Consider Heathcare Costs - Women's reproductive health the cost of various treatments and interventions

As the new Obama administration begin to take on trying to overhaul our health care system, it has brought to mind a few things that I thought I would share.

In reading the second volume of the Eleanor Roosevelt biography I was surprised to read how the United States had seriously considered implementing a national health care program but that it failed to get enough support. Whoa! Isn't that the same old tune we keep hearing.

At any rate, in light of my recent adventures in reproductive health and fertility I see the opportunity for savings. Here's how...

Fibroid interventions -- most American women seem to be offered hysterectomy as the ideal treatment for uterine fibroids. Regardless of whether the procedure is done with abdominal surgery or trans-vaginally, this is a major surgical procedure involving hospital stay, and with its inherent post-operative risks of infection, etc. Also, hysterectomy can be associated with physical changes which can lead to ongoing treatment with medication for pain, sexual side effects and more. Since most women have discussions solely with their ob/gyn about their fibroid related symptoms, and since ob/gyns are trained in hysterectomy that is what is offered. Yet, fibroid embolization is an appropriate treatment for women who are finished having families.

Abdominal myomectomy is the current standard of care for women wanted to preserve their fertility, and it costs are comparable, if not a little higher, to the cost of an abdominal hysterectomy (due to the longer length of the procedure as I understand it). Again, fibroid embolization (UFE, UAE) might also be appropriate for younger women as well -- further studies are needed to determine its affects on fertility post procedure. Also, I'm interested to see what ongoing screening and increased understanding of hormonal imbalances contributing to fibroid growth might uncover in the way of reducing the formation of more troublesome fibroid related symptoms.

Obstetrical care in the U.S. is a huge expense -- I saw mention that it might be a 5th of total health care costs -- and yet it isn't even a part of the discussion how unnecessary interventions and liability-based delivery management practices are driving costs much, much higher.

Check out some links on the subject:

Commentary in response to New York Times' November 25th Editorial on the High Cost of Health Care
Faith Gibson ~ December 31, 2007

How Childbirth Went Industrial: A Deconstruction

http://www.normalbirth.org/NYTimes_guest_opinion_Dec07.htm - mothering.com

Management of Suspected Fetal Macrosomia
Macrosomia is the medical term for a big baby -- noted in this article as "arbitrarily defined" at 8 lb, 13 oz. (4,000 g)
A recent decision analysis estimated that to prevent one case of permanent brachial plexus injury, 3,700 women with an estimated fetal weight of 4,500 g would need to have an elective cesarean section for suspected macrosomia at a cost of $8.7 million per case prevented.

Revealing the Real Risks: Obstetrical Interventions and Maternal Mortality
By Marsden Wagner - Issue 118, May/June 2003

A Guide to Effective Care in Pregnancy and Childbirth - Synopsis
This page links to interventions grouped as:
(1) beneficial forms of care;
(2) forms of care that are likely to be beneficial;
(3) forms of care with a trade-off between beneficial and adverse effects;
(4) forms of care of unknown effectiveness;
(5) forms of care that are unlikely to be beneficial;
(6) forms of care that are likely to be ineffective or harmful.


An Interview With Ina May Gaskin
by Stacy Fine - Web Interview - June 29, 2007
Both maternal and infant mortality are currently rising in the US. Maternal death rates have not improved, according to the Centers for Disease Control, since 1982. That's a long time to have had no progress, despite all of the technological innovations that have taken place since then. Part of the problem in this sector is that the US has never created a system of accurate reporting of the data necessary to find out what mistakes we might be making so that we can analyze them and then make policy that reduces the likelihood of mistakes being repeated. The United Kingdom (England, Scotland, Wales, and Northern Ireland) have had such a system in place since 1952, which is probably why their maternal death rate is significantly lower than ours in the US. I don't know of any European country in which maternal death classification is done according to an honor system, but that is exactly what is done in almost every US state. There is no audit, and autopsies are less likely to be performed here than in European countries.

