act (Obamacare)? If artificial birth control is morally OK, isn’t the contraceptive mandate is just politics?

I’m a Christian OB/GYN doctor who has practiced now more than 30 years. OB/GYN doctors more than any other group, in my observation, view birth control as a “right.” By that, I mean birth control should not be just available, but should be available and free paid by insurance or the government. Pro-contraception OB/GYN’s and their allies along with liberal politicians fuel the contraceptive mandate debate promulgated by the Affordable Care Act (Obamacare). Catholics generally oppose this mandate on moral, pro-life and religious freedom grounds and conservative Protestants generally on religious freedom, pro-life and anti-socialized medicine grounds.

90% of OB/GYN doctors are so-called “pro-choice” when it comes to abortion. I can’t give you a statistic on pro-birth control OB/GYN’s, but during my 30+ years as an OB/GYN doctor, I’ve seen near universal support for artificial birth control by OB/GYN doctors for any woman who is sexually active, including the unmarried and very young. That includes most Catholic OB/GYN doctors I’ve known as well.

I can count two hands the number of doctors I know who do not prescribe birth control and only three are OB/GYN physicians. (All three are Catholic.)

So, what’s the deal? Why oppose birth control morally? As a protestant Christian, the popes decrees against artificial birth control do not carry weight with me.

Historically, the church including Protestant churches after the Reformation opposed birth control especially after the decimation of Europe’s population by the plague in the 1400’s. Martin Luther said, “The purpose of marriage is not to have pleasure and to be idle but to procreate and bring up children, to support a household. Those who have no love for children are swine, stocks, and logs unworthy of being called men or women; for they despise the blessings of God, the Creator and Author of marriage.” Other Protestant leaders who opposed birth control included John Calvin, John Wesley, Charles Spurgeon, Cotton Mather, Matthew Henry, and John Machen.1 Religious objections continued until the Church of England (Anglican/Episcopal) approved artificial birth control at the Seventh Lambeth Conference in 1930.2

So, after 410 years of opposing birth control on moral grounds, Protestant churches followed the lead of the Anglicans embracing birth control the last 83 years. Eighty-three years is not very long. And what artificial birth control did they embrace? The birth control pill (BCP) wasn’t available until 1962. The intrauterine devise (IUD) was invented just before WW2, but was not in common use until the late 1950’s. So the birth control that was so controversial was…condoms. Condoms had been available for several centuries, but modern manufacturing made them more popular in the early 20th century.

Pope Pious XI, in response to the Anglicans, stated the Catholic Church’s position on the issue thusly:

“Since, therefore, the conjugal act is destined primarily by nature for the begetting of children, those who in exercising it deliberately frustrate its natural power and purpose sin against nature and commit a deed which is shameful and intrinsically vicious.” 3
Pope John Paul VI in his treatise on The Theology of the Body, Humana Vitae, redefined this objection from “all” birth control, to “artificial” birth control, and required Catholics to uphold natural law and not thwart the procreative purpose of the act except by abstinence during fertile times of the cycle.

He also predicted what would happen if artificial birth control were universally available, stating in effect, that we would see an increase in “conjugal infidelity” and a “lowering of moral standards.” He further posited that “the man…may finally lose respect for the woman and…consider[ing] her as a mere instrument of selfish enjoyment…” Finally, regarding government, he wrote, “Who will prevent public authorities from favoring those contraceptive methods which they consider more effective? Should they regard this as necessary, they may even impose their use on everyone.”4 His words were prophetic. I just hope his last prediction does not come true!

Protestant believers depend on the Bible as the arbiter of God’s design for man. The Bible speaks well of family and children, stating in Genesis 1:28a (ESV) “Be fruitful and multiply and fill the earth and subdue it,” and in Psalm 127: 3-5a (ESV) “Behold, children are a heritage from the Lord, the fruit of the womb a reward. Like arrows in the hand of a warrior are the children of one’s youth. Blessed is the man who fills his quiver with them!”

The Bible does not mention birth control, but gives the example of Onan. Onan did not wish to impregnate Tamar, the wife of his deceased brother as was required by the custom of the day and so, Genesis 38:9 (ESV) tells us, “…Onan knew that the offspring would not be his. So whenever he went in to his brother’s wife he would waste the semen on the ground, so as not to give offspring to his brother. And what he did was wicked in the sight of the Lord, and he put him to death also.”

Some protestant groups oppose birth control because they want to be open to however many children God would give them. They also generally do not practice natural family planning (NFP).5 Dr. John Piper, a Baptist preacher, author and theologian states, “We should make our decisions on Kingdom purposes. If—for Kingdom reasons, gospel reasons, advancement reasons, and radical service reasons—having another child would be unwise then I think we have the right and the freedom to regulate that. But such regulation must presuppose that we’re not doing anything like abortion to measure out when and how many children we have.”6

What about modern artificial birth control methods? Are they safe? Do they cause abortion?

