45 YMG physicians among New York Magazine’s “Best Doctors”

New York Magazine’s 2009 list of the region’s best doctors includes 45 Yale Medical Group physicians. Identified by their peers, the YMG doctors named in the 12th annual “Best Doctors” issue were selected from more than 6,000 physicians in the greater New York region and are listed among the top 10 percent of metro-area physicians.

“The strong representation of our faculty on the New York Magazine “Best Doctors” list highlights the broad geographic reach of our physicians’ referral network,” said David J. Leffell, MD, CEO of YMG.

John Aruny, MD Diagnostic Radiology, Vascular & Interventional Radiology Masoud, Azodi, MD Obstetrics & Gynecology, Gynecologic Oncology Robert Baltimore, MD Pediatrics, Pediatric Infectious Diseases William Batsford, MD Internal Medicine, Cardiology Henry Cabin, MD Internal Medicine, Cardiology Edward Chu, MD Medical Oncology Joshua Copel, MD Obstetrics & Gynecology, Maternal-Fetal Medicine Richard Edelson, MD Dermatology, General Dermatology Richard Ehrenkranz, MD Pediatrics, Pediatric Neonatal-Perinatal Medicine John Elefteriades, MD Surgery, Cardiac Surgery Sukru Emre, MD Surgery, Transplant & Immunology Richard Gusberg, MD Surgery, Vascular Surgery Silvio Inzucchi, MD Internal Medicine, Endocrinology & Metabolism William Kelly, DO Medical Oncology Walter Kernan, MD Internal Medicine, General Medicine Robert King, MD Child Study Center Gary Kopf, MD Surgery, Cardiac Surgery David Leffell, MD Dermatology, Dermatologic & Laser Surgery Walter Longo, MD Surgery, Colorectal Surgery Paul McCarthy, MD Pediatrics, Pediatric Primary Care R. Lawrence Moss, MD Surgery, Pediatric Surgery Edward Novotny, MD Pediatrics, Pediatric Neurology Michael Paidas, MD Obstetrics & Gynecology, Maternal-Fetal Medicine

Pasquale Patrizio, MD Obstetrics & Gynecology, Reproductive Endocrinology & Infertility John Persing, MD Surgery, Plastic Surgery Richard Peschel, MD Therapeutic Radiology Joseph Piepmeier, MD Neurosurgery, Neuro-Oncology Vincent Quagliarello, MD Internal Medicine, Infectious Diseases Kenneth Roberts, MD Therapeutic Radiology Clarence Sasaki, MD Surgery, Otolaryngology Margretta Seashore, MD Genetics Dennis Spencer, MD Neurosurgery, Epilepsy Surgery Susan Spencer, MD (1943 - 2009) Neurology Bauer Sumpio, MD Surgery, Vascular Surgery William Tamborlane, MD Pediatrics, Pediatric Endocrinology & Metabolism Lynn Tanoue, MD Internal Medicine, Pulmonary & Critical Care Medicine Hugh Taylor, MD Obstetrics & Gynecology, Reproductive Endocrinology & Infertility J. Grant Thomson, MD Surgery, Plastic Surgery Mary Tinetti, MD Internal Medicine, Geriatrics James Tsai, MD Ophthalmology, Glaucoma Service Robert Udelsman, MD Surgery, General Surgery - Endocrine Christopher van Dyck, MD Psychiatry, Adult Psychiatry Jeffrey Weinreb, MD Diagnostic Radiology, Body Imaging Robert White, MD Diagnostic Radiology, Vascular & Interventional Radiology Lynn Wilson, MD Therapeutic Radiology

Can You Be Too Old to Get Pregnant?

Elizabeth Adeney, a 66-year old woman, is now 8-months pregnant after undergoing infertility treatment in Ukraine. She is expected to be one of the oldest new mothers in the world, joining the growing list of women conceiving at an advanced age using assisted reproductive technologies.

Prior to Elizabeth Adeney, Rajo Devi, who claimed to be about 70 years old, gave birth in November 2008 to her first child, again following infertility treatment in India. In 2006, Carmela Bousada of Spain became what was believed to be the oldest new mother when she delivered twin boys at age 66. Before that, Romanian citizen Adriana Iliescu gave birth to a baby girl in January 2005, also at 66. Bousada was 130 days older than Iliescu when she gave birth.