CONFIDENTIAL ENQUIRIES INTO MATERNAL AND CHILD HEALTH (CEMACH)
Confidential Enquiry into Maternal and Child Health (CEMACH) commenced in April 2003. We aim to improve the health of mothers, babies and children by carrying out confidential enquiries on a nationwide basis and by widely disseminating our findings and recommendations.

(Vasectomy and) Vasectomy Reversal Information

I'm surprised that I haven't really posted about it before but I guess since my partner's reversal was so long ago (1998) that I haven't really gone into it in much detail over the past three years. I'll try to remedy that so that others can learn from what I've learned.

My partner thought that he was going to help out the overpopulation problem and in a fit of idealism and with encouragement from his wife at the time, underwent a vasectomy. That was several years before we met, and as it would happen, on the cusp of the end of his marriage. I can't really speak too much as to how his post-op recovery was though I know that he went in for the procedure alone and was hurt that she didn't even come to see him home afterwards. (Lesson #1 -- it is an emotional thing and the female partner should be there to provide support).

I've had a few sexual partners in my past and so I was a little familiar with what ejaculate looks like. What was weird about my partner's prior to his reversal was that it was thicker than the intact guys I engaged with. I guess this is due to the ejaculate just containing the portions from the prostate and seminal vesicals. After his reversal it returned to a normal looking consistency.

The final product of semen that you see when you come contains only 5% sperm; the other 95% is made-up of secretions from the seminal vesicles (considered an extension of the prostate) and prostate fluid (about 80% of the final mix), which gives ejaculate its whitish color.
From Premature Ejaculation


From when we first started dating he told me he intended to have a reversal, he had already worked through his regrets about having the procedure and so we knew it was on the horizon. From what we learned online at the time, having a reversal within 4-5 years of the initial vasectomy supposedly would help to ensure a greater likelihood of success.

The first step was to locate a doctor who specialized in vas reversals as we wanted this done right the first time. I searched online and at the time, Columbia University had and still has some great vasectomy reversal info and doctors who looked pretty good but through a friend's father who is a urologist in Washington, we learned about Dr. Dale McClure , a urologist specializing in fertility at Virginia Mason Hospital. My partner, since we were still just dating at the time, went for his appointments without me. I remember feeling embarrassed when he came back and told me that Dr. McClure asked about the fertility of his partner (me) and he provided some answer about my having regular cycles -- ack! things were going really fast for me and we'd only been together for a couple years.

The surgery was scheduled to be done through a facility at Group Health Hospital on Capitol Hill; there was some reason it was done there which if I recall correctly might have had to do with both insurance and the technology available. I insisted on being at the hospital the day of the operation, knowing how hurt he had been by the lack of support when he had his vas.

On the Internet prior, we had learned that the medical term for a vasectomy reversal is vasovasostomy and that there was a microsurgical technique used to sew the tiny vas deferens back together again using a fancy sewing technique under intense magnification -- this techique was supposed to have a higher success rates than older techniques.

Prior to the procedure my partner was sedated in a pre-op are and I was able to spend time with him and massaged his feet and kept him relaxed and calm (it was from this experience that he learned how to take care of me surrounding my first d&c and then my fibroid surgery which was really nice for me). The nurses told him that he better be really nice to me and that I was a "keeper". When he was good and loopy on the meds I stepped out into the waiting room and he went into the operatory. I told him that I would be there the entire time he was being operated on so he should know that he wasn't alone ever.

[Graphic detail]
From what he's told me, in the operatory he was awake but sedated during the operation. There was a camera pointed at his testes throughout the procedure, with a screen within his view which was fairly intense for him to watch. The doctor made two incisions into the front of he scrotum and lifted out his testicles to have access to the surgical site (in contrast, vasectomies are done through very small incisions through the back of the scrotum). When it would get too intense for my partner he would tell the nurse to dose him more. It took about two hours to do the operation and then he was moved out into post-op where I was able to come in and see him and rub his feet some more.
[end graphic detail]

We left the hospital that afternoon and went home to rest. He was instructed to not ejaculate/have sexual intercourse for four weeks after the operation to help with healing. Since then I've heard of other doctors wanting to have men begin ejaculating sooner (10 days post-op) to help keep the vas open. I don't know if there is a standard, I assume it is still going to be based on your doctor's own experience and preference. While he was healing the most noticible thing was that his scrotum was HUGE. His balls were swollen to the size of large oranges at least and it took weeks for the swelling to go down.

