Betsy Bates

SAN FRANCISCO — An office evaluation for incontinence and overactive bladder can begin with one simple screening question, and then a follow-up if the answer is yes, said Dr. Michael Moen, director of the division of urogynecology at Advocate Lutheran General Hospital in Park Ridge, Ill.

The first question is, “Do you have bladder problems that are troublesome, or do you ever leak urine?” If the patient answers in the affirmative, rule out a urinary tract infection and perform a focused history and physical examination.

But don't forget to include one more key inquiry before you move on.

That question is whether she has nocturia, which points strongly in the direction of overactive bladder rather than stress incontinence.

“If you have overactive bladder, it doesn't take the evening off,” said Dr. Moen at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

In contrast, urodynamic stress urinary incontinence is triggered by activity, not rest.

Many women will not volunteer the fact that they leak urine when they exercise, laugh, or cough, or that they rise four times a night to urinate—unless they're asked. “They think it's part of aging or part of having children.”

While symptomatic pelvic organ prolapse may propel a woman to make an appointment, it may take significant lifestyle disruption or a profoundly embarrassing public episode of leakage to make women seek care for urinary incontinence, which affects 20%–55% of American women.

Dr. Moen targets four important areas in a review of pelvic symptoms:

▸ Anatomic function. Is there a bulge? A mass? Pressure?

▸ Urinary function. Does she void at intervals of less than 3 hours? Experience urgency? Rise more than twice a night to urinate? Leak with urge? Leak with laughing, coughing, or sneezing? Leak with exercise? Does she have difficulty voiding? Does she need to wear pads?

▸ Bowel function. Does she experience leakage? Constipation?

▸ Sexual function. Does she have pain with intercourse? Anatomic issues? Embarrassment or avoidance due to urinary issues?

Constipation is a surprisingly frequent concurrent issue, said Dr. Moen, occurring in at least 30% of patients he sees for any pelvic floor disorder. It is uncertain whether constipation causes or is caused by pelvic floor dysfunction, but it needs to be addressed. “Some people think it is more normal to push and strain their insides out than to take fiber every day.”

He frames the issue within the context of modern life and the American diet. “I tell women it is virtually impossible to get enough usable fiber in their diet without consuming too many calories,” he said, suggesting that supplements are the answer, not a medicine.

Before conducting an examination, Dr. Moen also brings up the possibility that a woman's quality of life may have been affected by her problems with incontinence or overactive bladder. Perhaps she has restricted her exercise, social activities, and travel. In line with several studies on an association with incontinence, she may be suffering from clinical depression.

The visual and physical examination are aimed at detecting urogenital atrophy, “one of the most overlooked and easily treated conditions in women,” and/or pelvic organ prolapse, he said.

A simple cough stress test approaches a 95%–98% sensitivity and specificity in identifying incontinence.

Neuromuscular function should be assessed by eliciting perineal sensations with a light touch near the anus and an assessment of pelvic muscle strength, facilitated by asking the patient to isolate and squeeze pelvic floor muscles while one of the physicians' fingers is inserted 3–4 cm into the vaginal canal.

In an examination of young, asymptomatic women, Dr. Moen and associates found that 20%–30% were unable to properly contract their pelvic floor muscles, with 10% “actually perform[ing] a Valsalva” maneuver and believing they were doing a Kegel contraction, said Dr. Moen.

“This is critical, because even if you don't suggest to them that they do these types of exercises, they're reading about them in Elle, Self, and Good Housekeeping.”

Doing Kegel exercises improperly can actually exacerbate pelvic floor weakness. On the other hand, proper use of the exercise as few as 30 times, 3 times a week, can be effective in preventing or improving symptoms of stress and urge incontinence.

If simple instructions don't work, physical therapy, perhaps including biofeedback, electrical stimulation, and electromagnetic therapy, may be helpful in strengthening pelvic floor muscles.

Other potentially important therapeutic options for incontinence and/or overactive bladder may include medications, pessaries, and in 25% or fewer cases, eventual surgery if other measures fail.

The most important intervention, according to Dr. Moen, is bladder retraining. “If you do nothing else, tell patients to go to the bathroom on schedule. They will get better.”

If a woman estimates she is urinating every hour, he begins with that target, telling her to urinate every hour. Then, she is instructed to begin to “outsmart her bladder,” by stretching the intervals to 2 hours, then 3, and so on.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Tampons 'Mimic' Pessary Effects

Even very young women—and certainly many older women who lead physically active lives—may leak urine during vigorous exercise, but that doesn't mean they all need pessaries or surgery to get them on the court or the playing field, according to Dr. Michael Moen.

“For any woman who has stopped exercising due to leaking, the tampon trick is great,” said Dr. Moen. He instructs such women to use the largest tampon they can comfortably accommodate using lubrication to act as a buttress supporting the urethra, just as a pessary would.

The tampon trick should only be used during the period of time when a woman knows she will be engaged in doing vigorous activity.

“There's nothing wrong with using a tampon and wearing a pad and getting some biker shorts [for] support,” he emphasized. The point is to work with women to allow them to engage in activities they enjoy.

SAN FRANCISCO — An office evaluation for incontinence and overactive bladder can begin with one simple screening question, and then a follow-up if the answer is yes, said Dr. Michael Moen, director of the division of urogynecology at Advocate Lutheran General Hospital in Park Ridge, Ill.

The first question is, “Do you have bladder problems that are troublesome, or do you ever leak urine?” If the patient answers in the affirmative, rule out a urinary tract infection and perform a focused history and physical examination.

But don't forget to include one more key inquiry before you move on.

That question is whether she has nocturia, which points strongly in the direction of overactive bladder rather than stress incontinence.

“If you have overactive bladder, it doesn't take the evening off,” said Dr. Moen at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

In contrast, urodynamic stress urinary incontinence is triggered by activity, not rest.

Many women will not volunteer the fact that they leak urine when they exercise, laugh, or cough, or that they rise four times a night to urinate—unless they're asked. “They think it's part of aging or part of having children.”

While symptomatic pelvic organ prolapse may propel a woman to make an appointment, it may take significant lifestyle disruption or a profoundly embarrassing public episode of leakage to make women seek care for urinary incontinence, which affects 20%–55% of American women.

Dr. Moen targets four important areas in a review of pelvic symptoms:

▸ Anatomic function. Is there a bulge? A mass? Pressure?

▸ Urinary function. Does she void at intervals of less than 3 hours? Experience urgency? Rise more than twice a night to urinate? Leak with urge? Leak with laughing, coughing, or sneezing? Leak with exercise? Does she have difficulty voiding? Does she need to wear pads?

▸ Bowel function. Does she experience leakage? Constipation?

▸ Sexual function. Does she have pain with intercourse? Anatomic issues? Embarrassment or avoidance due to urinary issues?

Constipation is a surprisingly frequent concurrent issue, said Dr. Moen, occurring in at least 30% of patients he sees for any pelvic floor disorder. It is uncertain whether constipation causes or is caused by pelvic floor dysfunction, but it needs to be addressed. “Some people think it is more normal to push and strain their insides out than to take fiber every day.”

He frames the issue within the context of modern life and the American diet. “I tell women it is virtually impossible to get enough usable fiber in their diet without consuming too many calories,” he said, suggesting that supplements are the answer, not a medicine.

Before conducting an examination, Dr. Moen also brings up the possibility that a woman's quality of life may have been affected by her problems with incontinence or overactive bladder. Perhaps she has restricted her exercise, social activities, and travel. In line with several studies on an association with incontinence, she may be suffering from clinical depression.

The visual and physical examination are aimed at detecting urogenital atrophy, “one of the most overlooked and easily treated conditions in women,” and/or pelvic organ prolapse, he said.

A simple cough stress test approaches a 95%–98% sensitivity and specificity in identifying incontinence.

Neuromuscular function should be assessed by eliciting perineal sensations with a light touch near the anus and an assessment of pelvic muscle strength, facilitated by asking the patient to isolate and squeeze pelvic floor muscles while one of the physicians' fingers is inserted 3–4 cm into the vaginal canal.

In an examination of young, asymptomatic women, Dr. Moen and associates found that 20%–30% were unable to properly contract their pelvic floor muscles, with 10% “actually perform[ing] a Valsalva” maneuver and believing they were doing a Kegel contraction, said Dr. Moen.

“This is critical, because even if you don't suggest to them that they do these types of exercises, they're reading about them in Elle, Self, and Good Housekeeping.”

Doing Kegel exercises improperly can actually exacerbate pelvic floor weakness. On the other hand, proper use of the exercise as few as 30 times, 3 times a week, can be effective in preventing or improving symptoms of stress and urge incontinence.

If simple instructions don't work, physical therapy, perhaps including biofeedback, electrical stimulation, and electromagnetic therapy, may be helpful in strengthening pelvic floor muscles.

Other potentially important therapeutic options for incontinence and/or overactive bladder may include medications, pessaries, and in 25% or fewer cases, eventual surgery if other measures fail.

The most important intervention, according to Dr. Moen, is bladder retraining. “If you do nothing else, tell patients to go to the bathroom on schedule. They will get better.”

If a woman estimates she is urinating every hour, he begins with that target, telling her to urinate every hour. Then, she is instructed to begin to “outsmart her bladder,” by stretching the intervals to 2 hours, then 3, and so on.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Tampons 'Mimic' Pessary Effects

Even very young women—and certainly many older women who lead physically active lives—may leak urine during vigorous exercise, but that doesn't mean they all need pessaries or surgery to get them on the court or the playing field, according to Dr. Michael Moen.

