J.I.: Could you tell us a little bit about your training?
Dr. S.: I was in the M.D./Ph.D. program at the State University of New York at Buffalo. I started in '65 and I left in '72. From '72 to '73 I did an internship in obstetrics and gynecology. This was at the University of Michigan affiliated hospital at Ann Arbor. After that, I got accepted to the National Institute of Health, and I did a two-year post-doctoral fellowship at the National Cancer Institute from '73 to '75, at which point, I went back to clinical medicine. My wife is Canadian; we decided to see what Canada was like, so from '75 to '78 I did a residency in obstetrics and gynecology at McGill University in Montreal. Then I accepted a job as a junior professor at the University of Texas Health Science Center at San Antonio, and we were in San Antonio from the fall of '78 until we came to New York in '84. While I was there, the department was interested in having people do the fellowship in reproductive endocrinology, and being a faculty member I obliged. Then we came to New York in '84 and I've been in private practice since then.
J.I.: In terms of your experience with fertility issues, what is your perspective on what's going on in the fertility world in general? Are there issues that are in line with your beliefs, and issues that you feel need looking into?
Dr. S: The field is very technology driven. A lot of couples, when things don't work out, go into the more sophisticated, riskier, certainly more expensive technologies, simply because that is the pinnacle of what Western medicine, or what people would call, allopathic medicine has to offer. In other words, looking at an individual from a wellness or whole-body point of view, until fairly recently, has been rather foreign to the way reproductive endocrinology looks at things. When we go through a training program, the kind of things we focus on, are the more sophisticated procedures. The patients that come to a university teaching hospital have usually already explored other options available. The problem is that very often patients get on a reproductive treadmill of greater technology, greater risk, greater expense, with the hope of obtaining their goals, and of course sometimes it works, and sometimes it doesn't. Having been in the field for a number of years, having started an in-vitro fertilization unit at the University of Texas Health Science Center at San Antonio, I can say that, sometimes, if you do your homework well, you can obtain very good results with lower risk, lower cost, and less sophisticated technology. I'll give you an example: I have worked very closely with an andrologist who set up the semen lab at Rockefeller University a number of years ago. We worked together for a number of years before she left to go home to Israel and set up a unit there. Since she's an andrologist, meaning she's an expert in male infertility, she would often look at the semen analyses, and she could often tell me just by looking under a light microscope, a pretty simple tool, whether or not the person had an infection. And invariably she would be right. Very often by doing a simple diagnostic procedure, like cultures, you could find out what the problem was. And we had a lot of pregnancies simply by treating couples with antibiotics for an extended period of time to get rid of asymptomatic infections that had severe effects on their reproductive capacities. In other words, not chlamydia, which causes symptoms, but ureaplasma/mycoplasma, which is debated as to whether or not it causes infertility. In my colleague's opinion, it certainly affected sperm function, and by getting rid of the organism we would often obtain pregnancies without very high-tech procedures or tremendous expense for the couples. If you look at the overall couple from all spheres, you might avoid having them get on the treadmill of more sophisticated, more invasive, more expensive, procedures. Now, that's not true in all cases, but I think in a lot of cases you really have to have a solid history. You have to think about things like chronic diseases that may be asymptomatic, latent. You have to think about all the other factors that could go wrong in an infertility workup, then carry out the proper workup, come to some conclusion, and set a therapeutic goal for the couple.
J.I.: What about environmental issues, pesticides for example?
Dr. S.: My colleague and her husband, who's also a physician, published a paper in the Journal of the American Medical Association. Her husband is a world class expert in environmental medicine – toxicology and environmental pollution. A young man came to her because he and his wife had a long-standing infertility problem. His sperm count was very low and the over-all semen analysis was quite poor. It turned out he was an instructor in the police firing range somewhere in the city. No one had gotten that information from him up to that point. My colleague referred him to her husband, who did lead levels on this man – and they were astronomical! As soon as he was treated for lead intoxication his lead levels dropped, his semen count went up to the normal range, and, in the process of treatment, his wife became pregnant. So again, yes, environmental issues can be quite significant.
J.I.: How specifically do you feel about pesticides, DDT?
Dr. S.: That's a very tough question to answer, because we don't know the data well enough. But if, for example, you look at the history of the Peregrine Falcon in this country, there certainly seems to be a correlation between DDT and reproductive disorders. DDT has estrogenic properties and is picked up by estrogen receptors in the body, and the Peregrine Falcon in this country almost became extinct because of the widespread use of DDT. It disrupted their reproductive cycles. The hens couldn't lay eggs, or the eggs that they laid were soft-shelled and degraded rapidly. They stopped having offspring. When the federal government banned that pesticide from the environment, the birds made a comeback. Now, those same pesticides must have some effect in humans. Did anyone quantitate it? Were any studies done on it? I really don't know. But my intrinsic guess would be that anyone who worked around high concentrations of DDT or manufactured the material, or was exposed to it heavily for any reason, must have suffered reproductively.
J.I.: Can we talk a little bit about FSH levels. If you were to get a patient, let's say, with an elevated FSH, what would you say to them? How would you explain the situation to them?