I believe he was meant to have a semen analysis within a few months of the procedure but we weren't ready to start a family yet and the doctor said that he had found sperm during the procedure from the testical side of the vas. I think it was fear of it not working more than anything that made my partner delay his semen analysis. Finally over a year later he went in and had it done and the results were pretty poor by WHO standards. He was instructed to come back for another test in a few months if I recall correctly. He asked the doctor at the time about some ongoing pain that he had in his scrotum/testes and the doctor thought it might just be part of the healing process. We felt a bit discouraged but only time would tell.

Specific things we learned along the way from our experience:

There might be pain for a while

Sperm counts might be low for a while and continue to improve over time without intervention (we saw significant improvement after 2 years)

Ejaculate consistency will change after the reversal, to a more normal consistency

You should be sure to have a semen analysis based on Kruger morphology standards and not just WHO standards, and also make sure you are tested for anti-sperm antibodies as well

MFI supplement cocktails can actually improve morphology

The our doctor felt that our chances of conception would be better with a repeat reversal (though it wasn't required ultimately because things improved on their own) than with trying TESE/IVF

General post vas reversal fertility info:

There is a greater chance of having ROS damage to the sperm

That the success rates post procedure have more to do with the health and age of the female partner than just on the time between vasectomy and reversal

That there is about a 50% chance of conceiving on your own post reversal

Vasectomy and Vasectomy Reversal Links:

FIND A SURGEON

Society for Male Reproduction and Urology (SMRU) - Member Search

INFORMATION ABOUT THE PROCEDURE

The Patient's Guide to Vasectomy Reversal

Microscopic Vasovasostomy

Vasectomy Reversal - Introduction

Microsurgical Vasectomy Reversal

What's New in Male Infertility Treatment at Cornell
Vasectomy Reversal: The Microdot Method for Precision Suture Placement

Google Groups: alt.support.vasectomy

International Center for Vasectomy Reversal

Vasectomy Reversal - Johns Hopkins

Building Bridges to Conception - Vasectomy Reversal

Vasectomy Reversal Questions &s; Answers

Microscopic Vasectomy Reversal

Vasovasostomy

The Infertility Center - FAQs - vas reveral Qs and As link

Cary Urology Vasectomy Reversal

Vasectomy.com

ARTICLES ON VARIOUS RELATED TOPICS

Warning over vasectomy reversals

Vasectomy - Can it be reversed?

Morphological changes of spermatozoa in proximal vas deferens after vasectomy

Microsurgical Vasovasostomy versus Microsurgical Epididymal Sperm Aspiration/Testicular Extraction of Sperm Combined with Intracytoplasmic Sperm Injection

Some vasovasostomized men are characterized by low levels of P34H, an epididymal sperm protein.

Vasectomy Myth Debunked: NewYork-Presbyterian/Weill Cornell Study Finds Vasectomy Reversal Highly Effective, Even After 15 Years

Vasectomy Reversal & Sperm Antibodies

VASECTOMY

Vasectomy Blog

Vasectomy Information

To someone who is wondering whether or not to have a myo

Lots of women get pg with fibroids in place, it is an elective procedure however so in part you get to decide when it is right for you. Some considerations I've noted about when it is a good time to have fibroid surgery:

• you feel like you have exhausted all other possible treatment options
  
• you are feeling pain and discomfort, even some of the time. This can include back pain, pelvic pain, leg pain, etc.
  