Pro-contraception professionals are quick to point out that, when compared to the risks of childbirth, all the birth control methods are safe(r).

But not completely safe.

BCP’s have a risk of blood clots, strokes and heart attacks. A subgroup of young women who take the pill have a higher risk of breast cancer. Cervix cancer which is caused by the human papilloma virus (HPV) is more prevalent in BCP users possibly because of the license it provides for sex with many partners without the risk of pregnancy. IUD’s can cause infections, pain, sterility, hysterectomy and death, although uncommonly. The implants and shots cause abnormal bleeding. Women ovulate and can conceive with the IUD in which case the hostile uterine environment created by the IUD causes abortion of an early embryo. The package insert states it like this: “It [the ParaGard® IUD] may also prevent the egg from attaching to the uterus.”7 (Huh? The egg?) Likewise, some women will ovulate while on hormone shots, implants or pills and may conceive with the hostile uterine environment causing the early embryo to abort. (Ovulation is quite infrequent on the BCP.) Plan B or “the morning-after pill” works primarily by creating a hostile uterine environment so that an early embryo will not implant and pass through, an early abortion.

Pro-contraception professionals state, “ An abortion happens when an early embryo that is implanted is removed from a woman. It is only AFTER [emphasis theirs] implantation, that a woman is considered to be pregnant.”8 I’ve been told just that by other OB/GYN’s with whom I’ve worked. That’s how they can say with a straight face these methods of birth control do not cause abortion, including the “morning after pill.”

Sorry, an embryo before implantation is a new human life for us pro-life folks. If an early embryo passes through the uterus without implanting because of a hostile uterine environment created by artificial birth control, then that is an abortion.

Every year I served as a member of the board of the American Association of Pro-Life Obstetricians and Gynecologists, someone would propose the group take a stand against birth control as abortifacients. Every year, we concluded the data was not solid enough to make such a recommendation and that each doctor had to decide on his or her own whether or not to prescribe birth control.

I’ve searched out the history, the scripture and my own attitude toward birth control. Two years ago, I adopted a more historic protestant view of birth control and quit prescribing birth control to my patients. I believe not prescribing birth control for the above reasons is more honoring to God, will bring more glory to Him and is therefore the morally correct thing for me to do.

My decision has had consequences. I see fewer patients, make less money and have had trouble finding other doctors to cover my practice if I am gone. Also, I’m the only protestant OB/GYN I know not prescribing birth control which puts me in a confusing category for many of my patients as most (but not all) disagree with me.

I realize that committed Christians, both patients and doctors, can and do disagree with me. I pray that whatever decision about birth control a committed Christian makes, it will be serious, thoughtful, scriptural and intended to bring honor and glory to God.

Matt Anderson, MD

End Notes:

1. http://www.missionariestopreborn.com/birth_control.html
2. http://www.churchofengland.org/our-views/medical-ethics-health-social-care-policy/contraception.aspx
3. http://www.papalencyclicals.net/Pius11/P11CASTI.HTM
4. http://www.vatican.va/holy_father/paul_vi/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae_en.html
5. http://quiverfull.com/index.php, http://www.missionariestopreborn.com/
6. http://www.desiringgod.org/resource-library/ask-pastor-john/is-it-wrong-to-use-birth-control
7. http://hcp.paragard.com/About-Paragard/How-it-Works.aspx
8. http://www.managingcontraception.com/qa/questions.php?questionid=3206

Posted in Abortion, Doctoring, Faith and the Glory of God, Personal | 13 Comments »

The HPV Vaccine. Protecting Your Adult Child From Their Own Adult Decisions?

Posted by MDViews on January 9, 2013

A medical news article entitled, “Increasing HPV Vaccination Coverage Needed To Decrease HPV-Associated Cancer Incidence,” caught my eye and took me back to my days at Fairview when I was on the Quality committee. The HPV (human papilloma virus) vaccine (Gardasil) had just been release. The chairman of the committee, Mike Dummer, MD, told everyone that we needed to get as many adolescent girls vaccinated as possible. In order to do that, he said, we should present the vaccine to the mothers of these youngsters as a vaccine to prevent cancer of the cervix. We were not to use the word “STD” or sexually transmitted disease when speaking of the vaccine. He feared mothers of adolescent girls would refuse to have their daughters vaccinated if we called it an STD vaccine.