Dr. S: Well, it partially depends on their age. In other words, if you see a woman who's twenty-five to thirty-five, that's a pretty scary thing for a reproductive endocrinologist, because…well, let's look at menopause. The mean age for menopause is fifty-one and a fraction. If a woman goes through true menopause under thirty-five, it's considered early, but it happens because it's clearly a bell-shaped curve. If a woman is within two standard deviations of the mean, thirty-five is within that. On the other hand, if the woman is twenty-five or younger, and has an extremely elevated FSH – 30, 50 – then you feel that she's got what's known as premature menopause. If you see a woman that you feel has got an elevated FSH, there's really not a lot you can do therapeutically. What I tried in the past is, to let her body take a rest reproductively, hormonally. To that end I gave her birth control pills to suppress the elevation of the FSH from the pituitary and hope whatever trauma she might have undergone psychologically or neurophysiologically may heal in time. That would mean that after you stop the birth control pills her FSH will be in the normal range. But very often, in the cases that I've seen, I find it just doesn't work, and I really don't have a good way, therapeutically, to deal with a woman who has a very high FSH at a rather young age. The only other thing is that I start looking at what's going on in the environment; in other words, very often I see women who stop menstruating when they're under thirty-five, and they can point to a certain time and say, "Look – my father/mother died, and I was very close with my parents, and my body hasn't been the same since", or " I broke up with my fiancé and I went through a tremendously stressful period in my life and sort of never recovered".
J.I: You have seen that?
Dr. S.: Very often. Sure, in cases where you have an elevated FSH in a younger woman.
J.I.: Any thoughts about a correlation between POF and environmental issues?
Dr. S.: Well, the only thing that I can definitely point to is tremendous psychic stress. I very often see in women who become menopausal, let's say at 25 – 35, and as I said, they can point to a distinct period in time that their periods just stopped. That's anecdotal, obviously. Does it have tremendous significance? I don't know, because the number of patients that I think any single practitioner sees who have premature menopause or early menopause is pretty small. You don't see a lot of patients like that. I think the more common presentation is someone who is in their late thirties or early forties who let's say ten years before the mean age of menopause finds she has an elevated FSH. She's otherwise healthy; there doesn't seem to be a tremendous psychological reason to explain what's going on and you're a bit perplexed and you don't know really what to offer.
J.I.: Would you offer them fertility drugs?
Dr. S.: It's very unlikely that Clomid is going to have an effect, because how does Clomid work? Clomid works because it's a low estrogen. It binds estrogen receptors. It binds to the pituitary and the hypothalamus and so what you get is a further outpouring of FSH from the pituitary in response to the Clomid. So if the FSH level is already high, you really almost know it's not going to work. I might try a Clomid challenge test, but I would be very surprised if I got a good result. If the FSH is already high, you know that the ovary is being stimulated to the max . There's no point in further stressing the ovary by giving it either Clomid or Pergonal, etc. It doesn't accomplish anything.
You just usually don't see pregnancies with an elevated FSH. I think your experience is pretty unique.
J.I: It's not as unique as you may think. I realize that what I'm presenting is anecdotal evidence until we come up with a study, but I do know of a number of women who have in some way emulated my process, proceeded to have uneventful pregnancies and gave birth to healthy babies.
Dr. S: What you have to keep in mind with those women, is what percentage of women with those numbers will drop their numbers?
J.I: A more important question for me would be, did these women who did achieve good results do something that can be replicated. And, do they necessarily have to drop their FSH to get pregnant?
Dr. S.: You know the numerator, the small number who have contacted you to tell you that it worked out for them, thank God, but you don't know the denominator, the total population with a similar problem, and the success ratio. But if I were in that group, if it were my wife or myself, I would try anything, because what you would call mainstream, allopathic medicine, really doesn't have a good answer.
J.I.: As I said I have seen a number of women with elevated FSH have healthy babies. In most cases they are more committed to a holistic healing regimen precisely because mainstream medicine has no answers for them.
J.I.: What about thyroid function in terms of women who are hypothyroid?
Dr. S.: Well, you have to treat that, clearly, because the thyroid is intimately involved in the reproductive process. Very often, women who have a normal FSH but have very low, sluggish thyroid function will just not get pregnant.
J.I.: How does a sluggish thyroid manifest? What might be some of the symptoms?
Dr. S.: Loss of appetite, constipation, dry skin, and coarsening and thickening of the hair on the arms and often hair loss on the lateral third of the eyebrows. You might think that you are suffering from chronic fatigue syndrome. Now, everyone who has thyroid dysfunction may not present that way, and very often the only way I pick it up, especially if it's a very subtle thyroid loss, is as part of the routine endocrinological screening I do with all patients who aren't getting pregnant. I look at the hormone balance, and that's one of the tests I use.
J.I.: You mean a thyroid test?
Dr. S.: Yes. A specific thyroid test. You've got to look at TSH, which is the hormone that's secreted from the pituitary like LH and FSH, that is the hormone that drives the production of thyroxin, or T4, from the thyroid gland. And the other thing that I like to look at besides the TSH is the free T4, because that's the effective way of looking at the thyroid. Most general gynecologists would just order, in a routine thyroid test, probably a T4 and a T3 uptake. And if you order those two, very often they'll be normal. If they didn't order the TSH, they don't know that the thyroid gland is working at a maximum output to keep up with what the body needs, and already the TSH is above the normal limit even though the total T4 is normal.
J.I.: I think this is a very important point.
Dr. S.: Well, anyone who is trained in reproductive medicine would know that and would do the proper screening. I learned very quickly that often patients come in who have subtle thyroid problems and if I don't do the blood tests, it might be months or years before they'll actually become symptomatic. Of course, there's a cost associated with these tests, but I find that if we do a thorough history and all the appropriate testing we can pick up the problem before there's clinical evidence of it , and we can start treating a patient and avoid unnecessary procedures.