• you are having bleeding problems (really heavy periods, or periods that don't seem to stop -- this can lead to problems with anemia which can impair fertility and put you at risk for other health problems such as clotting)
  
• you have had trouble conceiving or have had miscarriage/s
  
• you are wanting to try hormonal fertility treatments and your fibroids are already a good size
  
• you are having difficulty urinating or are having to pee all the time or you are developing urinary tract infections
  
• you can't stand the thought of having fibroids inside of you and want to get rid of them
  
• you fibroids are compromising the interior space of the uterus
  

Since you are already dealing with TTC with one tube I can see that it doesn't feel like a straight shot decision for you at all. There is a risk of adhesions after any abdominal surgery, but whether or not these will cause problems is another question.

The surgery is a big deal in that it can be quite invasive and most of us haven't had that much physical trauma before. It is also one that you will recover from quickly. An abdominal myo is very similar to a c-section and loads of women have those operations every day.

Have you read What Your Doctor May Not Tell You About Fibroids yet? It is a super book that really helped me to feel empowered about my body and my fibroids. It describes in detail about the various procedure options and includes info about fertility success rates post-op.

14+ days post op

So I had my post-op visit yesterday morning and everything was good, she said I looked great. She said removing my retained POC was very difficult because of the fibroid and that there was no way for my uterus to expel the tissue on its own based on how the fibroid was positioned filling the interior of the uterus. So my prospects for a normal vaginal delivery were probably slim to none since my uterus couldn't contract well, or at least I would have had a complicated delivery. I was sooooo uncomfortable when I was pg with the rapid fibroid growth and the pregnancy having to grow off to the side because that was the only way my uterus would move, next time should be a lot better.

My doc also said that my uterus will be enlarged for a while, shrinking back some but that it would never be the size of a normal unpregnant uterus since the fibroid made the muscle wall have to grow larger. Maybe I'll be extra fertile now though, the interior of my uterus will be one vast space with lots of room for an embryo to settle in.

She said I could remove the steri strips in the shower or bath, I just pulled them off carefully when they were dry, the adhesive was already starting to go. Uncovering the incision though made it burn more, I think this is partly due to my nerves regrowing right now --
they have to cut through some in the skin there and they may or may
not grow back completely. I had to take the 600mg ibuprofen and after an hour that wasn't helping so I took a percocet and it really helped take the edge off the pain. My father said he had that same burning sensation as he healed from his triple by-pass a few years ago. The incision looks great and I don't think that it will show that much at all in a few months.



She agreed that starting trying to conceive (TTC) again in February
sounded like a good idea and that we should try for a few months on
our own before going back for any more fertility consultations. After having way too much medical attention over the past 6 months (due mostly to the pregnancy/miscarriage) and way, way too many blood draws for my liking, now I'm in a holding pattern and it feels so strange to be told that I'm healthy and back on my own. Not that I liked being not well but you do sort of get adapted to fitting in the medical care when things go wrong. Yeah to be healthy again though!

Oh and I guess it was around 11 days post op that I started to feel
more myself and I've been less fatigued and able to do more around
the house, tidying up, cooking, light cleaning, etc.

What happens when you are having a myo

I'm on bed rest one week and two days post abdominal myo and I'm feeling great. Tired but healing quickly. Since you were curious about the before and after...

Pre-op consult -- they take your blood pressure, weight, check your blood to make sure you aren't anemic and get your blood type if they don't have it on record. You meet with your doc and ask last minute questions and sign a few forms. Sometime you will get to meet with the anesthesiologist at this time but I didn't. They give you instructions on when to stop eating and drinking prior to surgery.

Day of surgery -- check in 2 hours beforehand. I brought knitting to keep my hands busy and mind calm. The hospital seems to make you keep signing forms that say the same thing (whatever). My surgery was delayed by more than an hour so we went home for an hour and I did some last minute housecleaning.

