Labor & Delivery

How I went in wanting a completely natural, unmedicated birth and came out with my worst nightmare: a C-section.

On July 13 we went to the hospital around 5 pm to preregister. My due date was still a ways off (July 27) but I thought we were long overdue for preregistration and also for installing the car seat. So we headed to the hospital to take care of the easy one. I had already been having contractions but didn't realize it. The menstrual-cramp like contractions were not the same as the Braxton-Hicks contractions I had been having but I thought these new ones were just my body's way of prepping for the big day in advance. Well in advance.

After the incredibly easy check-in, we went up to the maternity ward to look around and said we were just visiting. I asked to see a birthing room. A nurse at the front desk asked whether I was having contractions and I said no, just cramps. The birthing room was surprisingly nice. It was spacious and looked comfortable. The only weird thing was the crucifix mounted on the wall smack dab on the wall facing the bed. I didn't like that, but it is a Catholic hospital and as I found out later, I had my eyes closed during the vast majority of my late labor anyway so I wasn't going to be weirded out by the presence of a little metallic Jesus anyway.

When a nurse showed us the room she asked if I was in labor, and I said no but then we got to talking and my answers to her questions resulted in me getting checked in. They hooked me up to monitors (fetal heart rate and contraction) and we waited for about an hour. As coincidence would have it, my OB was in the hospital and came by to check in on me. That was a nice surprise. He was leaving for vacation the next day and wasn't coming back until after my due date so that was probably the last I'd see of him. I asked him to check my dilation because I was curious. I was 1 cm and -2 station. He thought it could be another week or two, no way to know and said we could all go home but to come back if things get more serious. He wasn't super specific.

So we went home. As it turned out, I had contractions all night and morning and got no sleep but I didn't think much of the cramps, really. Having experienced severe endometriosis for years and years plus an ER visit due to a ruptured cyst, these cramps were no big deal. I wasn't feeling up for work in the morning so I bagged out of that. Although I didn't realize I was in labor, I was.

I called my mom in the morning around 9 am and had some three-way talks with her and my sister (who had recently had a baby) but nobody thought I was in labor. I had been timing the contractions/cramps on a my iPhone through an app called "Labor Mate." That made it super easy to find out how long contractions were, how much time passed in between them and also what the average time was. It's a really neat app. I'm glad I used it. And, you could email the log! Awesome. Not that it helped me figure out ..when.. to go to the hospital. The app should have a pop-up screen that asks: Have you lost your mucus plug? Are you having 'bloody show'? Then go to the hospital woman! Go!

I called my OB nurse sometime in the morning and asked her how regular the contractions had to be to go the hospital. She was equivocal but said if I have a bright pink discharge, it is time to go. I called Mr. Field Notes at around 11am (while he was on deadline at the newspaper) and told him it was probably time to be thinking about going to the hospital. He got the voicemail around 11:30 am and finished out work for the daily paper then came home. I think he might have even gone swimming after deadline and in between coming home. That's how convinced I was that I was having false labor. Ha ha ha. Was I ever wrong.

I got the bright pink discharge after Mr. FN got home around 1pm. I packed my bag for the hospital.. hadn't even done that yet! And we left. It was a short, short drive to the hospital. If I wasn't well on my way into contractions-land, we could have walked. And, really, that probably would have been better for my delivery but as far along as I was, I may have ended up giving birth on the sidewalk halfway there, assuming we could even have made it that far. Yeah, I am just that crazy — thinking I could WALK to the hospital while in labor. Overachiever? Yep.

But we drove.

I had been laboring on my left side, on all fours, bent over a counter, table or chair or leaning up against a wall.

I got a ride up to the maternity ward in a wheel chair pushed by the front-desk lady. I recalled it was quite a ways to go to get there and I was tired. I hadn't slept since Sunday night (it was Tuesday afternoon).

We got settled into the birthing room and asserted myself by not putting their stupid hospital gown on. I stayed in my T-shirt and just took my skirt off so I'd be more comfortable. Two nurses came in to start an IV line. And, just like last time I was in the hospital (to have surgery for endometriosis), they had a hell of a time finding a vein to get the line started. I didn't want to be hooked up, but it was hospital policy to at least open the line. They didn't actually hook me up to an IV until much, much later. I had poke marks all over both arms and hands. I think they eventually used the smallest bore needle they had. I did not enjoy being a pincushion.

I was definitely in labor now. No doubt about it in their mind. I thought I was going to have my mom there with me, but I was 2 weeks early and she was 500 miles away still. So it was just the Official Help You Labor Nurse (OHYLN) and Mr. FN in the room with me, besides Dr. WooooooJ (who was much cooler than his nickname). He wasn't my regular doc because mine had ..just.. left for vacation. Dr. Wooj and I clicked instantly so I felt good about the whole new doc I've never met before looking at my hoo ha. OHYLN did a quick check and found out I was at 8 cm.

8 cm dilated.

I got to 8 cm dilation at home — alone.

Yes, I am that bad ass.

Everybody thought I was within two hours of delivery. But from that point (around 1:30 pm) until around 10 p.m., I stayed at 8cm despite the contractions getting stronger. I labored on my left side (at home, too) for a long time, because that's what felt the best but the OHYLN had me use other positions to try to move my dilation along. I did the birth ball, hip rocking on the ball, on all fours, leaning over the back of the inclined bed, etc but nothing was working.

My cervix was swelling too and I reverted to 6cm dilated.

An apologetic Dr. Wooj said it was really time for me to try lying on my back, which I really did not want to do, both because I knew that would be a lot less comfortable and because we'd lose the effect of gravity, but I listened to my doc and did it. The point was to get my swollen cervix to ease up, and that would theoretically be helped by taking some of the pressure of the baby's head off.

By this point, my breathing changed to the deep breaths in and out and the moans and groans and animalistic grunts associated with late labor. I went into meditation mode for the next god-knows-how-long. My eyes were closed most of the time and I kept seeing the game Zip Word. It's an iPhone game like Boggle. I had been playing it for the previous week.

Yep, it wasn't the image of 'Our Savior Jesus Christ' that got me through labor, it was...

Zip Word.

