My Life in Ob-gyn

1. My Life in Ob-gyn Vance Mason, MD 4-16-2010

2. What is ob-gyn? • Women’s health care & reproduction • I don’t see men unless part of infertility • I chose it because the patients are mostly healthy most of the time and I love surgery

3. Schooling • 4 years college • 4 years medical school- 1st 2 books, 2nd 2 “field work” • 4 years “residency” in Ob-Gyn ( also called ‘specialty training’) • I now teach young doctors and care for patients in Westminster

4. How do embryos know what gender to be? • It’s complicated –

5. How do embryos know what gender to be? • Y chromosome is key – • It tells fetal gonad to make testosterone and “Mullerian Inhibiting Factor” • MIF tells tubes that make uterus and top half of vagina to go away • Testosterone tells lower vagina/cloaca to fuse together and make a penis and scrotum

8. What if the testosterone receptor doesn’t work? • Tubes that make uterus still go away • Bottom half of vagina stays vagina-like • No scrotum made, • No penis made • Fetal gonad is still a testis though • Chromosomes are still XY

9. What would a person like this look like?

11. Jamie Lee Curtis • Looks female (very) • Testosterone is converted to estrogen which assures breast development • Can’t have children • Chromosomes are XY

12. How fertility works • Woman makes an egg (ovulates) • Egg pops loose from ovary, Fallopian tube picks it up • As the egg travels down the tube, it meets the sperm-sperm does not have to swim much • A single sperm enters the egg • Egg immediately changes so no more sperm can enter

13. Fertility • Egg cannot let in more than one sperm or there will be too many chromosomes – • Our cells each have 46 chromosomes • Egg has 23 • Sperm has 23 • Another sperm would make 69 chromosomes, pregnancy would miscarry

15. Fertilization • Fertilized egg begins dividing • Fertilized egg travels down tube to uterus • Fertilized egg plants in uterine lining (endometrium)

16. Pregnancy • Fertilized egg becomes an embryo • Embryo grows and grows • Nine months later, woman goes into labor • Baby is pushed out (head first is safest)

17. Do I ever have to choose between baby and mother’s life? • No- • Soap opera’s not very medically savvy

18. Can fraternal twins have different dads? • Yes! Tricky though- • Fraternal twins come from two different eggs • If woman had sex with two different men on the same day, a sperm from one man could fertilize one of the eggs and the other man the other • Very rare

19. These Dutch twins were conceived in vitro with sperm from 2 different donors accidentally

20. These twins look different but are really from the same dad- both mom and dad are “mixed race”-normal variation comes up with new gene combos to keep parasites and germs guessing

22. Why do some babies go breech? • No one really knows • Most probably just get “stuck” that way • Half or more can be turned around by pushing on mother’s stomach at 36 weeks (external version)

23. Why is breech birth more risky? • Head is biggest part of baby • Head can be trapped if baby is breech • Baby can die • Head makes the best “cork” – umbilical cord can sometimes pop out if breech • “Prolapsed” umbilical cord can get strangled, baby can’t get oxygen from cord

24. Who gets a Cesarean section? • Baby too big to fit through pelvis or • Baby suffers too much stress for safety or • Mother is very ill or • Breech presentation – dangerous for baby or • Mother wants a repeat CS after past CS • 32% of all babies in US now delivered by C-section

25. How to operate on a uterus • It takes many people – at least 4 – • Anesthesia person to take away pain • Surgeon • Surgical assistant • Helper for the baby if a c-section • Scrub nurse • Circulating nurse • Recovery room nurse

26. How to operate on a uterus • Cut the skin • Cut the “fascia” – strong white layer under skin • Cut the uterine wall – • Be careful not to cut baby or mom’s bladder • Deliver baby and placenta • Sew each layer up

27. Can you operate on a baby that is still in the womb? • Some super-specialists do this – • Some babies have large growths that must be removed or their lungs can’t grow • Very experimental still – • Risks preterm delivery

28. Miscarriage • If pregnancy doesn’t develop properly, it will miscarry • Most miscarriages are before the 12th week • Most miscarriages are from chromosome mismatches, even when both parents have normal chromosomes • 1/2 our chromosomes from Mom, ½ from Dad