“For any woman who has stopped exercising due to leaking, the tampon trick is great,” said Dr. Moen. He instructs such women to use the largest tampon they can comfortably accommodate using lubrication to act as a buttress supporting the urethra, just as a pessary would.

The tampon trick should only be used during the period of time when a woman knows she will be engaged in doing vigorous activity.

“There's nothing wrong with using a tampon and wearing a pad and getting some biker shorts [for] support,” he emphasized. The point is to work with women to allow them to engage in activities they enjoy.

SAN FRANCISCO — An office evaluation for incontinence and overactive bladder can begin with one simple screening question, and then a follow-up if the answer is yes, said Dr. Michael Moen, director of the division of urogynecology at Advocate Lutheran General Hospital in Park Ridge, Ill.

The first question is, “Do you have bladder problems that are troublesome, or do you ever leak urine?” If the patient answers in the affirmative, rule out a urinary tract infection and perform a focused history and physical examination.

But don't forget to include one more key inquiry before you move on.

That question is whether she has nocturia, which points strongly in the direction of overactive bladder rather than stress incontinence.

“If you have overactive bladder, it doesn't take the evening off,” said Dr. Moen at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

In contrast, urodynamic stress urinary incontinence is triggered by activity, not rest.

Many women will not volunteer the fact that they leak urine when they exercise, laugh, or cough, or that they rise four times a night to urinate—unless they're asked. “They think it's part of aging or part of having children.”

While symptomatic pelvic organ prolapse may propel a woman to make an appointment, it may take significant lifestyle disruption or a profoundly embarrassing public episode of leakage to make women seek care for urinary incontinence, which affects 20%–55% of American women.

Dr. Moen targets four important areas in a review of pelvic symptoms:

▸ Anatomic function. Is there a bulge? A mass? Pressure?

▸ Urinary function. Does she void at intervals of less than 3 hours? Experience urgency? Rise more than twice a night to urinate? Leak with urge? Leak with laughing, coughing, or sneezing? Leak with exercise? Does she have difficulty voiding? Does she need to wear pads?

▸ Bowel function. Does she experience leakage? Constipation?

▸ Sexual function. Does she have pain with intercourse? Anatomic issues? Embarrassment or avoidance due to urinary issues?

Constipation is a surprisingly frequent concurrent issue, said Dr. Moen, occurring in at least 30% of patients he sees for any pelvic floor disorder. It is uncertain whether constipation causes or is caused by pelvic floor dysfunction, but it needs to be addressed. “Some people think it is more normal to push and strain their insides out than to take fiber every day.”

He frames the issue within the context of modern life and the American diet. “I tell women it is virtually impossible to get enough usable fiber in their diet without consuming too many calories,” he said, suggesting that supplements are the answer, not a medicine.

Before conducting an examination, Dr. Moen also brings up the possibility that a woman's quality of life may have been affected by her problems with incontinence or overactive bladder. Perhaps she has restricted her exercise, social activities, and travel. In line with several studies on an association with incontinence, she may be suffering from clinical depression.

The visual and physical examination are aimed at detecting urogenital atrophy, “one of the most overlooked and easily treated conditions in women,” and/or pelvic organ prolapse, he said.

A simple cough stress test approaches a 95%–98% sensitivity and specificity in identifying incontinence.

Neuromuscular function should be assessed by eliciting perineal sensations with a light touch near the anus and an assessment of pelvic muscle strength, facilitated by asking the patient to isolate and squeeze pelvic floor muscles while one of the physicians' fingers is inserted 3–4 cm into the vaginal canal.

In an examination of young, asymptomatic women, Dr. Moen and associates found that 20%–30% were unable to properly contract their pelvic floor muscles, with 10% “actually perform[ing] a Valsalva” maneuver and believing they were doing a Kegel contraction, said Dr. Moen.

“This is critical, because even if you don't suggest to them that they do these types of exercises, they're reading about them in Elle, Self, and Good Housekeeping.”

Doing Kegel exercises improperly can actually exacerbate pelvic floor weakness. On the other hand, proper use of the exercise as few as 30 times, 3 times a week, can be effective in preventing or improving symptoms of stress and urge incontinence.

If simple instructions don't work, physical therapy, perhaps including biofeedback, electrical stimulation, and electromagnetic therapy, may be helpful in strengthening pelvic floor muscles.

Other potentially important therapeutic options for incontinence and/or overactive bladder may include medications, pessaries, and in 25% or fewer cases, eventual surgery if other measures fail.

The most important intervention, according to Dr. Moen, is bladder retraining. “If you do nothing else, tell patients to go to the bathroom on schedule. They will get better.”

If a woman estimates she is urinating every hour, he begins with that target, telling her to urinate every hour. Then, she is instructed to begin to “outsmart her bladder,” by stretching the intervals to 2 hours, then 3, and so on.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Tampons 'Mimic' Pessary Effects

Even very young women—and certainly many older women who lead physically active lives—may leak urine during vigorous exercise, but that doesn't mean they all need pessaries or surgery to get them on the court or the playing field, according to Dr. Michael Moen.

“For any woman who has stopped exercising due to leaking, the tampon trick is great,” said Dr. Moen. He instructs such women to use the largest tampon they can comfortably accommodate using lubrication to act as a buttress supporting the urethra, just as a pessary would.

The tampon trick should only be used during the period of time when a woman knows she will be engaged in doing vigorous activity.

“There's nothing wrong with using a tampon and wearing a pad and getting some biker shorts [for] support,” he emphasized. The point is to work with women to allow them to engage in activities they enjoy.

LAS VEGAS — When confronted with severe or refractory Clostridium difficile-associated disease, act fast, act aggressively, and don't be afraid to try unorthodox methods if standard therapies don't work, Dr. Christina Surawicz stressed during a symposium at the annual meeting of the American College of Gastroenterology.

Virulent strains are emerging, so look for a rapid response to standard therapy and then be prepared to move on, said Dr. Surawicz, professor of medicine at the University of Washington, Seattle.

“Basically, my philosophy is to throw everything at [it] because it's such a serious disease that there is no harm in maximizing treatment right away,” she said.

Metronidazole, given in a dosage of 250 mg four times daily for 10 days, is still considered first-line treatment for C. difficile disease, and it shows efficacy equal to vancomycin in patients with mild disease. However, patients with severe disease or risk factors for progression might be better off with vancomycin from the start.

“We've all been indoctrinated to use metronidazole first line,” she said. But “Metronidazole response rates are not the 90% or 95% we were used to seeing 5 or 6 years ago.” Recent data show metronidazole response rates in the 70%–78% range, or even lower, in severe C. difficile disease. Relapses are increasingly common.

Don't wait more than 3 days to make the switch in patients with mild to moderate disease, and consider vancomycin first line in those with severe disease, which is typically marked by pseudomembranous colitis, severe pain and abdominal distension, presence of colon wall thickening and/or ascites on CT, hemodynamic instability, declining mental status, elevated white blood cell count, elevated serum creatinine, and low albumin levels, Dr. Surawicz advised. The standard oral vancomycin dosage for C. difficile is 125–250 mg four times daily, but Dr. Surawicz advised quickly increasing the dosage to 2 g/day if necessary.

Small trials have convinced Dr. Surawicz to try 500 mg of intravenous metronidazole every 6–8 hours in patients with refractory disease, and to give vancomycin enemas using 500 mg of the intravenous form of the drug in 100 mL of normal saline 3–4 times daily.

“We should be consulting our surgical colleagues earlier rather than later,” said Dr. Surawicz, who disclosed that she is a consultant to or on the speakers' bureau for ViroPharma Inc., manufacturer of vancomycin.

LAS VEGAS — When confronted with severe or refractory Clostridium difficile-associated disease, act fast, act aggressively, and don't be afraid to try unorthodox methods if standard therapies don't work, Dr. Christina Surawicz stressed during a symposium at the annual meeting of the American College of Gastroenterology.

Virulent strains are emerging, so look for a rapid response to standard therapy and then be prepared to move on, said Dr. Surawicz, professor of medicine at the University of Washington, Seattle.

“Basically, my philosophy is to throw everything at [it] because it's such a serious disease that there is no harm in maximizing treatment right away,” she said.

Metronidazole, given in a dosage of 250 mg four times daily for 10 days, is still considered first-line treatment for C. difficile disease, and it shows efficacy equal to vancomycin in patients with mild disease. However, patients with severe disease or risk factors for progression might be better off with vancomycin from the start.

“We've all been indoctrinated to use metronidazole first line,” she said. But “Metronidazole response rates are not the 90% or 95% we were used to seeing 5 or 6 years ago.” Recent data show metronidazole response rates in the 70%–78% range, or even lower, in severe C. difficile disease. Relapses are increasingly common.

Don't wait more than 3 days to make the switch in patients with mild to moderate disease, and consider vancomycin first line in those with severe disease, which is typically marked by pseudomembranous colitis, severe pain and abdominal distension, presence of colon wall thickening and/or ascites on CT, hemodynamic instability, declining mental status, elevated white blood cell count, elevated serum creatinine, and low albumin levels, Dr. Surawicz advised. The standard oral vancomycin dosage for C. difficile is 125–250 mg four times daily, but Dr. Surawicz advised quickly increasing the dosage to 2 g/day if necessary.

Small trials have convinced Dr. Surawicz to try 500 mg of intravenous metronidazole every 6–8 hours in patients with refractory disease, and to give vancomycin enemas using 500 mg of the intravenous form of the drug in 100 mL of normal saline 3–4 times daily.

“We should be consulting our surgical colleagues earlier rather than later,” said Dr. Surawicz, who disclosed that she is a consultant to or on the speakers' bureau for ViroPharma Inc., manufacturer of vancomycin.