At some point, maybe around dinnertime, 6pm or so, my water broke. I barfed at the time, right immediately before or right after — I can't recall. However, the sensation of my water breaking, the explosion, was Intense. I don't recall it as being painful, but it must have been to make me barf. My water breaking was the coolest, most unexpected neat-o thing that happened during labor and delivery. I can't really describe how it felt, just that it was like nothing else I'd ever experienced and was intense. It was not even remotely similar to any waters breaking I had ever seen in the movies. Not even close. And, I would totally love to experience that again because it was so intense, but it's never ever gonna happen, ever, ever again. Humpf.

So, I eventually got back up to 8cm after being down at 6cm.

At some point prior, but after my water broke, Dr. Wooj hooked me up with an internal sensor to measure contractions. It showed weak contractions that weren't doing anything. Also at some point prior but after my water broke, the baby's heart rate slowed too much for the doctor's comfort, so Wooj administered a drug to ease the contractions, which were doubling up and too close together yet also not achieving any progress. The contractions started intensifying a bit after the drug wore off, but never fully recovered and made no impact on dilation for hours, so Dr. Wooj suggested a C-section. I had been stagnate at 8cm for six to eight hours at least.

I asked if there was anything else we could try to move things along. He said we'd tried re-positioning me and that didn't work but we could try an epidural and pitocin. The epidural was to relax me / my uterus, which he thought had been under stress for too long. I got the pitocin to re-kickstart delivery-stage contractions.

Lurch, the anesthesiologist with the iPhone, administered the epi, and then the pitocin was infused, but only for about 20 minutes or so. At that point, Wooj said he thought it was time to cut bait because the contractions were not strong enough according to the internal sensor. As much as I didn't want to have a c-section, I knew that if I wanted to have this baby it looked like the best option given the fact that for a good ten hours I showed no increased dilation.

The baby was in a good position, not posterior or anything like that which would have made labor slower and harder — nope, just my god-damned back fucking luck.

At one point after we decided to go ahead with the section, Doc Wooj remarked, "You may look like you're 15, but you have a 35-year-old uterus and it just doesn't know what to do." It seems he was right.

Upon arriving at the hospital and finding out I was at 8cm, I had been so excited. So excited! I knew that baby was going to be here soon — and on Bastille Day to boot. Bastille Day is like the Fourth of July but for France. I taught myself French after college, to read St. Exupery's Terre des Hommes (Wind, Sand and Stars for all you non-Francophiles) and also to prepare for doing field work in Africa where being able to converse in French makes the job easier. I never made it to Africa for fieldwork, but I retained a fondness for French stuff and did got to France a couple times after college. Although my accent was terrible, I am sure, I still got around splendidly. A fondness for France and French stuff is something I share with Mr. Field Notes' mom. For the longest time, I actually thought she was born on Bastille Day and I thought that was pretty cool. But she was born two days prior. When it came time for Baby Field Notes to be born, I was stoked that she was actually coming on Bastille Day!

So after the writing was on the wall for the c-section, I told Dr. Wooj that if I had to have a c-section I was cool with that if it could still happen that day, on Bastille Day. It was getting on toward 10 or 11pm at the time so they wheeled me down to the OR.

There, Lurch (he really did resemble the dude from the Addams Family), the anesthesiologist amped up the epidural and Dr. Wooj and another doc did the C-section. There were some other dudes in the room too, who may have been docs or just surgical nurses, I don't know, but in addition to me, there were at least 4 maybe 5 doctors who had to be there to get Baby Field Notes into this world. That's a lot of god-damned doctors!

Mr. FN had to disappear for a while to change into scrubs. I wish I had actually seen him in his scrubs, that would have been cool, but I never did. He sat up by my head and hung out for support, which was nice, but then as soon as Baby FN was cut out (11:05 pm, July 14) he was gone. He got to cut the umbilical cord. I didn't get to watch that, which makes me sad, really, but oh well. It's not like I had a choice. The tears rolling down my cheeks as I write this suggests it still matters a lot to me that I was robbed of that experience. Humpf.

For the next three hours — that's right — three painfully long hours, I laid alone (pretty much) waiting for my body to 'wake up.' God that was torture — mental torture. To lie there virtually motionless and with no one besides the wanker nurse to keep me company for three fucking hours was worse than labor. Much, much worse. I couldn't get the dipshit nurse to talk to me. Until I could wiggle my toes and bring my knees up, three hours later, I had to watch her stare at a computer or my chart. Or, I watched the clock. I wasn't even remotely tired and I was fucking paralyzed. Could they not get a fucking TV in the recovery room? Or a ream of paper and a basket to throw wads at? Anything for entertainment. Good god. Or at least a nurse who was talkative? She was brain dead. BRAIN DEAD. I just could not get her to talk to me. Even when she was right next to me staring at my god damned chart. And I am not a talkative person but I needed some social support then, even a modicum would have been nice. At one point, I must have been beyond frustrated at this point, I asked her if she was asleep! She said that's not allowed while working or would be bad while working, or something like that. Fortunately I realized quickly this lady was responsible for giving me meds and for ultimately getting me the heck out of there, so I recovered by saying, "Well you had a very studious look about you." Then I went back to hating her and atrophying from boredom.

I thought I was going to die of boredom, literally.

Why on earth I have not yet signed a DNR order is beyond me, because that lovely experience taught me I will be better off if someone just pulls the plug on me than to let me live paralyzed and helpless. I am no Steven Fucking Hawking. Let. me. tell. you. that. So, yeah, I hated that part.

While I was being sewn up and 'recovering,' I mean dying of boredom, Mr. Field Notes and Baby FN went up to the nursery for weighing, bracelets, other health checks, her first bath, plus lots of suctioning of meconium - yuck. Grandpa Field Notes arrived about 5 minutes after they got to the nursery.

I wish things had gone differently, but I am at peace with what happened. Yes, parts still make me sad, but I'm no longer blaming myself for having to have a c-section. I am no longer crying because "I didn't get to push" and therefore "don't deserve the push pressie" that Mr. Field Notes has for me. Instead, I didn't have to push. I didn't have to have an episiotomy or tear my perineum. My vagina isn't stretched out to kingdom come and back. Some things are not so bad about having a c-section. Some things. I still am not yet approved to drive anywhere and I can't lift anything over ten pounds. And that means I cannot walk those doggies, not for a very long time. But, I am recovering and it wasn't that bad. I can imagine doing it again.