These births, achieved through the use of donor eggs and in vitro fertilization raised concerns about the ethical implications of infertility treatment in women at advanced age, particularly with regard to maternal complications and the social issues related to the care of the children as they grow up. It is well established that advanced maternal age is associated with gestational diabetes and pregnancy induced hypertension, which, in turn, may result in preterm birth and associated adverse outcomes. Social implications of pregnancies that occur at such an advanced age are yet to be studied.

Currently, many programs in the United States use an age limit of 50 for infertility treatment based on the median age of menopause. However, these arbitrary age limits also bring additional discussions on patients’ autonomy. Therefore, the need remains for a multi-disciplinary discussion of regulatory strategies for assisted reproduction taking into account the medical, social, financial, and ethical aspects.

PCOS and Cardiovascular Risks

Women with Polycystic Ovarian Syndrome (PCOS) have an increased risk for heart disease and possibly heart attacks compared to other women of the same age and weight, studies show. Specifically, the indications of cardiovascular disease include sub-clinical hardening of the arteries and signs of significant vascular impairment, including irregularities of the cells lining the arteries and blood vessels and increased thickness and decreased compliance of arterial walls. While the main focus of PCOS specialists is treating infertility, menstrual irregularities and unwanted hair, it’s important for women and their physicians to pay attention to the increased cardiovascular risk that accompanies PCOS as well, said Dr. Pinar Kodaman, a reproductive endocrine specialist who focuses on reducing cardiovascular risks for PCOS patients through lifestyle modification and medication. Dr. Kodaman is part of the multidisciplinary team at the Yale Polycystic Ovarian Syndrome Program that treats all aspects of PCOS.

Cardiovascular disease remains the most common cause of death among women, and risk of death from a heart attack increases with age, especially in the United States where there is a high incidence of obesity, a key contributor to heart disease.

At least 50% of women with PCOS in the U.S. are obese, 40% are insulin resistant, and 10% have type II diabetes. Insulin resistance, coupled with the body’s tendency to compensate by producing even more insulin, is one of the major factors in the development of Metabolic Syndrome, and this condition exacerbates elevated lipids in the blood, obesity, glucose intolerance and unwanted facial and body hair among women with PCOS.

PCOS is also associated with increased oxidative stress, high blood pressure, elevated levels of homocysteine, an amino acid in the blood that is an indicator of higher risk of heart disease, and dyslipidemia (an imbalance of lipids in the blood), all of which also contribute to cardiovascular risk. Interestingly, even young and lean women with PCOS tend to have unfavorable cardiovascular risk profiles, Dr. Kodaman said.

The studies on cardiovascular illness and death among PCOS patients are limited; however, the cardiovascular risks associated with the syndrome are clear.

The medical management of PCOS includes therapy for failure to ovulate or irregular ovulation, unwanted body and facial hair, as well as treatment of endometrial hyperplasia, a condition in which the lining of the uterus grows too much. In addition, obesity, dyslipidemia, hypertension, and insulin resistance should also be addressed if present. Lifestyle modification with diet and exercise are first line treatments, followed by insulin sensitizers, such as metformin, for insulin resistance and statin drugs, like Lipitor, for dyslipidemia. Statins may have additional beneficial roles in decreasing oxidative stress and improving hyperandrogenemia and other biochemical disorders of PCOS.

PCOS is the most common endocrine disease affecting women of reproductive age. Up to 10 million women in the United States have PCOS, a condition characterized by hyperandrogenism (excessive secretion of male sex hormones that results in unwanted facial and body hair) and oligomenorrhea (irregular menstrual periods). Frequently, the ovaries also have a polycystic appearance on ultrasound, which appears as multiple small follicles around the perimeter of the ovary. The cause of PCOS is unknown and researchers are actively investigating it.

PCOS occurs shortly after puberty and consists of altered gonadotropin secretion favoring luteinizing hormone production, which stimulates the ovaries to produce increased levels of androgens (male sex hormones). In addition, at the level of the ovary, the follicles make less estrogen and luteinize prematurely, thereby failing to ovulate.