When it is your turn they take you into an area with a gurney and give you a hospital gown to change into. My partner was allowed to be with me until they were ready to take me into the operating room (my doc said -- be sure to ask yours ahead of time about this). They hook you up to an IV and the anesthesiologist asks you questions about your previous experiences with anaesthesia. You have the option of asking for an epidural with sedation if you prefer, it is up to you and the anesthesiologist. I did the general and it was fine. They take your bag and you say goodbye and then they wheel you in to a freezing cold room. They hook you up to a blood pressure cuff and the oxygen monitor (little finger cuff) and then put a blanket over you. The anesthesiologist puts a mask on your face and tells you to breathe in oxygen and the next thing you know you are waking up in recovery.

They keep taking your blood pressure alot post-op and you are groggy and have a hard time opening your eyes. You are hooked up to a PCA, where you are able to dose yourself with painkillers as needed -- don't hold back because staying on top of the pain at first will help you a lot. After about an hour they wheel you to your room. They put some pressure stocking on your legs and some cuffs that compress/decompress automatically to help prevent blood clots. My wound was covered with a bandage so I couldn't see the incision -- thankfully. I had a catheter in for not even a full day, but know that the first pee can be really difficult. The nurse gave me warm water to run over my vagina while on the toilet and that helped get things moving. I recommend drinking unsweetened grape or cranberry juice for a week afterwards to help ward off a urinary tract infection -- it helps prevent bacteria from adhering to the lining of your bladder, etc.

They will have you up and walking less than a day after surgery, take it slow and roll onto your side slightly, then drop your legs off the bed and use those side muscles to lift you up. The first few times you get up will be very awkward and painful. Stay on top of the pain meds and breathe a lot and you will do fine. The pain isn't excruciating, I ranked the worst at 5 on a scale of 1-10 but it was mostly around 3-4.

And then do as I've been advised from other post myo gals -- take it easy and don't push yourself. Even though my incision looks great I can't see my uterus and it has a lot more healing to do than my skin.

Preparing for surgery with homeopathy/naturopathy

I was directed by my naturopath to take phosphorus c, a homeopathic remedy, prior to having the surgery to help my body with nausea from the anaesthesia.

Homeopathic arnica was advised to help deal with the swelling and bruising. I am supposed to start taking this several days beforehand and several friends swear by it.

She also recommended Rescue Remedy from Bach's Remedies, flower essences, to help deal with the stress prior to the surgery. And Gelsemium 30c, 2 pellets as needed for anticipatory anxiety.

These "meds" are at worst sugar pills and quackery, at best they work wonders. They should not interfere with the procedure or anaesthesia and if you believe they will work then placebo affect or not they will provide you with some relief. I think I'll give them a go since I've got nothing to lose.

I will also be taking Traumogen, a vitamin supplement that helps aid the body with nutrients that aid in healing tissue.

Here are some links about natural medicine and surgery to check out:

Homeopathy and Surgery
http://www.drfeder.com/general-health/healing-surgery.htm

Surgery Recovery Program
http://www.naturodoc.com/library/surgery/surg_recovery.htm

Laparoscopy - how to prepare for your surgery
http://www.endo-resolved.com/laparoscopy_advice.html

Is Arnica montana safe to take after plastic surgery?
http://www.eclecticphysician.com/archive.php?action=Nbr&Nbr=235

Abdominals not cut, Myo not panacea for fertility problems

ARE THE ABDOMINAL MUSCLES CUT DURING MYO?

I was worried about my abdominal muscles being damaged during myo (which have yet to undergo) and I asked the surgeon about it. She told me that they do not cut the abdominal muscles, instead they just push them to the sides, and I imagine they brace them there.

They do cut through some connective tissue and the abdominal fascia, a membrane that holds your internal organs together, but they stitch the fascia closed at the end of the procedure (I'm not sure if they reconnect the connective tissue -- I haven't seen mention of that anywhere) What Your Doctor May Not Tell You About Fibroids includes a detailed description of the procedure that you may with to refer to.