One day Baby Field Notes will learn it took two scary surgeries to bring her into this world.

Whether she appreciates that or not, I am just relieved she's actually here now and so far, apparently healthy as can be!

I'm back - And with loads of NEWS!

For the last 2-plus weeks I've been in Japan! And, for the last 4 months I've been... pregnant!

See here for why that is actually a very, very big surprise. I am not a believer in miracles in the religious sense at all, but as far as miracles might represent statistically improbable events, me being pregnant is very much a miracle. Now that I'm out of the first trimester, I finally feel comfortable talking about it with others. Sometime around the end of July/beginning of August we'll have our lives rocked. I know what to expect, but also have a healthy (?) amount of anxiety over what I am sure is totally normal stuff.

Over the next few weeks and months, I'll share plenty of stories and photos from my travels in Japan and no doubt news and articles about pregnancy and parenting. It's a subject matter perfect for an evolutionary lens. Not that knowing the evolutionary underpinnings of morning sickness makes it at all easier!

And, for those of you dying to know whether I saw any of Japan's famous snow monkeys — the answer is YES! And I have photos and video clips too. Here's one of my favorites.

Health Orbit News

My junk mailbox has been delivering news from an oufit called HealthOrbit, Inc. I have no idea why it started showing up but occassionally I read it and every once in a while discover some story worth following up.
Today I found three:

Endometriosis
Apparently some researchers at the University of Michigan are starting clinical trials of rosiglitazone, a diabetes drug, for the treatment of endometriosis. Endometriosis is a chronic, incurable condition that is associated with pain and infertility. It occurs when the lining of the uterus, the endomtrium, grows outside of the uterus. All of the current treatments for endometriosis render a woman infertile. The researchers hope the drug will shrink endometrial growths and reduce pain without causing infertility.
Read the Health Orbit brief here.

Autoimmune Disorders
A particular cytokine (molecule that recruits T & B cells of the immune system) called TSLB plays the key role in the runaway immune attack characteristic of autoimmune disorders like lupus, MS, rheumatoid arthritis - and allergies. Controlling it maybe the key to mimizing the damage the immune system does in these conditions. Read the Health Orbit brief here.

The Brain's Braking System
The Journal of Neuroscience published an MRI study of a "high speed connection" in the human brain that controls our ability to start and stop actions. Disruption of this "braking system" may be responsible for numerous diseases - among them Parkinson's and obsessive compulsive disorders.

Parkinson's symptoms include an inability to move, but also includes an inability to control motion smoothly. Actions become jerky and shaky. Although no doubt an overly simplistic view, I think one could think of the braking system being stuck in the ON position at times in conditions like Parkinson's that are characterized by frozen motion.

However for OCDs like Tourette's that are characterized by behavior and thoughts that cannot be stopped, the braking system might be stuck in the OFF position at time. The brakes simply fail to stop the action. But with OCDs, the brakes don't fail for all actions across the board. With OCDs only some actions are uncontrollable, famously those involving grooming actions (like handwashing); other behaviors are completely controllable. It would be interesting to know which connections are faulty for particular OCD symptoms.
Read the Health Orbit brief here.

Endometriosis Surgery Photos

EDITED TO ADD (July 24, 2009):
If you're here because like me, you have endo and are scared about what it means for your ability to conceive and have children, here's my story. When I found out I had severe endo, and what that meant for my ability to have children, I scoured the internet for anything I could find about what my chances were. What I read was not encouraging. But, I am now here to say - it IS possible to get pregnant completely naturally if you have endo. It happened to me.

I had the surgery in Feb 2007 and by Oct 2008 I was pregnant with my first child. No fertility treatments, no drug therapy, just plain old, FUN, conventional conception. I think it is a medicial miracle, but I also think the surgery had a HUGE role in making it possible for me to conceive. I had my baby July 14.

When I was scouring the internet for info about endo and pregnancy, one of my big questions was how much labor and contractions would hurt because of the endo. Would they be more or less painful? I don't know if it was just me or my experience with the pain of endo, but the contractions I had were very managable. I really thought they were going to be A LOT, LOT worse. In fact, I labored at home, alone, until I was 8 cm dilated! I had no idea I was that far along by the time I checked into the hospital. I credit having gone through the pain of endo for preparing me.

I also ended up having a C-Section. My uterus and cervix would not dilate further despite the use of pitocin (something I had wanted to avoid) and I had already been laboring at 8 cm for 10 hours before the decision to do the c-sec. My doc said, "You may look 14, but you have a 35-year-old uterus." I don't know if my uterus gave out because I was in labor for so long, because I am 'older' or because I have endo, or perhaps because I had surgery on my uterus and cervix. The medical peeps don't know either, but I thought it's something you might be interested in knowing because more info never hurts, in my opinion!

__________________________________________
ORIGINAL POST:

My post-operative follow-up happened yesterday.

Scroll all the way down to see the photos and their explanation.

Dr. Bad News, as he has come to be known, went through my photos with me and I can say a couple of things: 1) I got a taste of what some of my students must have felt when I rushed through slides on occassion, 2) I like all the gory details and want them in official medical terms, 3) I hate feeling like I am being up-sold, and 4) I really hate wasting time being given info I already know.

Observations 3 & 4 come from Dr. Bad News pitching IUI (intrauterine insemination) and IVF (in vitro fertilization) as the first choice options for getting me pregnant. This came after he told me endo is associated with infertility and that there are two theories why: structural and inflammation/immunity problems, which I knew about and I also knew already that no one really knows to what extent or how or why endo is associated with infertility. A paper I read said there is no clear connection, and therefore no strong empirical support, for the widely held notion that endo and the immune system contribute to implantation problems. The idea persists like it some sort of old wives tale about not going out with wet hair or you'll catch pneumonia. Dr. Redwine in Bend, the other endo specialist I could have gone too, concurs that infertility is not strongly related to endo. It is incredibly vexing that no one really knows exactly what the hell goes on with endometriosis and infertility.