LAS VEGAS — When confronted with severe or refractory Clostridium difficile-associated disease, act fast, act aggressively, and don't be afraid to try unorthodox methods if standard therapies don't work, Dr. Christina Surawicz stressed during a symposium at the annual meeting of the American College of Gastroenterology.

Virulent strains are emerging, so look for a rapid response to standard therapy and then be prepared to move on, said Dr. Surawicz, professor of medicine at the University of Washington, Seattle.

“Basically, my philosophy is to throw everything at [it] because it's such a serious disease that there is no harm in maximizing treatment right away,” she said.

Metronidazole, given in a dosage of 250 mg four times daily for 10 days, is still considered first-line treatment for C. difficile disease, and it shows efficacy equal to vancomycin in patients with mild disease. However, patients with severe disease or risk factors for progression might be better off with vancomycin from the start.

“We've all been indoctrinated to use metronidazole first line,” she said. But “Metronidazole response rates are not the 90% or 95% we were used to seeing 5 or 6 years ago.” Recent data show metronidazole response rates in the 70%–78% range, or even lower, in severe C. difficile disease. Relapses are increasingly common.

Don't wait more than 3 days to make the switch in patients with mild to moderate disease, and consider vancomycin first line in those with severe disease, which is typically marked by pseudomembranous colitis, severe pain and abdominal distension, presence of colon wall thickening and/or ascites on CT, hemodynamic instability, declining mental status, elevated white blood cell count, elevated serum creatinine, and low albumin levels, Dr. Surawicz advised. The standard oral vancomycin dosage for C. difficile is 125–250 mg four times daily, but Dr. Surawicz advised quickly increasing the dosage to 2 g/day if necessary.

Small trials have convinced Dr. Surawicz to try 500 mg of intravenous metronidazole every 6–8 hours in patients with refractory disease, and to give vancomycin enemas using 500 mg of the intravenous form of the drug in 100 mL of normal saline 3–4 times daily.

“We should be consulting our surgical colleagues earlier rather than later,” said Dr. Surawicz, who disclosed that she is a consultant to or on the speakers' bureau for ViroPharma Inc., manufacturer of vancomycin.

LAS VEGAS — When Clostridium difficile disease recurs, look out.

It's likely to recur again and again in a cycle that can go on for “months or years,” Dr. Christina Surawicz said at the annual meeting of the American College of Gastroenterology.

“Are recurrences increasing? The Quebec experience suggests that yes, they are.” In the early 1990s, about 15% of patients with C. difficile disease experienced a recurrence. That figure climbed to 24%–25% in 1993–1998, and to 47% in 2003–2004, said Dr. Surawicz, professor of medicine at the University of Washington, Seattle.

In the United States, about 20% of patients who initially respond to standard antibiotic regimens for C. difficile-associated disease experience a recurrence, usually about 5–8 days after discontinuation of therapy. Subsequent recurrences are seen in 45%–65% of these patients.

Risk factors are thought to include advanced age, fecal incontinence, and disorders that require continuous antibiotic therapy, but Dr. Surawicz said she has also seen cases in young patients whose only initial exposure to antibiotics was for treatment of urinary tract infections or otitis. She has treated two patients who developed recurrent C. difficile disease after receiving antibiotics for complications of childbirth.

There is no single treatment strategy that seems to be uniformly efficacious. Some approaches have included repeating courses of metronidazole, or switching to vancomycin (or the reverse if vancomycin was used first), or using elevated doses or pulsed, tapered, or prolonged vancomycin dosing strategies.

Using toxin-binding resins such as cholestyramine or colestipol 3–4 hours after antibiotic administration may improve efficacy, Dr. Surawicz said.

A poster presented at the meeting described using a rifaximin “chaser” (400–800 mg/day in two or three divided doses for 2 weeks) following vancomycin. The strategy halted the recurrence cycle in six of seven patients, reported Dr. Stuart Johnson of Loyola University Medical Center and Hines VA Hospital in Chicago.

It may be useful to try to normalize fecal flora by using probiotic living organisms that are nonpathogenic and nontoxic, such as Saccharomyces boulardii, a yeast originally isolated from the lychee fruit. This yeast has been the subject of Dr. Surawicz's research for 14 years.

Several trials have shown efficacy with S. boulardii used as an adjunct to antibiotics in recurrent disease, but a prospective, placebo-controlled trial found significant efficacy only when it was used in combination with high-dose vancomycin (2 g/day). Subsequent evaluation suggested that recurrences were much more likely in patients with persistent C. difficile in their stools despite therapy with antibiotics and S. boulardii.

The value of other probiotics has similarly not held up in randomized, controlled trials; more research is needed to determine how to minimize the risks of using the agents while maximizing benefits, Dr. Surawicz said.

Bacteriotherapy using artificial stool created with anaerobic and aerobic bacteria, and administering nontoxic strains of C. difficile have also been reported anecdotally. A toxoid vaccine is in development and looks promising, with three of three treated patients experiencing a resolution of their recurrent disease.

Until such a vaccine is available, fecal enemas using emulsified donor stool is a highly unconventional approach that might actually work, she said.

“For years, I said the whole notion of fecal enemas was just an indication of just how desperate patients and their doctors are, but I changed my mind,” Dr. Surawicz said.

She had read about more than a dozen cases in which the technique worked, and she first performed a fecal enema on a patient with multiple recurrences despite repeated courses of vancomycin (tapered, then pulsed) and probiotics over 9 months.

Vancomycin was discontinued 3 days prior to the procedure, and the patient was instructed to use a standard colon cleansing preparation. Donor stool from the patient's husband was then emulsified in nonbacteriostatic saline, filtered, and introduced into the colon using a colonoscope.

The patient recovered fully from her C. difficile-associated disease and did not experience any more recurrences, Dr. Surawicz said.

LAS VEGAS — When Clostridium difficile disease recurs, look out.

It's likely to recur again and again in a cycle that can go on for “months or years,” Dr. Christina Surawicz said at the annual meeting of the American College of Gastroenterology.

“Are recurrences increasing? The Quebec experience suggests that yes, they are.” In the early 1990s, about 15% of patients with C. difficile disease experienced a recurrence. That figure climbed to 24%–25% in 1993–1998, and to 47% in 2003–2004, said Dr. Surawicz, professor of medicine at the University of Washington, Seattle.

In the United States, about 20% of patients who initially respond to standard antibiotic regimens for C. difficile-associated disease experience a recurrence, usually about 5–8 days after discontinuation of therapy. Subsequent recurrences are seen in 45%–65% of these patients.

Risk factors are thought to include advanced age, fecal incontinence, and disorders that require continuous antibiotic therapy, but Dr. Surawicz said she has also seen cases in young patients whose only initial exposure to antibiotics was for treatment of urinary tract infections or otitis. She has treated two patients who developed recurrent C. difficile disease after receiving antibiotics for complications of childbirth.

There is no single treatment strategy that seems to be uniformly efficacious. Some approaches have included repeating courses of metronidazole, or switching to vancomycin (or the reverse if vancomycin was used first), or using elevated doses or pulsed, tapered, or prolonged vancomycin dosing strategies.

Using toxin-binding resins such as cholestyramine or colestipol 3–4 hours after antibiotic administration may improve efficacy, Dr. Surawicz said.

A poster presented at the meeting described using a rifaximin “chaser” (400–800 mg/day in two or three divided doses for 2 weeks) following vancomycin. The strategy halted the recurrence cycle in six of seven patients, reported Dr. Stuart Johnson of Loyola University Medical Center and Hines VA Hospital in Chicago.

It may be useful to try to normalize fecal flora by using probiotic living organisms that are nonpathogenic and nontoxic, such as Saccharomyces boulardii, a yeast originally isolated from the lychee fruit. This yeast has been the subject of Dr. Surawicz's research for 14 years.

Several trials have shown efficacy with S. boulardii used as an adjunct to antibiotics in recurrent disease, but a prospective, placebo-controlled trial found significant efficacy only when it was used in combination with high-dose vancomycin (2 g/day). Subsequent evaluation suggested that recurrences were much more likely in patients with persistent C. difficile in their stools despite therapy with antibiotics and S. boulardii.

The value of other probiotics has similarly not held up in randomized, controlled trials; more research is needed to determine how to minimize the risks of using the agents while maximizing benefits, Dr. Surawicz said.

Bacteriotherapy using artificial stool created with anaerobic and aerobic bacteria, and administering nontoxic strains of C. difficile have also been reported anecdotally. A toxoid vaccine is in development and looks promising, with three of three treated patients experiencing a resolution of their recurrent disease.

Until such a vaccine is available, fecal enemas using emulsified donor stool is a highly unconventional approach that might actually work, she said.

“For years, I said the whole notion of fecal enemas was just an indication of just how desperate patients and their doctors are, but I changed my mind,” Dr. Surawicz said.

She had read about more than a dozen cases in which the technique worked, and she first performed a fecal enema on a patient with multiple recurrences despite repeated courses of vancomycin (tapered, then pulsed) and probiotics over 9 months.

Vancomycin was discontinued 3 days prior to the procedure, and the patient was instructed to use a standard colon cleansing preparation. Donor stool from the patient's husband was then emulsified in nonbacteriostatic saline, filtered, and introduced into the colon using a colonoscope.

The patient recovered fully from her C. difficile-associated disease and did not experience any more recurrences, Dr. Surawicz said.

LAS VEGAS — When Clostridium difficile disease recurs, look out.

It's likely to recur again and again in a cycle that can go on for “months or years,” Dr. Christina Surawicz said at the annual meeting of the American College of Gastroenterology.