MYO TO IMPROVE FERTILITY

The ability of myomectomy to improve fertility is not definative at this point in time (this is confirmed in What Your Doctor May Not Tell You About Fibroids by Dr Michael Brody, an ob/gyn and former RAND medical researcher). There have been annectodal stories of success by patients and doctors but current research has had flaws that limit its usefulness in determining the appropriateness of this procedure to treat infertility, especially if other factors exist that may be contributing to the infertility (male factor, blocked tubes, endocrine issues, etc.) This is partly why I have been reluctant to undergo this procedure for my largely asymptomatic fibroid, we have a known male factor.

Gynecologic Myomectomy
"Myomectomy is also performed frequently in patients with infertility with the presence of fibroids (Vercillini, 1998). Studies supporting myomectomy as a fertility-enhancing procedure are uncontrolled and do not use life-table analysis; nonetheless, a number of authors recommend offering myomectomy to women who are infertile after other causes of infertility have been eliminated (Hutchins, 1995;
Nachtigal, 1989; Verkauf, 1996).

Several papers suggest that patients with fibroids who are undergoing assisted reproductive technology procedures may have lower success rates compared to patients without fibroids. Stovall et al (1998) noted decreased fertility rates in patients with any myomas undergoing in vitro fertilization or zygote intrafallopian transfer. Eldar-Geva and coworkers (1998) noted decreased success in patients with intramural and submucosal myomas but not in those with subserosal myomas. Ramzy et al (1998) noted no change in fertility, but this study specifically excluded anyone with large, submucous, or intramural myomas that distorted the endometrial cavity. Importantly, note that no randomized studies document that removal of these myomas
improves success rates."


TABLE 1 - ACOG CRITERIA FOR MYOMECTOMY IN INFERTILITY PATIENTS
Procedure:
Myomectomy* (68.29) (CPT Codes 56309 [laparoscopy with removal of leiomyomata], 58140 [abdominal approach], or 58145 [vaginal approach]

Indication:
Leiomyomata (218.0-218.9) in infertility patients (628.3), asa probable factor in failure to conceive or in recurrent pregnancy loss
(646.3)

Confirmation of Indication:
In the presence of failure to conceive or recurrent pregnancy loss:
1. Presence of leiomyomata of sufficient size or specific location to be a probable factor
2. No more likely explanation exists for failure to conceive or recurrent pregnancy loss

Actions Prior to Procedure:
1. Evaluate other causes of male and female infertility or recurrent pregnancy loss
2. Evaluate the endometrial cavity and fallopian tubes, e.g. hysterosalpingogram
3. Document discussion that complexity of disease process may require hysterectomy

My Reasons for Not Wanting a Myo

Here are my reasons for not wanting a myomectomy:

1. major abdominal surgery
2. risk of adhesions
3. length of recovery period
4. fact that with multiple factors there isn't a documented increase
in fertility
5. they would require me to deliver by c-section if I did get pregnant post myo
6. that I'm largely asymptomatic except for slightly heavier periods and some pelvic pain for a few days prior to ovulation and at the start of my period

We don't even know if we want to do any assisted reproductive therapy anyway, we went to the reproductive endocrinologists (RE) to get their opinion on our situation (my partner had a vasectomy reversal and has an issue with sperm morphology -- morphology refers to shape of the sperm). It was just kind of intense having the head of reproductive endocrinology at a leading university tell you that he consulted with all of the other REs and they've decided they don't want to be my friend.

I've always wanted to go the natural way -- I was never on birth control pills, don't eat junk food really, stay fit. I don't like it when the medical establishment says (in its Terminator voice) "you are infertile. we will cut you open and remove that fibroid. take these drugs and we will harvest your eggs and MAKE you pregnant."

Now I don't know how the rest of you feel but I'm not feeling like I want to go out on a limb with any procedure since I would feel worse if I didn't feel like my care providers were on my side. I guess I will continue doing my watch and wait routine and in the meantime at least take advantage of the MRI order from the RE so I can learn more about what's inside of me. Maybe God or the Universe will intervene in the meantime.