So, Dr Bad News, who is in private practice at a fertility clinic walked me through the photos of my Roto Rooter surgery and then told me he thought I should immediately go for the heavy guns approach to getting me pregnant: IVF. It costs $12,000 just to try once. Most women need three tries; I'm sure you can do the math for the cost. And that all adds up to a 60% success rate. $36,000 for a 60% chance. Our insurance covers none of it. Nor does it cover the 10% success rate IUI route; who knows the cost there.

And - if infertility is related to immunity problems, getting rid of the endo inflammation *might* minimize the immunity problem (i.e. the immune system creates an environment that is hostile to the egg, sperm, and/or embryo implantion), but the longer we wait or the longer it takes to conceive through whatever means, the more likely the endo and hostile environment will come back, and the more likely it comes back with a vengence. So, if it takes three years to come up with $12,000, then it's pretty much a fool's errand because a) the endo will be back, b) my uterine/ovarian environment will be hostile to implanation, and c) my eggs, what's left of them after the surgery, will be in poorer condition because I will be that much older and the endo will have had that much more time to screw them up.

I know I have severe endometriosis. Dr. Bad News didn't need to sell me on IVF which we can't afford right now and which won't be likely to work when/if we can afford it. I know that if I get pregnant and don't miscarry it will be somewhat of a miracle. I'd at least like to give the surgery and my cleaned out body a chance to do what female bodies were molded over eons of evolution to do. And, if it doesn't, oh well. Why would I want to use artifical means to bring a life into this world who will likely carry the genes that contribute to endometriosis and infertility? If my body won't carry a pregnancy then I don't want to force it to. That seems like a bad idea.

By all other accounts, including Dr. Bad News when I prodded him for an answer, the surgery I had is supposed to make it more possible for conventional conception. That is not only free but FUN.

Here are the photos:

LEFT FALLOPIAN TUBE ENDOMETRIOSIS

The arrow points at a spot of endometriosis on my left fallopian tube. That yellowish-brown spot is about the size of a pin head. At the lower left corner you can see some blue stuff. That's the dye he shot through my tubes to see if they are open. The fact that you can see the dye means the left tube is open. That doesn't mean that an egg released from the left ovary will make it down the tube to be fertilized by sperm there. The inside of tubes can be like obstacle courses with many places for an egg and sperm to get stuck. Tubes can "not move well" even though they are open. That means the tube might be open but it doesn't move the egg along.

SCAR TISSUE in the Pouch of Douglas

All that greyish, filmy stuff is scar tissue that has connected the back of my uterus to my rectum. Endometriosis is commonly found in this space, called the Pouch of Douglas. It could be what was causing me to get diarrhea with my periods, a classic symptom of endo. The brownish spots near the top of the photo on the pink organ look like more endo.

ENDOMETRIOSIS on UTERUS

This photo shows my uterus looking an awful lot like a baseball (in pink) with yellowish-brown stitches pointed out by the arrow. That's an endometriosis adhesion. It may be what made menstrual cramps painful.

LEFT OVARIAN CYSTECTOMY

The photo above shows the cut open endometrial cyst on my left ovary. The red stuff is "old" blood that had filled the cyst. The cyst blood was allowed to spill into my body where it will presumably be reabsorbed. I was told the cyst wall is where the endometriosis is and the blood inside is harmless, but I don't believe that. Other surgeons put the entire, unruptured cyst into a a little baggy and then pull it all out of the laparoscopic tube. This means none of the contents of the cyst, and none of the endometriosis, has much of a chance of coming apart and then attaching somewhere else. I do not like, not one bit, that my cyst was ruptured and then only the cell wall was removed.

ENDOMETRIAL CYST CELL WALL

I was told that the endometrial cyst had grown into my ovary and that the presence of endo there can harm the eggs in the affected ovary, diminishing their "quality." What that means - if my left ovary is the one that produces an egg follicle, the egg that tries to make its way down that questionably okay fallopian tube might have genetic abnormalies that might impact its ability to implant and then be carried to term. Eggs with severe abnormalities are usually spontaneously aborted and end with a miscarriage, something that happens more often for women who have endo. Because my left ovary was monkeyed with, the eggs may have been reduced in number. By how much, no one knows.

RIGHT OVARY ENDOMETRIOSIS

The white thing is my right ovary, about the size of an olive or an almond. It had some smallish spots of endometriosis on it as well. It thankfully did not have a cyst as well which is good. However, no one has told me whether my right ovary is functional, and none of the photos I have show dye flowing out of my right ovary. The doppler echo on my last ultrasound didn't make any noise when they listened to my right ovary. The left one did. I did not think to ask about the status of my right ovary at the follow-up because so much of the talk was about the other more glaring problems. I called my surgeon's office and left a voice mail with him asking about the right ovary, but I'm not expecting a call back.

***
I wonder if I will ever be able to get pregnant given the extent of the endometriosis I had. My left ovary is seriously screwed up at best, and although the left tube is open, it has questionable structural quality so I may have to rely entirely on my right ovary and right fallopian tube to work in order to get me pregnant. That's why I am freaking out about the lack of a photo showing that my right tube is open. On the bright side, I have always had regular cycles, so I have most likely been ovulating. I got my period right on schedule just two weeks after the surgery, so my cycle seems to still be regular. If so, I am supposed to ovulate in a couple of days. An OPK (ovulation predictor kit) will tell us whether that's the case. Although my surgeon said he removed everything he saw that he thought looked like endometriosis, there is no guarantee that he got it all. In fact, he most likely didn't given that some of it was too small to see. That, combined with how the cyst was removed, makes it possible that I will have endo show up where it hadn't previously been somewhere down the line as long I continue to ovulate.

Sonic Blade

Just by chance I happened to see a TV advert for a revolutionary new home kitchen tool, the Sonic Blade. It cuts through layers of a sandwich without smooshing everything in the process. The 30 seconds I saw hooked me. The images were compelling. The blade cuts so finely and crisply that your sandwich looks like it has been cut with surgical precision.

Immediately I thought, "Ah ha!" that sonic blade is a mass marketed version of the precision surgical instrument my surgeon used to remove my endo. It looked like it vibrated quickly and that is what made it slice through the sandwich with minimal damage.