29. Miscarriage • Miscarriage is very common – at least 25% of women will have one • Mother’s health usually normal even after several miscarriages • Mother’s body usually has no trouble miscarrying and getting ready for future pregnancy afterward

30. Infertility • If 100 couples try, 90 will be pregnant within one year • Half of those who try will get pregnant within 3 months • Woman’s most fertile time is the few days around ovulation – days 12-15 of a 28 day cycle (day 1 is first day of any bleeding)

31. Infertility • Can vigorous weight lifting cause infertility? • No

32. Infertility – what is the workup? • Make sure man is making sperm (40% of men getting workup will not be) • Make sure woman is ovulating • Make sure Fallopian tubes are open • Make sure uterus has normal shape • Make sure woman’s other hormones are normal (thyroid, prolactin, insulin)

34. Infertility - treatments • Use donor sperm • Give drugs to woman to help her ovulate • Operate on Fallopian tubes to open them • Bring egg and sperm together in petri dish, then put embryo in uterus

35. Signs of ovulation • Mittelschmerz – side pains when ovary stretches ovary capsule • Clear, sticky cervical mucus (Spinbarkeit mucus)

36. Contraception • Abstinence • Withdrawal – not very effective, better than nothing • Condoms – also prevents most infections • Birth control pill/Vaginal ring/ Patches • Morning after pill • Intrauterine device (IUD)(hormone or Cu) • Depo Provera shots (hormone shots) • Implanon (Hormone implant in arm) • Vaginal sponge with spermicide

37. contraceptive myths • You can’t get pregnant the 1st time you have sex • You can’t get pregnant unless you’re married • You can’t get pregnant if your periods are irregular

38. Which contraceptives affect hormones? • Birth control pills • Vaginal ring • Implanon • Depo Provera • Patch • Plan B • Hormone IUD (Mirena)

39. What are pill hormone side effects? • Bad side effects: • Nausea • Headache • Sore breasts • Good side effects: • Lighter periods or no periods • Less painful periods • Less acne

40. Morning after pill • Brand name: Plan B • The sooner after sex you take it the more effective • 90% effective if taken <72 hrs after sex • Prescription needed if under 17 • Cost is $50

41. How does Plan B work? • Egg has to travel down fallopian tube at a normal rate to be fertile • Hormones in Plan B probably speed up tubal transport • Egg may be in wrong part of tube when sperm arrives, can’t receive/accept sperm • Egg may arrive in uterus before it is ready and cannot implant

42. How does Birth control pill work? • Hormones in pill tell ovary not to make an egg • Hormones in pill tell cervix not to make stringy, clear mucus (sperm need that type of mucus to get through the cervix)

43. Ovary Cancer • Affects one woman in 50 • Symptoms are often vague until too late • Oncologists specialize in cancers • Gyn-oncologists ( Gyn-Oncs) care for women with ovary cancer • Five year survival after diagnosis is 20% • Taking birth control pill cuts risk 50%

44. Age at first sex • National average is 16 • The more schooling you get, the older you are when you first have sex • For college students, average is 19 • Allpersons having sex should be contracepting unless they want to get pregnant

45. Stress and ob-gyn doctors • Sleep deprivation • Lawsuits • People can die • Many things happening at once • Need to be able to make good decisions quickly • Money decreasing

46. Prenatal diagnosis • Can you tell if a baby will have a mental health issue before they are born? • Usually no – • Exceptions: Fetal Alcohol syndrome (babies born to alcoholics often mentally retarded), Down syndrome (trisomy 21)

47. Pregnant women who smoke & drink • Smoking during pregnancy causes preterm delivery and skinny babies • Alcohol during pregnancy causes mental retardation and skinny babies • Counsel women to stop, give nicotine patch, Alcoholics Anonymous, jail if judge thinks baby threatened enough (rare)

48. Career highlights/lowlights • Worst part: Time away from family • Best part: Working w/mostly healthy patients most of the time • Worse part: Stifling, nonsensical, bureaucratic regulatory agencies and insurances • Better part: Getting to talk to all different kinds of people

49. Career highlights/lowlights • First surgery ever: circumcision • Most unexpected thing: Finding two babies at a c-section when only one was expected • Best moment of my career: Graduating residency

50. What areas of gynecology are poorly understood? • All of them • Research is hard to do – • Many human-subject-committees reluctant to allow research on pregnant women • American health system very fragmented, no good central databases