“Are recurrences increasing? The Quebec experience suggests that yes, they are.” In the early 1990s, about 15% of patients with C. difficile disease experienced a recurrence. That figure climbed to 24%–25% in 1993–1998, and to 47% in 2003–2004, said Dr. Surawicz, professor of medicine at the University of Washington, Seattle.

In the United States, about 20% of patients who initially respond to standard antibiotic regimens for C. difficile-associated disease experience a recurrence, usually about 5–8 days after discontinuation of therapy. Subsequent recurrences are seen in 45%–65% of these patients.

Risk factors are thought to include advanced age, fecal incontinence, and disorders that require continuous antibiotic therapy, but Dr. Surawicz said she has also seen cases in young patients whose only initial exposure to antibiotics was for treatment of urinary tract infections or otitis. She has treated two patients who developed recurrent C. difficile disease after receiving antibiotics for complications of childbirth.

There is no single treatment strategy that seems to be uniformly efficacious. Some approaches have included repeating courses of metronidazole, or switching to vancomycin (or the reverse if vancomycin was used first), or using elevated doses or pulsed, tapered, or prolonged vancomycin dosing strategies.

Using toxin-binding resins such as cholestyramine or colestipol 3–4 hours after antibiotic administration may improve efficacy, Dr. Surawicz said.

A poster presented at the meeting described using a rifaximin “chaser” (400–800 mg/day in two or three divided doses for 2 weeks) following vancomycin. The strategy halted the recurrence cycle in six of seven patients, reported Dr. Stuart Johnson of Loyola University Medical Center and Hines VA Hospital in Chicago.

It may be useful to try to normalize fecal flora by using probiotic living organisms that are nonpathogenic and nontoxic, such as Saccharomyces boulardii, a yeast originally isolated from the lychee fruit. This yeast has been the subject of Dr. Surawicz's research for 14 years.

Several trials have shown efficacy with S. boulardii used as an adjunct to antibiotics in recurrent disease, but a prospective, placebo-controlled trial found significant efficacy only when it was used in combination with high-dose vancomycin (2 g/day). Subsequent evaluation suggested that recurrences were much more likely in patients with persistent C. difficile in their stools despite therapy with antibiotics and S. boulardii.

The value of other probiotics has similarly not held up in randomized, controlled trials; more research is needed to determine how to minimize the risks of using the agents while maximizing benefits, Dr. Surawicz said.

Bacteriotherapy using artificial stool created with anaerobic and aerobic bacteria, and administering nontoxic strains of C. difficile have also been reported anecdotally. A toxoid vaccine is in development and looks promising, with three of three treated patients experiencing a resolution of their recurrent disease.

Until such a vaccine is available, fecal enemas using emulsified donor stool is a highly unconventional approach that might actually work, she said.

“For years, I said the whole notion of fecal enemas was just an indication of just how desperate patients and their doctors are, but I changed my mind,” Dr. Surawicz said.

She had read about more than a dozen cases in which the technique worked, and she first performed a fecal enema on a patient with multiple recurrences despite repeated courses of vancomycin (tapered, then pulsed) and probiotics over 9 months.

Vancomycin was discontinued 3 days prior to the procedure, and the patient was instructed to use a standard colon cleansing preparation. Donor stool from the patient's husband was then emulsified in nonbacteriostatic saline, filtered, and introduced into the colon using a colonoscope.

The patient recovered fully from her C. difficile-associated disease and did not experience any more recurrences, Dr. Surawicz said.

Researchers at the Mayo Clinic and elsewhere are racing to develop rapid-detection tests for Staphylococcus aureus, both to better tailor appropriate antibiotic prescribing and to halt the galloping spread of methicillin-resistant strains of the bacteria.

The race for quicker, easier, better rapid detection tests has been intense, said Betsy McCaughey, Ph.D., director of the New York City-based nonprofit Committee to Reduce Infection Deaths.

“There are many companies now developing rapid tests. I've visited at least half a dozen,” she said in an interview.

Among the contenders are Innovative Biosensors Inc. in College Park, Md., which is using light-based technology developed at the Massachusetts Institute of Technology; Cepheid, a Sunnyvale, Calif.-based company about to introduce another genetic-based rapid test; and 3M, which has “waded deep into this territory,” Dr. McCaughey said.

Progress has been keenest in identifying colonized patients prior to or during hospitalization to help reduce the spread of resistant bacteria.

At the University of Maryland Medical Center in Baltimore, for example, patients considered at risk for methicillin-resistant S. aureus (MRSA) can be screened in 2 hours with a polymerase chain reaction (PCR) DNA test developed by Becton, Dickinson & Co., rather than waiting 24–48 hours to get an answer by culturing for the bacteria.

All intensive care unit patients are being screened at admission, on a weekly basis, and on discharge so that infected patients can be identified and treated with appropriate isolation and contact precautions, said Richard Venezia, Ph.D., professor of pathology and director of clinical microbiology at the university.

Efforts to further screen patients with risk factors—a previous hospital admission or recent use of antibiotics, for example—are “almost in full swing,” he said in an interview.

“This is the first of a generation of tests that are going to be using 'within-the-tube' closed systems,” based on either DNA or immunology, that represent a major technological advance in the way risky bacteria are identified, he said.

The tests do not require the level of training or sophisticated precautions against cross-contamination that were necessary with previous PCR procedures developed in research laboratories; neither do they require complex interpretation, because they provide a “yes/no/repeat the test” type answer.

The new tests are currently confined to hospital or community laboratories, but Dr. Venezia said that they will almost certainly be available for bedside or community office practices within 5 years.

At the Mayo Clinic in Rochester, Minn., two swab-based PCR tests are being developed, one to signal the presence of S. aureus and the other to identify MRSA, Dr. Mark Pittelkow, professor of dermatology, said in an interview.

The Mayo tests are expected to receive FDA approval in early 2007 and to be available by midyear.

Although the tests are envisioned as entrants into the hospital infection prevention market, Dr. Pittelkow emphasized their usefulness for clinicians in private practice as well, particularly when their patients have serious disorders that could be exacerbated by a delay in treating MRSA.

“We're seeing a number of [skin] infections occurring as comorbidities or aggravating skin conditions.” In the past, many physicians empirically treated patients using antibiotics that could put patients at risk of resistance to a different bug causing a bigger problem, he said.

From minor skin conditions such as impetigo to serious keratodermas, pemphigus, and blistering disorders, S. aureus is rapidly overcoming streptococcus as the bacteria of concern, Dr. Pittelkow said.

The Mayo tests, to be marketed by Roche Pharmaceuticals, use a specially designed swab that does not wick samples in the same way as a cotton-tipped swab. For now, it still requires laboratory technicians to transfer material from the applicator to a plate for analysis, but the technology is heading toward a self-contained swab similar to those used for rapid strep tests in physicians' offices.

The Becton, Dickinson & Co. test, which has been available since early 2006, is approved only for detecting colonization, not to guide antibiotic choices in individual patients. It requires laboratories to make an initial investment of more than $20,000 for a real-time PCR cycler, plus $20-$30 for each test performed. The equipment, however, can be used to perform other cutting-edge tests for detection of influenza, respiratory syncytial virus, and vancomycin-resistant enterococci, and it potentially saves hospitals the substantial cost of treating MRSA infections, said Dr. Venezia.

Rapid, practical, easy-to-perform tests for S. aureus will become even more necessary for hospitals, because the Centers for Medicare and Medicaid Services has proposed that Medicare diagnosis-related group reimbursements for nosocomial infections be stopped.

Pressure is already on hospitals to reduce transmission of infections, but the advent of such restrictions on payments for hospital-acquired illnesses might lead some institutions to universally test patients on admission and throughout their stays. Treatment of an MRSA infection can run as much as $36,000, said Barbara Kalavik, director of worldwide public relations for Becton, Dickinson & Co.

Just who pays for the tests is still a matter of contention.

When a physician orders a test to pinpoint the best antibiotic to treat a patient, the cost can be charged to the patient or insurance,

Who will bear the cost of screening hospital patients is less clear, said Ms. Kalavik.

“Most hospitals absorb the cost of these programs,” she said, but “starting Jan. 1, 2007, new CPT codes have been instituted that allow for hospitals to be reimbursed approximately $49 for screening outpatients to see if they are positive for MRSA.”

From a research point of view, widespread use of tests to detect S. aureus and MRSA could better characterize the incidence of infections and their hosts. For example, “there may be three to four body surface areas more likely to be harboring S. aureus, along with nasal carriage,” Dr. Pittelkow said.

These tests would be useful when patients have serious disorders that could be exacerbated by a delay in treatment. DR. PITTELKOW

Researchers at the Mayo Clinic and elsewhere are racing to develop rapid-detection tests for Staphylococcus aureus, both to better tailor appropriate antibiotic prescribing and to halt the galloping spread of methicillin-resistant strains of the bacteria.

The race for quicker, easier, better rapid detection tests has been intense, said Betsy McCaughey, Ph.D., director of the New York City-based nonprofit Committee to Reduce Infection Deaths.

“There are many companies now developing rapid tests. I've visited at least half a dozen,” she said in an interview.

Among the contenders are Innovative Biosensors Inc. in College Park, Md., which is using light-based technology developed at the Massachusetts Institute of Technology; Cepheid, a Sunnyvale, Calif.-based company about to introduce another genetic-based rapid test; and 3M, which has “waded deep into this territory,” Dr. McCaughey said.

Progress has been keenest in identifying colonized patients prior to or during hospitalization to help reduce the spread of resistant bacteria.

At the University of Maryland Medical Center in Baltimore, for example, patients considered at risk for methicillin-resistant S. aureus (MRSA) can be screened in 2 hours with a polymerase chain reaction (PCR) DNA test developed by Becton, Dickinson & Co., rather than waiting 24–48 hours to get an answer by culturing for the bacteria.