So, remembering that my surgeon said he used a "harmonic scalpel" that vibrates, I googled it and found that the "ultrasonic" blade he used vibrates 55,500 times per second.
Here's how it works.

Having read the blurb about the ultrasonic harmonic scalpel used on me, I can say I am impressed and fortunate that he used this tool instead of a laser. Lasers burn the endo away and cauterize at much higher temperatures. That creates more tissue damage, kind of like what happens when you use an ordinary kitchen knife to cut through a sandwich - you end up with seriously torn up insides.

Unfortunately, lasers are foisted off on many women who have surgery for endometriosis and aren't lucky enough to get sent to a surgeon who uses such fancy equipment. I recall reading somewhere, I forget exactly where, that lasers are actually more expensive than scalpels. That makes intuitive sense. I wonder about cost of the harmonic vibrating scalpel.

I couldn't easily find out how much the harmonic scalpel costs, but I bet it is be pretty pricey given its Lilliputian proportion. It's only 5mm in diameter.

The knock-off As Seen On TV version costs $100, and if you buy now, you get one for free, reducing the per item cost to $50. That's so cheap I wonder if the quality matches. In any case, I am certainly glad my surgeon didn't use such a crude instrument on me! The Sonic Blade only vibrates a few hundred times per MINUTE, allegedly. Here's how it works.

Study Links Surgeons' Competence to Video Game Proficiency

Study Links Surgeons' Competence to Video Game Proficiency
By Denise Gellene
Los Angeles Times

Worried that kids spend too much time playing video games? Take heart, they may become great surgeons. New research Monday found that surgeons with the highest scores on ``Super Monkey Ball 2,'' ``Stars Wars Racer Revenge'' and ``Silent Scope'' performed best on tests of suturing and laparoscopic surgery.

Doctors who had played video games at least three hours a week sometime in their past worked 27 percent faster and made 37 percent fewer errors on the surgical tasks compared to those who had never picked up a game controller, according to the study.

``For as little as three hours a week, you could help your children become the cyber-surgeons of the 21st century,'' said Dr. James C. Rosser Jr. of Beth Israel Medical Center in New York and lead author of the study in the Archives of Surgery.

The research looked at 33 surgeons attending a course on laparoscopic surgery and found that their game-playing skill was a better predictor of success on the surgical tests than years of medical practice or number of surgeries performed.

Expertise with ``Super Monkey Ball 2,'' which involves steering a ball containing a monkey down a serpentine track while simultaneously targeting bananas, was most closely linked with high test scores.

Dr. Myriam J. Curet, a Stanford University surgeon who wrote an accompanying critique, cautioned against uncontrolled gaming, which has also been linked with aggressive behavior and bad grades.

The study agreed, saying ``indiscriminate video game play is not a panacea.''

Properly channeled, game playing can foster the hand-eye coordination and fine-motor skills needed by laparoscopic surgeons, who rely on television monitors to guide them during surgery, said Rosser, who plays video games five to six hours a week.

``Where did you go to school? Did you pass your boards?
... Patients may also ask their doctors, `Are you a 'Super Monkey Ball player?' ''

****

FIELD NOTE:
Psychology textbooks frequently criticize video games, citing studies that show violent video games beget violent behavior in real life too. It's great to see studies that show video games, albeit non-violent ones, can actually have a positive effect.

I definitely do think the key is to limit the amount of videogame play a budding surgeon, or any other child, indulges in. Three hours a week isn't that much, but it appears to make a difference. Any more than that and other important skills may fail to be developed. You might end up with the equivalent of a kid who exercises only his right arm, lifting heavier and heavier weights until his right arm so outpaces his left arm in strength that he not only looks ridiculously unbalanced, but is left with a left arm so atrophied it's useless.

I don't know if my surgeon played videogames, but he's got a track record of not making mistakes, so he must have developed an impressive degree of hand-eye coordination and fine motor skills somewhere.

When Sorrows Come

They come not single spies but in battalions.

At least, that's the way it seems lately. I don't care to list all the gory details to convince you that my laundry list of bad experiences over the last few years warrants the melodramatic use of Hamlet, but it is my favorite play and it captures how I imagine at least one member of my family must feel.

First things first, I am fine. I had the laparoscopic surgery rather than the big scary version, and my cyst is gone without any major complications. I did have an allergic reaction to an anti-nausea drug that earned me an overnight stay in the hospital for what was supposed to be outpatient surgery. I vomited three times and got the detox shakes really bad when coming down from the anesthesia but those wore off at about the same time I could finally hold down food. I ate an excellent filet of salmon with rice and cooked carrots at 2am. It was seriously excellent - or - the two days of fasting made it so.

I do have endometriosis but it is only stage 3 (out of 4) and my tubes are open, so I can theoretically be a mom to my own child someday, hopefully soon. We have a 3-6 month window to try and then we'll have to use more "aggressive" measures... whatever those are. We'll see how it goes.

My surgeon was wonderful; I like him more every time I have to talk to him. He used a harmonic scalpel to excise the endo which is wonderful news - it means less chance of the endo coming back, less pain, etc, etc. We'll see how it goes. I have NO expectations except that I will have to take birth control pills continuously until menopause. Oh well, no more periods for me! What a deal.

I even got pictures... haven't looked at those yet. Should I post with explanation or not?

To do, or not to do. That is the question I put to you. Wanna see 'em?

Immune System Involvement with Endometriosis

I love doing research, so of course I have found out a few interesting things about endometriosis.

The nutshell version:
Baboons get endo too. It may be an autoimmune disorder. Contrary to popular belief, there is no evidence that the immune system attacks embryos in endo. Weaknesses in the immune system can promote and sustain endometriosis. The immune system of women with endo pumps out too many of certain kinds of molecules. Once those molecules can be more easily isolated in the blood or abdominal fluid of women with suspected endo, the invasive approach of diagnosing endo through laparoscopic surgery could be avoided. Proteins that bind to the molecules and thereby prevent them from attaching to endo cells instead are already in development. This new form of therapy could be used to treat endo noninvasively while keeping a woman's estrogen levels and ability to conceive intact.