I challenged him and told him I thought that approach was wrong and could violate Fairview’s diversity and tolerance policies by not being culturally sensitive to devoutly religious folks, Christians in particular. I knew some Christian women who did not want their daughters vaccinated against an STD. He shot back that I was wrong, that it was important to tell them it was a cancer vaccine. After all, we didn’t tell patients with cervix cancer or an abnormal pap smear that it was caused by an STD. I challenged him again and told him I always told my patients with an abnormal pap or cancer of the cervix that the disease was from an STD, more likely in those with early onset sexual activity and multiple life time partners. He was truly surprised, that I would honestly share that information with my patients. The conversation ended with him sticking to his guns, that we should not tell moms of young girls that the vaccine was intended to prevent an STD which caused 70% of cervix cancers.

There were probably 15 docs at that meeting. None supported me. I resigned from the committee after that. I could see I didn’t belong there.

I’ve spoken with doctors and patients who fall on both sides of the issue, but most advance the notion that young girls (and now young boys) should receive the vaccine.

Protecting children from physical harm is a parental duty and cervix cancer causes real physical harm. So, aren’t we obligated to protect our young girls from this STD and get them the vaccine? No, I don’t think so. We can give them the vaccine, of course, as many do. But we are not obligated to do so as I argue below.

A child does not catch an STD by a sneeze or a cough so I can’t place this vaccine in the same category as the vaccine for whooping-cough or measles. If I had a preadolescent or adolescent daughter at home today, I would speak to her around the time of her menarche of the availability of the vaccine, its purpose, its effectiveness and encourage her to remain chaste until marriage. Should she decide to become sexually active prior to that, she would be making an adult decision and it would be her job to make another adult decision and go to her own doctor for the vaccine if she wished to receive it or talk to me about her desire to receive the vaccine. And once she were 18, she could make up her own mind without my input.

Cervix cancer is an adult disease. Currently, the CDC doesn’t even recommend a pap test for any woman until age 21. Receiving the vaccine before exposure to the HPV virus 9,11,16 or 18 will theoretically stop 70% of cervix cancers since 70% are caused by 16 and 18. (9 and 11 cause warts.)  Fortunately, even without the vaccine, cancer of the cervix is uncommon and is treatable in its pre-cancer state. 50% of cases of cervix cancer occur in women who have never (that’s right, never) had a pap test.

And, I would contend that sexual intercourse is an adult act.

I have difficulty generating excitement about protecting my adult children from an adult act for which they are responsible.

The other side of the argument cites the irresponsibility and rebelliousness of adolescent boys and girls who may have sex. Is that really an adult act? Shouldn’t you protect her then? What if your daughter gets raped at age 14? Wouldn’t you want her protected in that event? And what about those cultures in our society in which sex at age 15 or 16 is accepted as the norm, multiple partners are the norm and marriage is rare? I’m thinking of inner city minority populations where 80% of babies are born to unmarried women. Shouldn’t they receive the vaccine at age 10 or 11? Shouldn’t you push hard to get them vaccinated, even if it involved lying to them as in, “This is a cancer vaccine, not STD vaccine?”

My own approach on this issue is to inform patients of the vaccines availability but encourage no sex until marriage and one partner for life. That’s a medical recommendation. (What? A medical recommendation?) By remaining chaste until marriage and having one partner for life, an entire plethora of disease can be avoided, including HPV, HIV, Chlamydia, gonorrhea, genital herpes, pelvic inflammatory disease, infertility, hysterectomy and on and on. That’s what I mean by encouraging no sex until marriage, then one partner for life being a medical recommendation.

Think of this. No doctor hesitates to scold a patient for smoking cigarettes and tell them to quit smoking because of the increased risk of lung cancer, heart disease and emphysema. No doctor hesitates to scold the overweight patient and tell them to start exercising and losing weight because of the increased risk of high blood pressure, diabetes and heart disease. No doctor hesitates to tell a patient to wear their seat belt, lower their cholesterol, treat their high blood pressure, get their eyes checked, and on and on and on.

Why the taboo against recommending abstinence until marriage and one partner for life to avoid the diseases which result from promiscuous sexual activity? Mainstream medicine conveys the message that adolescents will have sex like rabbits anyway, so limit disease and pregnancy. Get the vaccine, wear a condom, use birth control, have an abortion if the birth control doesn’t work, don’t ruin you life with a (gasp!) baby.

Only, that message hasn’t worked, doesn’t work and won’t ever work. Just look around. God knew what He was doing when He defined marriage as the union of one man and one woman and that sex outside of the marriage bond was sin. He defined this morality which, no surprise to me, is medically spot on.

Posted in Doctoring, Medical Issues | 5 Comments »