All intensive care unit patients are being screened at admission, on a weekly basis, and on discharge so that infected patients can be identified and treated with appropriate isolation and contact precautions, said Richard Venezia, Ph.D., professor of pathology and director of clinical microbiology at the university.

Efforts to further screen patients with risk factors—a previous hospital admission or recent use of antibiotics, for example—are “almost in full swing,” he said in an interview.

“This is the first of a generation of tests that are going to be using 'within-the-tube' closed systems,” based on either DNA or immunology, that represent a major technological advance in the way risky bacteria are identified, he said.

The tests do not require the level of training or sophisticated precautions against cross-contamination that were necessary with previous PCR procedures developed in research laboratories; neither do they require complex interpretation, because they provide a “yes/no/repeat the test” type answer.

The new tests are currently confined to hospital or community laboratories, but Dr. Venezia said that they will almost certainly be available for bedside or community office practices within 5 years.

At the Mayo Clinic in Rochester, Minn., two swab-based PCR tests are being developed, one to signal the presence of S. aureus and the other to identify MRSA, Dr. Mark Pittelkow, professor of dermatology, said in an interview.

The Mayo tests are expected to receive FDA approval in early 2007 and to be available by midyear.

Although the tests are envisioned as entrants into the hospital infection prevention market, Dr. Pittelkow emphasized their usefulness for clinicians in private practice as well, particularly when their patients have serious disorders that could be exacerbated by a delay in treating MRSA.

“We're seeing a number of [skin] infections occurring as comorbidities or aggravating skin conditions.” In the past, many physicians empirically treated patients using antibiotics that could put patients at risk of resistance to a different bug causing a bigger problem, he said.

From minor skin conditions such as impetigo to serious keratodermas, pemphigus, and blistering disorders, S. aureus is rapidly overcoming streptococcus as the bacteria of concern, Dr. Pittelkow said.

The Mayo tests, to be marketed by Roche Pharmaceuticals, use a specially designed swab that does not wick samples in the same way as a cotton-tipped swab. For now, it still requires laboratory technicians to transfer material from the applicator to a plate for analysis, but the technology is heading toward a self-contained swab similar to those used for rapid strep tests in physicians' offices.

The Becton, Dickinson & Co. test, which has been available since early 2006, is approved only for detecting colonization, not to guide antibiotic choices in individual patients. It requires laboratories to make an initial investment of more than $20,000 for a real-time PCR cycler, plus $20-$30 for each test performed. The equipment, however, can be used to perform other cutting-edge tests for detection of influenza, respiratory syncytial virus, and vancomycin-resistant enterococci, and it potentially saves hospitals the substantial cost of treating MRSA infections, said Dr. Venezia.

Rapid, practical, easy-to-perform tests for S. aureus will become even more necessary for hospitals, because the Centers for Medicare and Medicaid Services has proposed that Medicare diagnosis-related group reimbursements for nosocomial infections be stopped.

Pressure is already on hospitals to reduce transmission of infections, but the advent of such restrictions on payments for hospital-acquired illnesses might lead some institutions to universally test patients on admission and throughout their stays. Treatment of an MRSA infection can run as much as $36,000, said Barbara Kalavik, director of worldwide public relations for Becton, Dickinson & Co.

Just who pays for the tests is still a matter of contention.

When a physician orders a test to pinpoint the best antibiotic to treat a patient, the cost can be charged to the patient or insurance,

Who will bear the cost of screening hospital patients is less clear, said Ms. Kalavik.

“Most hospitals absorb the cost of these programs,” she said, but “starting Jan. 1, 2007, new CPT codes have been instituted that allow for hospitals to be reimbursed approximately $49 for screening outpatients to see if they are positive for MRSA.”

From a research point of view, widespread use of tests to detect S. aureus and MRSA could better characterize the incidence of infections and their hosts. For example, “there may be three to four body surface areas more likely to be harboring S. aureus, along with nasal carriage,” Dr. Pittelkow said.

These tests would be useful when patients have serious disorders that could be exacerbated by a delay in treatment. DR. PITTELKOW

Researchers at the Mayo Clinic and elsewhere are racing to develop rapid-detection tests for Staphylococcus aureus, both to better tailor appropriate antibiotic prescribing and to halt the galloping spread of methicillin-resistant strains of the bacteria.

The race for quicker, easier, better rapid detection tests has been intense, said Betsy McCaughey, Ph.D., director of the New York City-based nonprofit Committee to Reduce Infection Deaths.

“There are many companies now developing rapid tests. I've visited at least half a dozen,” she said in an interview.

Among the contenders are Innovative Biosensors Inc. in College Park, Md., which is using light-based technology developed at the Massachusetts Institute of Technology; Cepheid, a Sunnyvale, Calif.-based company about to introduce another genetic-based rapid test; and 3M, which has “waded deep into this territory,” Dr. McCaughey said.

Progress has been keenest in identifying colonized patients prior to or during hospitalization to help reduce the spread of resistant bacteria.

At the University of Maryland Medical Center in Baltimore, for example, patients considered at risk for methicillin-resistant S. aureus (MRSA) can be screened in 2 hours with a polymerase chain reaction (PCR) DNA test developed by Becton, Dickinson & Co., rather than waiting 24–48 hours to get an answer by culturing for the bacteria.

All intensive care unit patients are being screened at admission, on a weekly basis, and on discharge so that infected patients can be identified and treated with appropriate isolation and contact precautions, said Richard Venezia, Ph.D., professor of pathology and director of clinical microbiology at the university.

Efforts to further screen patients with risk factors—a previous hospital admission or recent use of antibiotics, for example—are “almost in full swing,” he said in an interview.

“This is the first of a generation of tests that are going to be using 'within-the-tube' closed systems,” based on either DNA or immunology, that represent a major technological advance in the way risky bacteria are identified, he said.

The tests do not require the level of training or sophisticated precautions against cross-contamination that were necessary with previous PCR procedures developed in research laboratories; neither do they require complex interpretation, because they provide a “yes/no/repeat the test” type answer.

The new tests are currently confined to hospital or community laboratories, but Dr. Venezia said that they will almost certainly be available for bedside or community office practices within 5 years.

At the Mayo Clinic in Rochester, Minn., two swab-based PCR tests are being developed, one to signal the presence of S. aureus and the other to identify MRSA, Dr. Mark Pittelkow, professor of dermatology, said in an interview.

The Mayo tests are expected to receive FDA approval in early 2007 and to be available by midyear.

Although the tests are envisioned as entrants into the hospital infection prevention market, Dr. Pittelkow emphasized their usefulness for clinicians in private practice as well, particularly when their patients have serious disorders that could be exacerbated by a delay in treating MRSA.

“We're seeing a number of [skin] infections occurring as comorbidities or aggravating skin conditions.” In the past, many physicians empirically treated patients using antibiotics that could put patients at risk of resistance to a different bug causing a bigger problem, he said.

From minor skin conditions such as impetigo to serious keratodermas, pemphigus, and blistering disorders, S. aureus is rapidly overcoming streptococcus as the bacteria of concern, Dr. Pittelkow said.

The Mayo tests, to be marketed by Roche Pharmaceuticals, use a specially designed swab that does not wick samples in the same way as a cotton-tipped swab. For now, it still requires laboratory technicians to transfer material from the applicator to a plate for analysis, but the technology is heading toward a self-contained swab similar to those used for rapid strep tests in physicians' offices.

The Becton, Dickinson & Co. test, which has been available since early 2006, is approved only for detecting colonization, not to guide antibiotic choices in individual patients. It requires laboratories to make an initial investment of more than $20,000 for a real-time PCR cycler, plus $20-$30 for each test performed. The equipment, however, can be used to perform other cutting-edge tests for detection of influenza, respiratory syncytial virus, and vancomycin-resistant enterococci, and it potentially saves hospitals the substantial cost of treating MRSA infections, said Dr. Venezia.

Rapid, practical, easy-to-perform tests for S. aureus will become even more necessary for hospitals, because the Centers for Medicare and Medicaid Services has proposed that Medicare diagnosis-related group reimbursements for nosocomial infections be stopped.

Pressure is already on hospitals to reduce transmission of infections, but the advent of such restrictions on payments for hospital-acquired illnesses might lead some institutions to universally test patients on admission and throughout their stays. Treatment of an MRSA infection can run as much as $36,000, said Barbara Kalavik, director of worldwide public relations for Becton, Dickinson & Co.

Just who pays for the tests is still a matter of contention.

When a physician orders a test to pinpoint the best antibiotic to treat a patient, the cost can be charged to the patient or insurance,

Who will bear the cost of screening hospital patients is less clear, said Ms. Kalavik.

“Most hospitals absorb the cost of these programs,” she said, but “starting Jan. 1, 2007, new CPT codes have been instituted that allow for hospitals to be reimbursed approximately $49 for screening outpatients to see if they are positive for MRSA.”

From a research point of view, widespread use of tests to detect S. aureus and MRSA could better characterize the incidence of infections and their hosts. For example, “there may be three to four body surface areas more likely to be harboring S. aureus, along with nasal carriage,” Dr. Pittelkow said.

These tests would be useful when patients have serious disorders that could be exacerbated by a delay in treatment. DR. PITTELKOW

LAS VEGAS—The average net collected revenue per full-time equivalent physician in 2005 was $1,436,837 for cosmetic medical practices, according to a benchmarking survey of 61 offices, said William Miller, a management consultant with the Allergan Practice Consulting Group of Allergan Inc., a pharmaceutical company based in Irvine, Calif.