While PCOS is an endocrine disorder affecting women during their reproductive years, its consequences continue to have detrimental effects in the postmenopausal years. A recent a study found that postmenopausal women with clinical features of PCOS had a greater incidence of cardiovascular events. Therefore, it is imperative that PCOS be diagnosed in a timely fashion and treated effectively across the lifespan.

PCOS and Nutrition

While the causes of PCOS remain unclear, most experts believe insulin plays a major role in its development. The majority of PCOS patients have decreased insulin insensitivity, causing high levels of insulin or what is commonly known as insulin resistance. Approximately 50% of women affected by PCOS are overweight.

Risk Factors
Insulin resistance places an individual at increased risk for:
• Abnormal carbohydrate metabolism – raising the likelihood of developing type II diabetes
• Heart disease due to:
– Increased levels of LDL or “bad” cholesterol
– Decreased levels of HDL or “good” cholesterol
– Increased levels of triglycerides
– Increased blood pressure
• Significant weight gain and difficulty losing weight
• Low self-esteem

Lifestyle Modifications

Diet
Diet and exercise have been established as the first line of defense against PCOS. Studies show that a 5%-10% weight loss may substantially improve the metabolic and reproductive abnormalities associated with PCOS while lowering the risk of heart disease and type II diabetes. A registered dietitian (RD) can help customize a balanced diet, low in fat and moderate in carbohydrates, to help you achieve and maintain your weight loss goals. The RD will evaluate your current diet, lifestyle and risk factors and
establish a nutrition plan specific to your individual needs.
The following factors will be considered:
• Current height and weight
• Ideal body weight (IBW)
• Age, overall health and medical history
• Current medications or supplements taken
• Current eating patterns, food preferences and dietary customs

Exercise
Evidence clearly supports the importance of physical activity for women affected by PCOS; exercise may be just as important as diet in treating the disorder. Both aerobic exercise and strength conditioning can be effective in:
• Improving lipid levels
• Improving insulin insensitivity
• Lowering blood pressure
• Improving self-esteem
• Managing weight
• Aiding in prevention and treatment of chronic disease

An RD can help develop a customized exercise plan based on your preferences and lifestyle pattern.

Pregnant with PCOS

Pregnant women with PCOS face a number of challenges before, during and after their pregnancies. To address these concerns, Yale’s infertility specialists and Maternal-Fetal Medicine specialists at the Yale PCOS Program provide on-site consultations prior to conception and throughout pregnancy for women likely at high risk for pregnancy-related complications.

Pregnancy Risks
• Infertility – Due to ovulation disturbances, women with PCOS may find it difficult to get pregnant. YFC boasts one of the highest success rates in the region for managing PCOS-related infertility, offering individualized management strategies to minimize the risks of ovarian hyperstimulation and multiple pregnancy while maximizing success of fertility treatments. Fertility therapies include ovulation induction strategies, injectable hormones, aromatase inhibitors and in vitro fertilization.

We also recommend lifestyle interventions that may help with spontaneous ovulation.
• Miscarriage – Women with PCOS may be at increased risk for spontaneous miscarriage. Contributing factors include elevated insulin levels (insulin resistance) and high levels of luteinizing hormone (LH) or androgens (male hormones). Miscarriage risk can be reduced by lowering insulin levels through weight loss or with insulin-lowering medicines such as Metformin. Women with elevated homocysteine levels may also require increased folic acid.
• Pregnancy Complications – Women with PCOS are particularly at risk for gestational diabetes, which may increase the risk of birth defects, miscarriage, preeclampsia, preterm delivery, macrosomia (excessive birth weight) and birth injury. Weight reduction and lowering insulin levels before pregnancy are beneficial to ensuring a healthy pregnancy.
• Multiple Pregnancy – Pregnancy with more than one fetus increases the overall risk for pregnancy-related complications in women with PCOS. Because they are at high risk for multiple pregnancy following fertility treatment compared to women with other causes for infertility, our goal is to minimize this risk by utilizing gentler treatment protocols that reduce the likelihood of multiple gestation.
In addition to working with high-risk pregnant women with PCOS, YFC monitors all PCOS pregnancy outcomes to help the medical community understand the fetal and perinatal implications of PCOS.

