William D. Schlaff

Integrating Infertility Evaluation and Treatment Into the General Ob/Gyn Office

Infertility in reproductive-age couples is extremely common and represents a significant number of patient visits to the gynecologist. The prevalence of infertility in the United States and other developed countries ranges from approximately 13% to 14% of reproductive-age couples. It is estimated that at least 25% of women experience infertility at some point in their reproductive life. Diagnosis and management of infertile couples seems increasingly difficult to perform in the office of the general obstetrician/gynecologist. There are at least three major contributors to the stresses associated with seeing such couples. First, couples suffering from infertility tend to bring intense, passionate feelings and needs to the clinical setting. Although their medical problem is not life threatening in the traditional sense, it is nevertheless life defining. Physicians experienced in caring for infertile couples clearly understand the degree of intensity in such couples. The amount of time required to deal with the emotional and clinical needs of the couple can be extensive. Second, the field of reproductive medicine and infertility is expanding at a rapid rate. Diagnostic and treatment options that were common during the training of many generalist obstetrician/gynecologists are often outdated or even obsolete. Thus, the generalist may not be able to provide all of the most advanced treatment options. Finally, as resident work hours have been limited, resident education and training in reproductive endocrinology is often the first service to be sacrificed. This has resulted in many young obstetrician/gynecologists with extremely limited experience in this field who therefore feel challenged to provide such treatment. In considering how best to integrate the diagnosis and treatment of infertile couples into a generalist’s office, the obstetrician/gynecologist should initiate a self-evaluation process in his or her practice. The first requirement is a strong interest and desire to address the complex and demanding needs of infertile couples. It is usually not enough for a single physician within the practice to have this interest. A strong team approach involving nurses, physician assistants, and/or partners is critically important to caring for infertile couples effectively. For example, certain diagnostic tests and treatments are often linked to specific times in a patient’s cycle. General obstetrician/gynecologists are often required to be present for labor and delivery or in an operating room, and a team member must be available to provide the diagnostic service or treatment required during those absences. Furthermore, the physician must decide how the practice can accommodate weekend visits. Such visits are routinely required for ovulation monitoring and inseminations and may not be feasible within the practice unless there is a broad acceptance of these responsibilities by a critical mass of practitioners within the group. Integrating Infertility Evaluation and Treatment Into the General Ob/Gyn Office

Prevention of Venous Thromboembolic Events Associated With Gynecologic Surgery

Venous thromboembolic events (VTEs), including deep vein thrombosis (DVT) and pulmonary embolus (PE), are known complications of surgery. The morbidity associated with VTE includes both the acute and chronic consequences of the event, but the primary importance is the mortality associated with PE. PE is known as the most common preventable cause of death among hospitalized patients in the United States.1 Because thromboembolic events can lead to death, current efforts are aimed at identifying patients at risk and instituting steps to prevent this complication. The risk of a patient having a VTE is a combination of the patient’s predisposing factors, the type of surgery that is planned, and the postoperative management and course. The current options for prophylaxis include pneumatic compression, unfractionated or low-molecular-weight heparin (LMWH), or a combination of the two. The type of prophylaxis chosen should be specific to each patient after considering her risk factors.

Evaluation of Patients With Primary Amenorrhea

Initiation of menses depends on maturation of the hypothalamic-pituitary signaling process, the presence of at least one functional ovary, and an intact anatomic tract. The absence of normal functioning at any of these three levels can result in primary amenorrhea. The differential diagnosis of the cause of primary amenorrhea may be daunting to obstetrician/gynecologists who do not often see this problem. Therefore, evaluation of patients with primary amenorrhea may be stressful to the physician, in part due to the infrequency with which patients present with this problem, but also due to the gravity and importance of making a proper diagnosis.

Diagnosis and Treatment of Asherman Syndrome

Heinrich Fritsch was the first to describe the condition of intrauterine adhesions in 1894. He reported a patient who experienced secondary amenorrhea after a postpartum curettage. Little was written about this syndrome until the 1940s, when Joseph G. Asherman recognized and described the now well-known relationship between endometrial trauma and the development of intrauterine adhesions. Following several publications on this topic, the condition of intrauterine adhesions became commonly known as Asherman syndrome.