Mr. Miller and his associates have been conducting comprehensive economic evaluations of dermatology and cosmetic surgery practices for years so that other physicians can see how they measure up.

The latest twist is a survey of cosmetically oriented practices, including 19 cosmetic dermatology offices, 12 facial plastic surgery offices, 2 oculoplastic surgery offices, and 28 plastic surgery offices.

Comparative data from the 2003, 2004, and 2005 surveys of these practices were released at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The practices selected for the benchmark survey are not necessarily "average," Mr. Miller emphasized. They are selected by the Allergan consulting group and may be either more or less profitable than the average cosmetic practice in the United States.

They are, however, quite geographically representative because they draw from cities in the eastern, southern, midwestern, and western regions of the United States.

To verify its numbers, the firm analyzes financial statements, income tax returns, employee census data, and productivity reports.

The net collected revenue per full-time equivalent MD or DO in cosmetic practices was $1,436,837 in 2005, up from $1,416,326 in 2004 and $1,291,392 in 2003, Mr. Miller said.

The revenue rate per hour per full-time equivalent MD or DO (based on 1,600 hours per year) averaged $898 in 2005, $885 in 2004, and $807 in 2003.

The net collected revenue per full-time equivalent aesthetician decreased slightly in 2005, totalling $149,145, compared with $151,046 in 2004 and $134,905 in 2003.

Retail sales in cosmetic offices vary tremendously, from $10,000 a year to more than $500,000 annually, he said.

The benchmark survey found that average retail sales added up to $138,865 in 2005, $135,065 in 2004, and $117,842 in 2003.

Operating expense ratios, which do not include provider compensation, bonuses, or retirement contributions, averaged 63.6% in 2005, 63.4% in 2004, and 65% in 2003.

Rent expense ratios (not including utilities and other peripheral expenses) averaged 5.0%, 4.9%, and 5.5% in 2005, 2004, and 2003, respectively.

"Five percent to 8% is a healthy range" when including utilities and insurance, he said.

Wide variations were seen in marketing expenses, which totalled from 3.9% to 4.3% between 2003 and 2005.

Mr. Miller strongly encouraged clinicians to track the efficacy of their marketing "somehow," if only on a spreadsheet used by a receptionist to find out how new patients heard about the practice.

When deciding if you have the right number of staff members, Mr. Miller said, it is important to look at three data points: "How productive is my staff?" "Do I have the right number of staff?" "What is my payroll ratio?"

The net collected revenue per full-time equivalent employee was $300,582 in 2005, $325,880 in 2004, and $313,807 in 2003.

The number of full-time employees per full-time provider was another figure that varied among practices, explained Mr. Miller. The healthy range is four to six full-time equivalent employees per provider.

He noted that many cosmetic dermatology practices in the survey also perform general dermatology, resulting in a higher patient volume than is typically seen in a plastic surgery practice, for example.

On average, though, cosmetically-oriented practices had 5.4 full-time equivalent employees per each full-time equivalent provider in 2005. That compared with 5.2 in 2004 and 4.9 in 2003.

To conclude his talk, Mr. Miller said that in his visits to many practices, he has found that a key element to success lies with hiring and appreciating excellent staff members.

Begin with a job description, he suggested.

"You cannot hire the right person if you don't know what skill set is required," he said. "I don't believe in merry-go-round jobs within the practice."

Make sure each employee's strengths match the tasks he or she is assigned, and offer frequent training opportunities, he said.

Finally, practice simple good manners and collegiality from the moment you step in the door.

"Say good morning. Say thank you at the end of the day," he said.

"It's amazing. I've been in offices where the employees don't even know if the doctor's in the office or not."

LAS VEGAS—The average net collected revenue per full-time equivalent physician in 2005 was $1,436,837 for cosmetic medical practices, according to a benchmarking survey of 61 offices, said William Miller, a management consultant with the Allergan Practice Consulting Group of Allergan Inc., a pharmaceutical company based in Irvine, Calif.

Mr. Miller and his associates have been conducting comprehensive economic evaluations of dermatology and cosmetic surgery practices for years so that other physicians can see how they measure up.

The latest twist is a survey of cosmetically oriented practices, including 19 cosmetic dermatology offices, 12 facial plastic surgery offices, 2 oculoplastic surgery offices, and 28 plastic surgery offices.

Comparative data from the 2003, 2004, and 2005 surveys of these practices were released at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The practices selected for the benchmark survey are not necessarily "average," Mr. Miller emphasized. They are selected by the Allergan consulting group and may be either more or less profitable than the average cosmetic practice in the United States.

They are, however, quite geographically representative because they draw from cities in the eastern, southern, midwestern, and western regions of the United States.

To verify its numbers, the firm analyzes financial statements, income tax returns, employee census data, and productivity reports.

The net collected revenue per full-time equivalent MD or DO in cosmetic practices was $1,436,837 in 2005, up from $1,416,326 in 2004 and $1,291,392 in 2003, Mr. Miller said.

The revenue rate per hour per full-time equivalent MD or DO (based on 1,600 hours per year) averaged $898 in 2005, $885 in 2004, and $807 in 2003.

The net collected revenue per full-time equivalent aesthetician decreased slightly in 2005, totalling $149,145, compared with $151,046 in 2004 and $134,905 in 2003.

Retail sales in cosmetic offices vary tremendously, from $10,000 a year to more than $500,000 annually, he said.

The benchmark survey found that average retail sales added up to $138,865 in 2005, $135,065 in 2004, and $117,842 in 2003.

Operating expense ratios, which do not include provider compensation, bonuses, or retirement contributions, averaged 63.6% in 2005, 63.4% in 2004, and 65% in 2003.

Rent expense ratios (not including utilities and other peripheral expenses) averaged 5.0%, 4.9%, and 5.5% in 2005, 2004, and 2003, respectively.

"Five percent to 8% is a healthy range" when including utilities and insurance, he said.

Wide variations were seen in marketing expenses, which totalled from 3.9% to 4.3% between 2003 and 2005.

Mr. Miller strongly encouraged clinicians to track the efficacy of their marketing "somehow," if only on a spreadsheet used by a receptionist to find out how new patients heard about the practice.

When deciding if you have the right number of staff members, Mr. Miller said, it is important to look at three data points: "How productive is my staff?" "Do I have the right number of staff?" "What is my payroll ratio?"

The net collected revenue per full-time equivalent employee was $300,582 in 2005, $325,880 in 2004, and $313,807 in 2003.

The number of full-time employees per full-time provider was another figure that varied among practices, explained Mr. Miller. The healthy range is four to six full-time equivalent employees per provider.

He noted that many cosmetic dermatology practices in the survey also perform general dermatology, resulting in a higher patient volume than is typically seen in a plastic surgery practice, for example.

On average, though, cosmetically-oriented practices had 5.4 full-time equivalent employees per each full-time equivalent provider in 2005. That compared with 5.2 in 2004 and 4.9 in 2003.

To conclude his talk, Mr. Miller said that in his visits to many practices, he has found that a key element to success lies with hiring and appreciating excellent staff members.

Begin with a job description, he suggested.

"You cannot hire the right person if you don't know what skill set is required," he said. "I don't believe in merry-go-round jobs within the practice."

Make sure each employee's strengths match the tasks he or she is assigned, and offer frequent training opportunities, he said.

Finally, practice simple good manners and collegiality from the moment you step in the door.

"Say good morning. Say thank you at the end of the day," he said.

"It's amazing. I've been in offices where the employees don't even know if the doctor's in the office or not."

LAS VEGAS—The average net collected revenue per full-time equivalent physician in 2005 was $1,436,837 for cosmetic medical practices, according to a benchmarking survey of 61 offices, said William Miller, a management consultant with the Allergan Practice Consulting Group of Allergan Inc., a pharmaceutical company based in Irvine, Calif.

Mr. Miller and his associates have been conducting comprehensive economic evaluations of dermatology and cosmetic surgery practices for years so that other physicians can see how they measure up.

The latest twist is a survey of cosmetically oriented practices, including 19 cosmetic dermatology offices, 12 facial plastic surgery offices, 2 oculoplastic surgery offices, and 28 plastic surgery offices.

Comparative data from the 2003, 2004, and 2005 surveys of these practices were released at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The practices selected for the benchmark survey are not necessarily "average," Mr. Miller emphasized. They are selected by the Allergan consulting group and may be either more or less profitable than the average cosmetic practice in the United States.

They are, however, quite geographically representative because they draw from cities in the eastern, southern, midwestern, and western regions of the United States.

To verify its numbers, the firm analyzes financial statements, income tax returns, employee census data, and productivity reports.

The net collected revenue per full-time equivalent MD or DO in cosmetic practices was $1,436,837 in 2005, up from $1,416,326 in 2004 and $1,291,392 in 2003, Mr. Miller said.

The revenue rate per hour per full-time equivalent MD or DO (based on 1,600 hours per year) averaged $898 in 2005, $885 in 2004, and $807 in 2003.

The net collected revenue per full-time equivalent aesthetician decreased slightly in 2005, totalling $149,145, compared with $151,046 in 2004 and $134,905 in 2003.

Retail sales in cosmetic offices vary tremendously, from $10,000 a year to more than $500,000 annually, he said.

The benchmark survey found that average retail sales added up to $138,865 in 2005, $135,065 in 2004, and $117,842 in 2003.

Operating expense ratios, which do not include provider compensation, bonuses, or retirement contributions, averaged 63.6% in 2005, 63.4% in 2004, and 65% in 2003.

Rent expense ratios (not including utilities and other peripheral expenses) averaged 5.0%, 4.9%, and 5.5% in 2005, 2004, and 2003, respectively.

"Five percent to 8% is a healthy range" when including utilities and insurance, he said.