The longer, more descriptive story:

*Baboons & Endometriosis*
As a primatologist I think it's interesting to know that baboons get endometriosis too. Apparently 83% of baboons have what's called "retrograde menstruation" which occurs when endometrial tissue from inside the uterus flows backwards through the fallopian tubes and out in to the abdominal cavity. This is one theory for the origin of endometriosis. However, retrograde menstruation occurs in about 80% of human women too and only 10% of women actually have endo. 25% of baboons have it. So, that's not much of a theory.

*Immune System Involvement*
What do I think is happening? Well, affected women could have been born with stem cells that become endometriosis at puberty when they get bathed in hormones, specifically estrogen. That could be the problem. Or, every woman is born with cells that become endometriosis but they are normally removed by the immune system. Affected women might have an immune system that fails to recognize and then kill the endo cells.

It's important to know the cause of endometriosis so that better therapies can be developed. Currently the standard procedure is to treat it hormonally by getting a woman to stop producing estrogen, or at least not so much of it. If a woman wants to keep endometriosis under control, her only option is to prevent ovulation. For women who want to produce a family, that's not much of an option.

"Although endometriosis can be treated using hormonal suppression, there is need for non-hormonal drugs, which can inhibit the development of endometriosis and alleviate pain or infertility without inhibition of ovulation. New molecules that modulate immune function in endometriosis should be the targets for future research" say the authors of an interesting study published in the Journal of Reproductive Biology and Endocrinology.

The article suggests that what actually happens in endometriosis is that cytokines (proteins synthesized by immune cells which promote inflammation) make endometrial cells proliferate (divide and multiply) and implant/adhere to nearby organs (like ovaries, bladder, colon, etc). So, inflammation is definitely the problem and one particular protein called TNF, tumor necrosis factor, is the real culprit.

Given that inflammation is associated with endometriosis, it stands to reason that immunosuppresive therapy (corticosteroids) could provide relief as it does for a wide variety of auto-immune disorders like rheumatoid arthritis. However, baboons who received the drugs didn't show any regression of endometriosis. The authors hope that more specific immunosuppressive drug therapies could be developed so that rather than attacking the entire immune system, only one part of it, perhaps the TNF, could be targeted.

*Endometriosis May be an Autoimmune Disorder*
The article also suggests that endometriosis may be an autoimmune disorder - the immune system produces antibodies that go unchecked. They secrete too many cytokines and too much inflammation, thus the problem. Meanwhile, other cytokines tell the endometrial tissue to vascularize (form new capillaries). What does that mean? Basically a superhighway is built to transport ever more inflammatory cells to the area. It grows like cancer.

*Impaired Embryo Implantation*
I often come across statistics and anecdotes from women trying to conceive with endo that suggest one reason women with endo have trouble getting pregnant is not that the fallopian tubes are blocked as is commonly thought, but rather that the fertilized embryo fails to implant into the uterine wall, i.e. the place where endometriosis is actually supposed to grow. This explains why so many women with this condition experience repeated "chemical pregnancies," miscarriages, and IVF failure.

The article has this to say, however, "The failure of NK cells to scavenge autologous endometrial cells may allow development of endometriosis. It has been hypothesized that natural killer cells in the endometrium can attack the implantation site of the embryo as it tries to attach to the uterine wall and that autoantibodies can play a role in this process. However, a recent review has shown that there is no proven relationship between abortion, recurrent abortion and endometriosis, and at present there is no proof that endometriosis- associated subfertility is caused by impaired embryo implantation."

-- Translation --
One kind of really-important-for-keeping-you-healthy, immune cell (natural killer cell) was thought to prevent the embryo from implanting in the uterus, but this turns out to not be the case. In fact, there is no evidence that failure to implant is the reason women with endometriosis have trouble becoming pregnant.

*The Immune System - What's Really Happening*
So what the heck is going on with endometriosis and the immune system?
T-cells (those immune cells that attack "germs" and what not and are depleted in people who have AIDS) are less toxic to cells they are supposed to kill. So, they don't kill the endometriosis like they are supposed to in affected women (and baboons!). Also, various other molecules that normally work to initiate programmed cell death (apoptosis) and also mark cells for elimination by the immune system - fail. So, endometriosis flies under the radar of the immune system and then fails to respond to the immune system's own form of euthanasia. Lovely. Absolutely lovely.

*New Diagnosis & Treatment Ideas*
The authors of the study I read think that invasive surgery, the gold standard for an official endometriosis diagnosis, could be rendered unnecessary by measuring the levels of two cytokines in abdominal fluid: TNF and IL-6 (interleukin 6). They say, "Endometriosis could be diagnosed if TNF-alpha levels in PF were higher than 15 pg/ml (100% sensitivity and 89% specificity) and if IL-6 levels in serum were above 2 pg/ml (90% sensitivity and 67% specificity)."

Endo can be treated by surgery and by hormonal suppression (progestins, continuous use of oral contraceptives, danazol, GnRH agonists). Danazol is also an immunosuppressive drug (steroid) that in addition to turning a woman into a She-Man, also makes her immune system quiet down. It shuts of TNF and some other cytokines like IL-1 (not 6).

The authors would really like to see other forms of treatment that don't deplete estrogen and therefore retain a woman's ability to not only get pregnant, but still look feminine. I would appreciate that too! Mouse, rat, and baboon models are being used to develop proteins that will give stuff like TNF and IL-6 something else to bond to instead of the endometrial cells. Already, a protein (recombinant human tumour necrosis factor-binding protein-1) has been shown to decrease endometriosis by 64% - in mice. Cool.

More thoughts on ENDO

In the language of the iVillage message boards I have started reading on the recommendation of my SIL, AF arrived today with the expected discomfort. I've been on Aleve and glued to a hot pad all day with periods of nausea that come and go. I thought I could get some work done today, but didn't have the patience to monkey around with spreadsheets.

Earlier this morning I felt better at one point and got out my laptop to download the latest surveymonkey data in the hopes that enough people participated over the weekend to fill up a cell I still need participants for. I got as far as requesting the data so that I can download it when surveymonkey makes it available. It can take them anywhere from a day or two to 15 minutes to make it available for me to download. It takes me an afternoon to get it all into SPSS depending on the number of people.