Risks to Children of Women with PCOS
Studies suggest that PCOS diagnosis may have implications for the children of women with PCOS.
• Daughters of women with PCOS may grow up to exhibit the characteristic features of PCOS.
• Weight problems, insulin resistance and high cholesterol are consistently seen in children of women with PCOS.

Healthy lifestyle and healthy weight goals are therefore important not just for women with PCOS, but also for their children.

Infertility and PCOS

Ovulation disturbance is the most likely cause of infertility in women with PCOS who do not ovulate regularly, although other factors may contribute to fertility problems in some couples. The Yale PCOS Program provides state-of-the-art management of PCOS-related infertility. With one of the highest success rates in the region, our experts offer individualized management strategies to maximize success while minimizing the risks of ovarian hyperstimulation and multiple pregnancy in patients with PCOS.

Treatment begins with a basic infertility workup:
• Pelvic ultrasound
• Prenatal lab tests
• HSG (hysterosalpingogram) – X-ray of the uterus and fallopian tubes
• SHG (sonohysterogram) – saline ultrasound to determine uterine abnormalities
• Semen analysis
• Complete health assessment, including a risk profile for diabetes, heart disease and other diseases associated with PCOS
After reviewing these test results, we meet with
you to determine the best course of action.

Options include:
• Ovulation induction – A number of medications are available to induce ovulation in women with PCOS; dose and treatment duration are individualized:
– Clomid – orally administered fertility medication
– Gonadotropins – injectable fertility medications for those who do not respond to simpler treatments; more expensive with greater chance of multiple pregnancy
– Aromatase inhibitors – trigger ovulation in women; safer and less expensive than some alternatives
• Insulin sensitizing agents – Metformin has been shown to restore normal ovulation in some women with PCOS, may improve response to other fertility drugs, and has little or no risk of multiple pregnancies.
• In vitro fertilization (IVF) – removing eggs from your body, fertilizing them with your partner’s sperm, and implanting a fertilized egg into your womb. We utilize minimal stimulation and blastocyst culture and transfer strategies to reduce risks for such problems as ovarian hyperstimulation syndrome and multiple pregnancy.
• Lifestyle modifications – Because being overweight or obese may reduce a woman’s fertility, weight loss is highly recommended to improve fertility and pregnancy outcome. We provide a comprehensive lifestyle management program that includes weight management counseling.
• Optimizing Vitamin D status – Our ongoing research indicates lower pregnancy rates following IVF in women with low blood levels of Vitamin D. Vitamin D levels are assessed for all women attending the Yale PCOS Program and treatment provided to achieve normal levels.

Health Risks of PCOS

Women with PCOS are at increased risk fordeveloping a number of long-term health problems. At the Yale PCOS Program, we seek to address these risks before they become serious medical issues, with a combination of lifestyle modifications and medical interventions.
• Endometrial Hyperplasia – A thickening of the endometrium (uterine lining) can cause heavy or irregular bleeding, and may lead to pre-cancerous changes in the endometrium that could develop into endometrial cancer.
• Cardiovascular Disease Risk – Women with PCOS have a greater chance of developing Metabolic Syndrome – a cluster of risk factors that raise the likelihood of a heart attack or stroke later in life.
These factors include:
• Obesity – approximately 50% of women with PCOS in the US are obese
• Dyslipidemia – increased total cholesterol, triglycerides or both and decreased HDL (good cholesterol)
• Elevated blood pressure (hypertension)
• Insulin resistance – 40% of women with PCOS are insulin resistant
• Type II diabetes – affects 10% of women with PCOS
• Sleep apnea – can present as disturbed sleep, frequent sleep interruptions, restlessness, snoring, and daytime fatigue and sleepiness

Given these risk factors, women with PCOS have a seven-fold increased risk for heart attack and are four times more likely to have a stroke compared to women without PCOS.
• Breast Cancer – Some studies indicate that there is a correlation between PCOS and breast cancer, but the evidence so far is inconclusive.

Women with PCOS are encouraged to visit the Yale PCOS Program for a complete metabolic assessment and risk profile. Your initial examination will include a complete medical history, physical exam with BMI measurement, pelvic ultrasound and all appropriate lab tests. Once we have assessed your risk, we will tailor an individualized plan to meet your specific needs.