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Q+A ask the Doc Shepherd Center physicians answer medical questions from patients and family members. Q: What infertility problems are found in people with spinal cord injury? A: Most spinal cord injury (SCI) patients with infertility issues are men. Women may be concerned about obstetrical issues and complications – depending on whether they have lung, kidney, neurologic and clotting problems. If women are over 35, the normal issues with achieving a pregnancy relate to age, rather than their SCI status. But if there are medical concerns regarding carrying a pregnancy successfully, a gestational carrier (surrogate) can be used through in vitro fertilization (IVF). Men with SCI may have varying types of erectile dysfunction (ED) that may lead to infertility. It is important to have a semen analysis (SA) to determine what options are available for treatment. But many men with more extensive injuries may need to have electroejaculation (EEJ) to determine what treatment is indicated for achieving a pregnancy. If the SA is normal and the spouse is under age 35, ovulation induction with Clomid can be used with intrauterine inseminations (IUI) with a success rate of 8 to 12 percent per cycle. If the woman is over 35, medications may need to be more extensive with injectable drugs that can increase results up to 20 percent. EEJ can cause concern because it may have to be done under anesthesia, and repeated procedures may irritate the rectal mucosa. Most couples in these situations should do IVF so an EEJ may be done only once, if possible. The success rate can be 45 to 50 percent, depending on the woman’s age. If sperm aspiration or testicular sperm extraction (TESE) is needed due to a failed EEJ or extremely low sperm count, IVF is the only option for achieving a pregnancy. When a couple is considering a pregnancy with known issues, they should consult with a urologist specializing in male infertility. This may be done in combination with a reproductive endocrinologist and infertility specialist. Each case is individualized. Overall, pregnancy rates are excellent, and if IVF is considered, most couples will have a sufficient number of embryos stored to complete their family with one cycle if all factors are optimal. — Dorothy Mitchell-Leef, M.D. Q: Do I really need to start one of the injectable medications if I've just been diagnosed with relapsing-remitting MS? Can’t I just wait and see how things go over the next couple of years? A: There are several reasons to strongly consider starting an injectable medication soon after a diagnosis of relapsing-remitting MS. 1) Nerve fiber damage may occur early in MS. For years, MS was thought to involve mainly damage to the insulation (myelin) of the nerve fibers (axons) in the brain and/or spinal cord. This is referred to as demyelination. In 1998, researchers confirmed that MS also can damage axons themselves. This damage is permanent and leads to disability. It has been shown to occur early in MS. Starting an injectable MS therapy early may help prevent this. 2) MS changes over time. Without treatment, most people with relapsing-remitting MS will move toward secondary progressive MS. This form of MS does not respond well to currently approved therapies and is characterized by a steady accumulation of disability. Starting treatment early may slow or prevent this move from relapsing-remitting to secondary progressive MS. 3) While benign forms of MS exist, we are not good at predicting who might follow a milder course. We have some clues in early MS that may point toward someone doing well versus someone who’s going to have a more aggressive course, but most MS healthcare providers would not feel confident enough in them to recommend absolutely against starting therapy. — Ben Thrower, M.D. contributors Submit your questions for “Ask the Doc” to jane_sanders@shepherd.org or via fax at 404-350-3145 Dorothy Mitchell-Leef, M.D., Shepherd consulting physician, reproductive endocrinologist and infertility specialist with Reproductive Biology Associates Ben Thrower, M.D., medical director of the Andrew C. Carlos Multiple Sclerosis Institute at Shepherd Center 2 4 Spinal Column w w w. s h e p h e r d . o r g
Q&A Q+A with John Lin, M.D., Associate Medical Director of Post-Acute Services Interviewed by Kayla Eubanks Q: How did you come to Shepherd Center – both as a patient and a doctor? A: In 1991, I had an aneurysm-like condition known as epidural arteriovenous malformation, which left me paralyzed. At the time, I was on summer break from college, visiting my parents in Charleston. A Shepherd Center admissions liaison came to my hospital to discuss rehabilitation options. I had never heard of Shepherd Center before – like most people who had no reason to. However, it was apparent to me that the Center had the expertise I needed since it treated more spinal cord injuries than the average rehabilitation facility. After my discharge, I wanted to practice medicine. I spoke with (Medical Director) Dr. Donald Leslie who mentored me before, during and after medical school. When I completed my residency, we discussed my joining Shepherd, but the timing wasn’t right. I practiced general rehab medicine for a while and worked at a VA hospital for a few years. Then in 2005, I joined the Shepherd medical staff. Q: What is it like going from patient to doctor? Does that make your approach unique from other physicians? A: It was a transformative process. At first, it was difficult to readjust my mindset. I found myself getting lost in patients’ tragic stories. It became difficult to hear again and again. To be emotionally immersed was draining and did not allow me to be as objective as necessary. As a doctor, you have to be objective. Today, I am better able to find a balance: Be empathic when I can, but be objective when possible. Q: Explain how your experience in internal medicine and physical medicine and rehabilitation (PM&R) work together to benefit your patients. A: Internal medicine is the prevention, diagnosis and care of general illness, disease and injury. Having knowledge in both fields makes it easier to take patients from acute injury to preventative treatment. I find myself able to see things happening and prevent it, rather than having to deal with the consequences. For the patient, it’s better because there are many interactions with the various medications that require deeper knowledge of the drugs and their effects. Q: How important is research to patients with SCI? What expectations should people have about discoveries in the future? A: Research is critical to advance the field and impacts people worldwide. Without it, we would be stuck in the past. With as many clinical trials as our staff conduct and the tremendous number of patients we see with SCI, we are becoming leaders in SCI research. Our experience and knowledge in this field goes beyond what people can get at many other facilities because they simply don’t have the same volume of cases. When setting expectations, it’s important for patients and families to realize there are two types of research – bench research, which is conducted prior to human trials, and clinical research, which is the phase when studies start being tested on humans. For research like stem cells, which is moving to the clinical phase, it will take many years to see any impact. However, there will be a more immediate impact from testing new medications or therapies. Some of this research will have an effect within months or a year. But a cure will take many years. Q: What advice do you give patients and their family members when they arrive at Shepherd? A: When patients first arrive, I tell them to keep an open mind. A lot of things are possible here. Don’t be confined by presumptions of what your injury will or will not allow you to do. You have the chance to become a person with an SCI, not an SCI person. When patients return home, it’s important to jump back into life. The most successful patients are the ones who integrate back into society and do well enough that we only see them every year or so. INTERESTING FACTS John Lin, M.D. Shepherd File Photo Residency: Internal Medicine and Rehabilitation Medicine at Temple University Medical School: Medical University of South Carolina Undergraduate Degree: Emory University Board Certification: Physical medicine and rehabilitation, spinal cord injury medicine and internal medicine Experience: Joined Shepherd medical staff in January 2005 Random Facts: • English was Dr. Lin’s fourth language. He learned Taiwanese, Mandarin-Chinese and Spanish first. • Dr. Lin is an avid wheelchair tennis player and competes in local league tournaments. • He travels to a new country every year. Fall 2009 2 5
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