I was just about to check back with surveymonkey when I got inundated with phone calls. First my mom (who is normally absentee mom) called to tell me she found the perfect post-surgery outfit. I have been looking for something ultra-comfortable around the waist because the gas they pump in for the surgery is decidedly uncomfortable according to everyone who has had the procedure. Then my SIL called just to say hi and pass on warm thoughts. I called the kennel to get the doggy hotel squared away; in haste I reserved their kennel stay for the day of the surgery and the day Mr. Sleyed needs to get back to work, totally forgetting that we are leaving early so I don't have to do the day-before-surgery prep in the car. I have to totally void my digestive system, to put it delicately. I can't eat anything that day either.... so, we are leaving early so that whole business can happen at my home away from home during the lap experience. Fortunately the kennel had space and I was able to straighten out the problem with over-vaccinating our dogs for kennel cough.

Finally I was on the horn to find out how much it will cost us to get the bloodwork done that my FBCD (fancy big city doc) wants me to get done to find out if my hormone levels will allow me to conceive and sustain a pregnancy. Insurance won't cover the tests because they don't cover any infertility diagnosis or treatment. Rat bastards! It's absolutely assinine that they are allowed to get away with that at the same time they cover insanely expensive end-of-life care and conditions people earn through bad habits. Some states actually have passed laws to make insurance companies cover infertility treatments if they provide pregnancy care. Unfortunately WA is not one of those states. My former state of MT is. Weird. This list identifies states with mandated infertility coverage. The cost of the bloodwork is $420.

I would be surprised if they revealed anything abnormal, but I suppose he wants to know the results so that he can help me figure out what the best post-op treatment will be. Getting pregnant is one approach, but if I can't do that w/o some form of treatment (who knows the cost of that???) then I may have to go on BCPs until I go through menopause. Endo isn't something that can go untreated. If BCPs don't work I may have to take Lupron which gives you menopause and all of the side effects early. I don't want to become a She-Man in my early thirties !@&^% Yuck. If I am unlikely to get pregnant according to the tests, and the cost of treatment to try to get me pregnant is too much, well, then I will have to keep my fingers crossed that BCPs will keep my endo from getting worse and also get used to the idea of only ever having fur kids.

With my time spent laid up today I searched blogger for people who have endo and have had or will have laparoscopic surgery. I have found and read quite a few so I know what to expect. This story of one woman's laparoscopy was the most informative. If you want to know what will be happening to me in a few weeks, check it out.

Unfortunately I also read a lot of stories about people never being able to conceive even after the surgery. And - to make me really worry - quite a few have had more than one laparscopy. One even had more than TEN! Zounds! Why? The endo aggressively comes back even after it's surgically removed, and adhesions (scar tissue) forms where the endo was cut/burned away. That can actually make pain worse. So....

Now I am feeling like there is a chance that this surgery may actually make my pain much, much worse in time, and I will have to have another lap to get rid of the pain. Sheeeesh!

Maybe I should call Ruth (who is incidentally a gyno) so she is actually Dr. Ruth, just not the Dr. Ruth.

*********
The BEST thing that happened today -- I received a card in the mail today from my dissertation advisor. There's a chimp holding a beach ball and wishing me well with my surgery on the front, and inside a hopeful messgae about being well enough to get back to monkeying around again soon. It was really so sweet and unexpected that I actually felt some regret for all of the times I complained about her being a horrible advisor. She really came through, in a small albeit symbolic way.

Fair Medical Care?

Is a medical system fair if you have to be proactive and intelligent in order to get better care?

When I called my doc's office a few weeks ago to describe my symptoms, I had a good guess about what the problem was - endometriosis and endometrial ovarian cysts.

For those of you who don't know, endometriosis occurs when the cells that line the uterus grow outside the uterus too. The cells grow and shrink in unison with a woman's menstrual cycle and unlike the cells that grow inside the uterus that get shed each month when a woman doesn't get pregnant, the cells that grow in the wrong place have nowhere to go. Women with endo essentially bleed internally each month. The cells can grow anywhere in the pelvis and often attach to the ovaries, outside of the uterus, on the bladder, bowels, and sometimes even higher up in the lungs. It's really nasty stuff but usually is not cancerous. It is, however, graded like cancer to describe its severity. So, someone could have stage 3 or stage 4 endo. Severity of symptoms is not correlated with severity of endo. It causes pain and cramping (more than the usual menstrual cramps that women get), diarrhea, pain with intercourse, fatigue, and infertility. Not all women who have endo have symptoms.
I do. And - it sucks.

After speaking with my doc's nurse, I got orders to go get "monkey wanded" in the language of the iVillage discussion group I've been reading. That means I get to lay down in a dark room half naked while an ultrasound technician moves a gizmo around in my vagina that looks more like something you'd see in a sex toy shop. She showed me the 7x6x5 cm cyst on my left ovary and pointed out that my uterus is seriously catawampus. It's supposed to be pointed up at about 11 o'clock and straight. Mine is C shaped with the top part of the C pointed at about 4 o'clock. This kind of retroverted uterus is common in women who have endo. The uterus can get mishapen due to adhesions of endo scar tissue that attach the uterus to something else.

I got sent to a specialist the very next day who told me absolutely nothing new. That's because I had already researched my options - go on drugs that put me into early menopause with all of the well-known side effects or have a surgery, either laparoscopic or a laparotomy. Another option is to go on birth control pills or get pregnant because both make the endometrial tissue regress.

All of these are temporary solutions because there is no cure for endometriosis - not even a total hysterectomy and removal of both ovaries will make it go away forever. The only solution is to have all of the endometrial tissue surgically excised - removed completely, down to every last microscopic cell, which is of course, impossible in practice. Getting pregnant or taking drugs to stop ovulation only holds the growth of endo at bay. Surgical removal of the endo results in good prognosis for pain management and fertility. Women with moderate to severe endo (stage 3 or 4), have a 40% better chance of getting pregnant in the year after the surgery compared with not having one.

She wanted me to go on the menopause drugs. No thanks. I'd like to keep trying to get pregnant. Having the surgery may be my only way to achieve that. Besides, going on drugs just postpones that and doesn't remove the endo. I want the surgery I told her.