Wide variations were seen in marketing expenses, which totalled from 3.9% to 4.3% between 2003 and 2005.

Mr. Miller strongly encouraged clinicians to track the efficacy of their marketing "somehow," if only on a spreadsheet used by a receptionist to find out how new patients heard about the practice.

When deciding if you have the right number of staff members, Mr. Miller said, it is important to look at three data points: "How productive is my staff?" "Do I have the right number of staff?" "What is my payroll ratio?"

The net collected revenue per full-time equivalent employee was $300,582 in 2005, $325,880 in 2004, and $313,807 in 2003.

The number of full-time employees per full-time provider was another figure that varied among practices, explained Mr. Miller. The healthy range is four to six full-time equivalent employees per provider.

He noted that many cosmetic dermatology practices in the survey also perform general dermatology, resulting in a higher patient volume than is typically seen in a plastic surgery practice, for example.

On average, though, cosmetically-oriented practices had 5.4 full-time equivalent employees per each full-time equivalent provider in 2005. That compared with 5.2 in 2004 and 4.9 in 2003.

To conclude his talk, Mr. Miller said that in his visits to many practices, he has found that a key element to success lies with hiring and appreciating excellent staff members.

Begin with a job description, he suggested.

"You cannot hire the right person if you don't know what skill set is required," he said. "I don't believe in merry-go-round jobs within the practice."

Make sure each employee's strengths match the tasks he or she is assigned, and offer frequent training opportunities, he said.

Finally, practice simple good manners and collegiality from the moment you step in the door.

"Say good morning. Say thank you at the end of the day," he said.

"It's amazing. I've been in offices where the employees don't even know if the doctor's in the office or not."

LAS VEGAS—Surgical consent is not just a signed piece of paper clipped into a patient's chart. It is an understanding that begins when a prospective patient hears your name or spots your Web site during an Internet search, according to Dr. Greg S. Morganroth, a Mohs surgeon practicing in Mountain View, Calif.

"The potential for misunderstandings in the consent process may begin long before you've met the patient," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The best policy is to provide education and realistic expectations every time the patient encounters you or your practice, beginning with your Web site and extending to what information your office staff provides over the phone, he said.

Dr. Morganroth said there is value in having prospective cosmetic surgery patients spend one or two visits in the office for consultation before a procedure, meeting with the surgeon but also spending considerable time with a cosmetic consultant—a nurse or office manager who has excellent communication skills and thorough training in procedures.

A cosmetics consultant can speak with potential clients on the phone, take photographs, discuss procedures in depth, make appointments, explain the price structure, and write thank-you notes—essentially reiterating important messages conveyed by the surgeon and printed in consent documents, but also making patients feel comfortable and appreciated.

Both you and your cosmetics consultant should speak directly and honestly about your credentials and the potential benefits and risks of every procedure, Dr. Morganroth stressed. "I always make it very clear to patients that I am a dermatologist and not a plastic surgeon," he noted. "I take pride in the specialty and promote dermatologists' unique perspective and skills."

He encourages patients to get second opinions, but cautions that they may hear negative feedback about dermatologic surgeons from plastic surgeons or other specialists. He takes time to explain the differences in specialties, emphasizing why he feels his local anesthesia approach is best for certain problems but inadequate to achieve results that can only be obtained with extensive surgery under general anesthesia.

Regardless of whether a patient asks, he reviews his safety record and the number of cases he's done of a particular procedure. He explains the rare cases in which patients were dissatisfied and tells what he did in response. Dr. Morganroth shows prospective surgical patients before-and-after photographs that depict good, medium, and minimal results in older and younger patients. In providing references, he offers the names of patients who were not thrilled as well as those who were.

Preoperatively, he prepares patients for every aspect of the postoperative course, including reviewing with them photographs of patients at various stages of healing. Patients should have all prescriptions they will need and know how much everything, including supplies, will cost prior to surgery.

Consent documentation signed by the patient reiterates the fact that the procedure is being performed by a dermatologic, not a plastic, surgeon; reviews the patient's preexisting asymmetry and imperfections; lists potential complications of the procedure and the surgeon's previous experience with complications; and includes a photo consent and an arbitration agreement.

Dr. Morganroth tells patients, "We are a team. I care about you as a person and [about] your results." He asks them to sign a form in which they agree to come to him if there is a problem so that he can be "by your side [treating] you like a relative," to resolve the situation.

If a patient cancels a procedure, he refunds all of the patient's money.

If a patient seems overwhelmed and repeatedly questions the treatment plan, Dr. Morganroth encourages a second opinion.

He sends flowers to each patient on postoperative day 2.

By being completely candid, enlisting the patient as a team member, and treating patients with special care, a surgeon can be assured that a consent form will serve as more than a legal document. It also can serve as a reminder of the faith the patient has placed in the surgeon and of the surgeon's steadfast commitment to live up to that responsibility, said Dr. Morganroth said.

LAS VEGAS—Surgical consent is not just a signed piece of paper clipped into a patient's chart. It is an understanding that begins when a prospective patient hears your name or spots your Web site during an Internet search, according to Dr. Greg S. Morganroth, a Mohs surgeon practicing in Mountain View, Calif.

"The potential for misunderstandings in the consent process may begin long before you've met the patient," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The best policy is to provide education and realistic expectations every time the patient encounters you or your practice, beginning with your Web site and extending to what information your office staff provides over the phone, he said.

Dr. Morganroth said there is value in having prospective cosmetic surgery patients spend one or two visits in the office for consultation before a procedure, meeting with the surgeon but also spending considerable time with a cosmetic consultant—a nurse or office manager who has excellent communication skills and thorough training in procedures.

A cosmetics consultant can speak with potential clients on the phone, take photographs, discuss procedures in depth, make appointments, explain the price structure, and write thank-you notes—essentially reiterating important messages conveyed by the surgeon and printed in consent documents, but also making patients feel comfortable and appreciated.

Both you and your cosmetics consultant should speak directly and honestly about your credentials and the potential benefits and risks of every procedure, Dr. Morganroth stressed. "I always make it very clear to patients that I am a dermatologist and not a plastic surgeon," he noted. "I take pride in the specialty and promote dermatologists' unique perspective and skills."

He encourages patients to get second opinions, but cautions that they may hear negative feedback about dermatologic surgeons from plastic surgeons or other specialists. He takes time to explain the differences in specialties, emphasizing why he feels his local anesthesia approach is best for certain problems but inadequate to achieve results that can only be obtained with extensive surgery under general anesthesia.

Regardless of whether a patient asks, he reviews his safety record and the number of cases he's done of a particular procedure. He explains the rare cases in which patients were dissatisfied and tells what he did in response. Dr. Morganroth shows prospective surgical patients before-and-after photographs that depict good, medium, and minimal results in older and younger patients. In providing references, he offers the names of patients who were not thrilled as well as those who were.

Preoperatively, he prepares patients for every aspect of the postoperative course, including reviewing with them photographs of patients at various stages of healing. Patients should have all prescriptions they will need and know how much everything, including supplies, will cost prior to surgery.

Consent documentation signed by the patient reiterates the fact that the procedure is being performed by a dermatologic, not a plastic, surgeon; reviews the patient's preexisting asymmetry and imperfections; lists potential complications of the procedure and the surgeon's previous experience with complications; and includes a photo consent and an arbitration agreement.

Dr. Morganroth tells patients, "We are a team. I care about you as a person and [about] your results." He asks them to sign a form in which they agree to come to him if there is a problem so that he can be "by your side [treating] you like a relative," to resolve the situation.

If a patient cancels a procedure, he refunds all of the patient's money.

If a patient seems overwhelmed and repeatedly questions the treatment plan, Dr. Morganroth encourages a second opinion.

He sends flowers to each patient on postoperative day 2.

By being completely candid, enlisting the patient as a team member, and treating patients with special care, a surgeon can be assured that a consent form will serve as more than a legal document. It also can serve as a reminder of the faith the patient has placed in the surgeon and of the surgeon's steadfast commitment to live up to that responsibility, said Dr. Morganroth said.

LAS VEGAS—Surgical consent is not just a signed piece of paper clipped into a patient's chart. It is an understanding that begins when a prospective patient hears your name or spots your Web site during an Internet search, according to Dr. Greg S. Morganroth, a Mohs surgeon practicing in Mountain View, Calif.

"The potential for misunderstandings in the consent process may begin long before you've met the patient," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The best policy is to provide education and realistic expectations every time the patient encounters you or your practice, beginning with your Web site and extending to what information your office staff provides over the phone, he said.

Dr. Morganroth said there is value in having prospective cosmetic surgery patients spend one or two visits in the office for consultation before a procedure, meeting with the surgeon but also spending considerable time with a cosmetic consultant—a nurse or office manager who has excellent communication skills and thorough training in procedures.

A cosmetics consultant can speak with potential clients on the phone, take photographs, discuss procedures in depth, make appointments, explain the price structure, and write thank-you notes—essentially reiterating important messages conveyed by the surgeon and printed in consent documents, but also making patients feel comfortable and appreciated.

Both you and your cosmetics consultant should speak directly and honestly about your credentials and the potential benefits and risks of every procedure, Dr. Morganroth stressed. "I always make it very clear to patients that I am a dermatologist and not a plastic surgeon," he noted. "I take pride in the specialty and promote dermatologists' unique perspective and skills."

He encourages patients to get second opinions, but cautions that they may hear negative feedback about dermatologic surgeons from plastic surgeons or other specialists. He takes time to explain the differences in specialties, emphasizing why he feels his local anesthesia approach is best for certain problems but inadequate to achieve results that can only be obtained with extensive surgery under general anesthesia.

