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Hopkins News for You
This is a monthly service for our friends and patients around the world from Johns Hopkins International. To receive monthly reports via e-mail, please send e-mail to patientnewsletter@jhmi.edu .
August 2002
1. Avoiding the Big One
2. Dealing with PSA Anxiety
Dr. Jairo Garcia discusses treatments for infertility
1. Avoiding the Big One
Shortness of breath or pain in the chest and arms can be the first signs of heart disease, but Hopkins cardiologist Roger Blumenthal, M.D., says this is not always the case. "In about 20 percent of patients we studied, sudden cardiac death is the first sign of heart disease. In 30 percent, the first sign of heart disease is a major heart attack." Often, doctors use physical exertion or stress tests to determine the level of heart disease in a patient. But according to Dr. Blumenthal, these tests can give false results. "Many times a stress test may be normal even if an artery is clogged 60 percent or more, so you can have a high level of heart disease and still have a normal stress test."
So, how does one spot a heart attack before it occurs? For many patients, the answer could be a relatively new type of CAT scan called Electron Beam Tomography, or EBT. Doctors have long sought to non-invasively measure how much plaque has built up in coronary arteries. This plaque can completely clog an artery and cause a heart attack, or it can break loose and lead to a heart attack or stroke. EBT is considered more accurate than a stress test and its results allow doctors to design medical, lifestyle, or surgical interventions that reduce the risk of heart attack and stroke. The test takes less than 10 minutes and can be scored quickly by a technologist and a physician.
2. Dealing with PSA Anxiety
The possible return of PSA after prostate cancer surgery is a patient's worst fear. The good news is, you may not need to do anything for years. In a major study of the return of PSA after surgery, Hopkins urologists have developed guidelines in a table format to help patients and doctors know what to do if PSA comes back. The tables consider the patient's Gleason score (the removed prostate evaluated by a pathologist after surgery), the time it takes for PSA to come back, and how rapidly the PSA level doubles, in order to predict the patient's chances of developing metastatic disease (cancer that has spread beyond the prostate). "We asked if we could predict how long it would take for metastases to show up on a bone scan, and once that happened, how long would the patient live?" explains Patrick Walsh, M.D., head of urology. "The news is good: most patients do very well for a long period of time."
On average, it took eight years from the time a man's PSA first went up until he developed metastatic disease which suggests, according to Dr. Walsh, "there is no need to panic" at the first sign of a rise in PSA. Even after developing metastatic cancer, men still lived an average of five years. And if the metastases showed up more than seven years after surgery, men had a seventy percent chance of being alive seven years later. "When men see their PSA levels rise again, they think it means the cancer is back and they need to get treated right away," says oncologist Mario Eisenberger, M.D., co-author of the study. "But men often live for years without having the cancer spread." "The first thing these tables can do is reassure the many patients who are going to have a long-term, symptom-free, metastatis-free interval, that close observation is all that is really necessary," says Dr. Walsh.
Question: When should a woman consider using ART to enhance her chances of becoming pregnant?
Dr. Garcia: ART is indicated in patients who have no fallopian tubes because of previous infections, exposure to DES, or because they have been removed due to previous tubal pregnancy; patients who have had a tubal ligation and whose fallopian tubes are beyond repair; and patients whose husbands have a low sperm count or have had a vasectomy.
Question: What are the various procedures available?
Dr. Garcia: Patients interested in ART can look for centers that offer the following procedures:
1. Assisted Hatching : Helps embryos attach to the lining of the uterus for implantation.
2. Intrauterine Insemination (IUI): Semen from the husband is "washed" to improve its concentration and function, and placed into the uterine cavity.
3. In Vitro Fertilization (IVF): Medications stimulate the ovaries to produce more eggs, which are then harvested and placed with the husband's sperm in a culture dish for fertilization and subsequent transfer into the uterus.
4. Gamete Intrafallopian Transfer (GIFT): Involves placing eggs and sperm into the open end of a healthy fallopian tube, allowing fertilization to occur naturally.
5. Zygote Intrafallopian Transfer (ZIFT): Identical to GIFT except that the eggs are fertilized in a culture dish before being placed in the fallopian tubes two days later.
6. Intracytoplasmic Sperm Injection (ICSI): A variation of IVF in which the egg is injected with a single sperm and embryos are placed in the uterus several days later.
7. Cryopreservation: Embryos are frozen for future IVF attempts.
8. Donor Egg: women unable to produce an egg or an embryo but who still wish to carry a baby to term may use eggs donated by another woman between the ages of 21 and 30 years of age.
9. Donor Sperm: Used when the man is sterile, donor sperm is screened for several hereditary and infectious diseases, and to match desired physical characteristics as closely as possible.
10. Transmyometrial Embryo Transfer: Involves placing the embryos between the endometrial mucosa and the myometrium (uterine muscle).
Question: What should I look for when selecting an IVF specialist?
Dr. Garcia: Look for an IVF program that is affiliated with the Society for Assisted Reproductive Technology (SART), that has a group of physicians and embryologists with good experience in the field, who are knowledgeable about all the forms of ovulation induction, oocyte retrieval, embryo transfer, and the ART procedures listed above. You should also look for a program where the ICSI procedure is performed. The pregnancy rate depends upon the age of the patient, the ovarian stimulation, and the number of embryos to be transferred, and is judged on a case-by-case basis.
Question: What are the risks of undergoing IVF?
Dr. Garcia: Risks include multiple pregnancy, tubal pregnancy, infection, bleeding during the procedures, development of Ovarian Hyperstimulation Syndrome (enlarged ovaries, fluid retention, shortness of breath, and other complications that require immediate and expert attention).
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