Then she told me that it would have to be a laparotomy due to the size of my cyst. That would mean a sizable incision and at least 6 weeks recovery time. I told her I want to have the surgery done laparoscopically and explained my situation with needing to finish my dissertation in the next three months. I don't have time for a laparotomy - especially when it could be taken care of laparoscopically, a procedure with a one week recovery and fewer risks. Plus, through my research I found out that the success of surgery is completely dependent on the skill of the surgeon and his/her experience in recognizing endometriosis. If someone was going to open me up to scrape out the junk, I sure don't want a small town hack doing the job.

I insisted on a laparoscopic approach. She called Seattle Reproductive Medicine and got me hooked up with a surgeon who is experienced at laparoscopic surgery for this problem. My surgery will happen in February a few days before my birthday. It will be an outpatient procedure and I should be able to go home the same day.

The only reason I am having the better procedure in more experienced hands is because I was proactive enough to research the options, smart enough to comprehend the medical terminology and weigh it, and confident enough to assert my choice. If it hadn't been for that, I'd be having a laparotomy in Walla Walla.

I am very fortunate to know enough to insist on going elsewhere for medical care - and - am even more fortunate to be able to go to an expert in Seattle and have insurance that will cover 80% of the cost of the procedure. Not everyone is so fortunate.

Too Much Information

Yahoo! Over the weekend I got all of my data into SPSS and cleaned up - i.e. naming variables, computing new ones based on the received data, filling in the blank spaces, adding new data... It took several hours but now BOTH studies are ready to go. I can begin analyzing any time.

I even have 80% of the responses I need for one cell that I inadvertently screwed up by having the wrong experimental treatment condition assigned to it. Given my complicated 2 x 3 x 4(3) design, I think it's pretty decent to have made only two mistakes in assigning treatment conditions. If I had had no other thing going on at the time, I might have been 100% but I was teaching three classes at the time - one for the very first time. It's sometimes difficult to remember exactly how busy I was!

The end is definitely in sight now. It sure will be wonderful to finally get this dissertation bumped off.

There's just one thing. It's about the size of a tennis ball and it has to be dealt with right away. I don't know how everything will turn out, and all I can do is hope for the best but prepare for the worst (which would be a major surgery and some amount of recovery that may mean I won't be able to defend my dissertation this spring as planned). Even if I have to have a major surgery, I am confident that I will still be able to go to Japan this summer as planned. And, if I have to defend after I get back or sometime after the deadline for spring graduation, I will still be able to participate in the next year's commencement ceremony. After all of the nuisance of grad school, I sure don't want to miss out on the hoopla of getting hooded. I will be the first doctor in my family.

When faced with uncertainty, I take great comfort in acquiring information. Hell - I thrive on information acquisition regardless of circumstances! However, I am one of those people health psychologists say thrive on information and feel better with more of it. It's sometimes hard to imagine there are people out there who are the exact opposite - the kind who would prefer to be willfully ignorant because that feels better. Not me. I went so far as to locate papers my new doc has published... Is that overkill?

To prepare for what might happen, I spent time making phone calls and sending out emails to my committee. I actually called my advisor at home (the one I have ranted about before). She was very supportive, which I very much appreciated. I've got a plan now, but I am still trying to figure out what to do about dog care while My Man With Gills is at work. Giant Newfsance, the Baroness von Roughenhausen, is a bit much to deal with even when everything is wonderful. I might need somebody around for a while who can let her out do her business, entertain her, and reel in her enthusiasm so she doesn't injure me (or Max) while I am in recovery. I am hoping I can have "my buddy" taken care of laparoscopicly so that won't be necessary.

I think I am done being scared, for now.

Soy & Phytoestrogens

Last week I finished reading an article from Hormones and Behavior about the metabolism of hunger and sex drive. Within it, I learned some more interesting factoids about the consequences of ingesting soy. I think I drink a lot of soy, and I also eat tofu occassionally, so I am interested.

I'm still trying to wrap my head around the wide-ranging article, to fit the pieces together myself, so I'll just report some of the more interesting elements of the story.

1 - Fat cells have estrogen receptors! Mice without working estrogen receptors become obese.

2 - Body fat distribution is more critical to long term cadiovascular health than body fat content or BMI. Gluteofemoral fat deposits are cardioprotective. So, if you have an hourglass figure (narrow waist with wide hips and fleshy butt and hips - an hourglass/pear figure rather than an apple) you're at reduced risk of heart disease. Also, women with a .70 waist to hip ratio (the hourglass figure) have higher fertility.

3 - Insulin levels are associated with visceral (deep belly) fat, whereas leptin levels are associated with subcutaneous gluteofemoral (butt, hips, thigh) fat. Hormones of the HPA axis (hypothalamus - pituitary - adrenal glands), such as cortisol, are also implicated in body fat distribution. Stress may cause you to put on more visceral fat.

4 - Eating disorders (of which the author seems to be primarily interested in obesity) may arise from changes in neural sensitivity to estrogen that occur early in brain development.

5 - These changes might be intitiated by exposure to phytoestrogens in our diet and pollutants.

So, evidently, consuming soy is cardioprotective and reduces the risk of developing obesity only when consumed as an adult. BUT - and this is a big but - consumption of soy during pregnancy or exposure of a fetus to soy and phytoestrogens actually increases the risk of cardiovascular problems and obesity.

Pregnant women and infants should not consume soy or any products containing phytoestrogens because the phytoestrogens bind to the body's estrogen receptors in the brain, various internal organs, and particular body cells like fat cells. This leads to organizational changes in the infant's brain that masculinize a female's body fat distribution after puberty: more visceral fat around the waist, less around the hips and butt. This places her at greater risk of developing heart disease and obesity.

The paper, however, focused on an evolutionary theory that there are brain mechanisms dependent on hormones that serve to signal an animal when it's time to eat vs. mate. The author explored the metabolic control of hunger inhibition, arguing that such a mechanism is adaptive because it would "bring the cessation of hunger and eating long enough to find and court potential mates." She suggests that the hormone leptin, known as a hunger hormone because high levels of it inhibit appetite, should come to be viewed as a sex hormone too. Evidently, leptin enhances sex behavior - in rats and mice. It stimulates the preference of having sex over eating. The author also argues that the hormone neuropeptide Y which is known as an appetite stimulant, should also come to be viewed as a sex hormone that stimulates the preference for food over sex.