Regardless of whether a patient asks, he reviews his safety record and the number of cases he's done of a particular procedure. He explains the rare cases in which patients were dissatisfied and tells what he did in response. Dr. Morganroth shows prospective surgical patients before-and-after photographs that depict good, medium, and minimal results in older and younger patients. In providing references, he offers the names of patients who were not thrilled as well as those who were.

Preoperatively, he prepares patients for every aspect of the postoperative course, including reviewing with them photographs of patients at various stages of healing. Patients should have all prescriptions they will need and know how much everything, including supplies, will cost prior to surgery.

Consent documentation signed by the patient reiterates the fact that the procedure is being performed by a dermatologic, not a plastic, surgeon; reviews the patient's preexisting asymmetry and imperfections; lists potential complications of the procedure and the surgeon's previous experience with complications; and includes a photo consent and an arbitration agreement.

Dr. Morganroth tells patients, "We are a team. I care about you as a person and [about] your results." He asks them to sign a form in which they agree to come to him if there is a problem so that he can be "by your side [treating] you like a relative," to resolve the situation.

If a patient cancels a procedure, he refunds all of the patient's money.

If a patient seems overwhelmed and repeatedly questions the treatment plan, Dr. Morganroth encourages a second opinion.

He sends flowers to each patient on postoperative day 2.

By being completely candid, enlisting the patient as a team member, and treating patients with special care, a surgeon can be assured that a consent form will serve as more than a legal document. It also can serve as a reminder of the faith the patient has placed in the surgeon and of the surgeon's steadfast commitment to live up to that responsibility, said Dr. Morganroth said.

LAS VEGAS—A new version of the Fraxel laser penetrates more deeply—yet causes less pain and requires fewer treatments—than does the original Fraxel system, speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new Fraxel SR1500, approved by the Food and Drug Administration in August 2006, promised enhanced efficacy and safety, said Dr. Richard Fitzpatrick, a dermatologist in private practice in La Jolla, Calif.

"For the most part, I think that has held up," he said.

The idea behind Fraxel lasers is to deeply penetrate dermal tissue in a specific pixel-like pattern, leaving behind healthy tissue surrounding the tiny wounds.

The original Fraxel was approved by the FDA in 2003 for the treatment of wrinkles, melasma, and scars from acne and surgery, among other indications. The new Fraxel, which costs in the range of $110,000, is capable of deep penetration—to 1,200 microns—and includes a telescopic lens and dosage-control system that permits the use of much higher energy ranges.

"You almost have to rethink Fraxel" in adjusting to the new device, said Dr. Vic Narurkar, who is in private practice in San Francisco. "Depth really does matter."

Moreover, it is important to understand the confusion regarding the term "fractional resurfacing," he said in an interview following the meeting.

True nonablative fractional resurfacing requires a midinfrared wavelength, such as the 1550-nm wavelength of the Fraxel SR1500 and the original Fraxel SR750. "Most other fractional devices are marketing toys and are not supported by clinical and histologic studies," Dr. Narurkar said.

Although Dr. Fitzpatrick limited his energy settings to about 8–20 mJ/cm

Dr. Narurkar now routinely treats Fitzpatrick skin types I-III at 40 mJ/cm

"Coverage"—the number of microthermal zones of damage required—depends on the condition being treated and the anatomical location, the speakers agreed.

A level 6 setting on the laser translates to 20% coverage, with levels building or declining in 3% increments, Dr. Fitzpatrick explained. A level 7 achieves 23% coverage, for example.

The ease of the system does not negate the importance of being careful, however. The laser's capability of going to extreme depths with a high degree of energy can produce "an intense collimated dermal reaction," which Dr. Fitzpatrick said is unlike any he has ever seen.

Choosing a coverage setting that is too high can be dangerous.

"You will reach the point, if you go too far, where you will risk bulk heating. You will generate thermal necrosis of the area," he said.

On the other hand, significant swelling and erythema are very unusual, and the increased energy delivery makes for better results, Dr. Fitzpatrick said, adding, "High pulse energies are more effective for almost everything."

For mild to moderate photodamage on the face, he performs four treatments using energy in the range of 10–20 mJ/cm

For acne scars, he starts at 25 mJ/cm

"The Fraxel does better with acne scars than any device I've ever used," he said.

Dr. Narurkar agreed, saying that both the first- and second-generation Fraxel lasers are "rapidly becoming the treatment of choice" for this indication.

Across indications, fewer treatments are required with the second-generation Fraxel, although patients can expect more edema when higher settings are used, he said.

"They will see results in three treatments instead of five," Dr. Narurkar said. "It hurts less and my patients are extremely satisfied with the treatment."

Both speakers disclosed that they have received grant or research support from Reliant Technologies Inc., maker of the Fraxel laser. Dr. Fitzpatrick is a paid consultant to the company as well.

'Most other fractional devices are marketingtoys' that are not supported by clinical studies. DR. NARURKAR

LAS VEGAS—A new version of the Fraxel laser penetrates more deeply—yet causes less pain and requires fewer treatments—than does the original Fraxel system, speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new Fraxel SR1500, approved by the Food and Drug Administration in August 2006, promised enhanced efficacy and safety, said Dr. Richard Fitzpatrick, a dermatologist in private practice in La Jolla, Calif.

"For the most part, I think that has held up," he said.

The idea behind Fraxel lasers is to deeply penetrate dermal tissue in a specific pixel-like pattern, leaving behind healthy tissue surrounding the tiny wounds.

The original Fraxel was approved by the FDA in 2003 for the treatment of wrinkles, melasma, and scars from acne and surgery, among other indications. The new Fraxel, which costs in the range of $110,000, is capable of deep penetration—to 1,200 microns—and includes a telescopic lens and dosage-control system that permits the use of much higher energy ranges.

"You almost have to rethink Fraxel" in adjusting to the new device, said Dr. Vic Narurkar, who is in private practice in San Francisco. "Depth really does matter."

Moreover, it is important to understand the confusion regarding the term "fractional resurfacing," he said in an interview following the meeting.

True nonablative fractional resurfacing requires a midinfrared wavelength, such as the 1550-nm wavelength of the Fraxel SR1500 and the original Fraxel SR750. "Most other fractional devices are marketing toys and are not supported by clinical and histologic studies," Dr. Narurkar said.

Although Dr. Fitzpatrick limited his energy settings to about 8–20 mJ/cm

Dr. Narurkar now routinely treats Fitzpatrick skin types I-III at 40 mJ/cm

"Coverage"—the number of microthermal zones of damage required—depends on the condition being treated and the anatomical location, the speakers agreed.

A level 6 setting on the laser translates to 20% coverage, with levels building or declining in 3% increments, Dr. Fitzpatrick explained. A level 7 achieves 23% coverage, for example.

The ease of the system does not negate the importance of being careful, however. The laser's capability of going to extreme depths with a high degree of energy can produce "an intense collimated dermal reaction," which Dr. Fitzpatrick said is unlike any he has ever seen.

Choosing a coverage setting that is too high can be dangerous.

"You will reach the point, if you go too far, where you will risk bulk heating. You will generate thermal necrosis of the area," he said.

On the other hand, significant swelling and erythema are very unusual, and the increased energy delivery makes for better results, Dr. Fitzpatrick said, adding, "High pulse energies are more effective for almost everything."

For mild to moderate photodamage on the face, he performs four treatments using energy in the range of 10–20 mJ/cm

For acne scars, he starts at 25 mJ/cm

"The Fraxel does better with acne scars than any device I've ever used," he said.

Dr. Narurkar agreed, saying that both the first- and second-generation Fraxel lasers are "rapidly becoming the treatment of choice" for this indication.

Across indications, fewer treatments are required with the second-generation Fraxel, although patients can expect more edema when higher settings are used, he said.

"They will see results in three treatments instead of five," Dr. Narurkar said. "It hurts less and my patients are extremely satisfied with the treatment."

Both speakers disclosed that they have received grant or research support from Reliant Technologies Inc., maker of the Fraxel laser. Dr. Fitzpatrick is a paid consultant to the company as well.

'Most other fractional devices are marketingtoys' that are not supported by clinical studies. DR. NARURKAR

LAS VEGAS—A new version of the Fraxel laser penetrates more deeply—yet causes less pain and requires fewer treatments—than does the original Fraxel system, speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new Fraxel SR1500, approved by the Food and Drug Administration in August 2006, promised enhanced efficacy and safety, said Dr. Richard Fitzpatrick, a dermatologist in private practice in La Jolla, Calif.

"For the most part, I think that has held up," he said.

The idea behind Fraxel lasers is to deeply penetrate dermal tissue in a specific pixel-like pattern, leaving behind healthy tissue surrounding the tiny wounds.

The original Fraxel was approved by the FDA in 2003 for the treatment of wrinkles, melasma, and scars from acne and surgery, among other indications. The new Fraxel, which costs in the range of $110,000, is capable of deep penetration—to 1,200 microns—and includes a telescopic lens and dosage-control system that permits the use of much higher energy ranges.

"You almost have to rethink Fraxel" in adjusting to the new device, said Dr. Vic Narurkar, who is in private practice in San Francisco. "Depth really does matter."

Moreover, it is important to understand the confusion regarding the term "fractional resurfacing," he said in an interview following the meeting.

True nonablative fractional resurfacing requires a midinfrared wavelength, such as the 1550-nm wavelength of the Fraxel SR1500 and the original Fraxel SR750. "Most other fractional devices are marketing toys and are not supported by clinical and histologic studies," Dr. Narurkar said.

Although Dr. Fitzpatrick limited his energy settings to about 8–20 mJ/cm

Dr. Narurkar now routinely treats Fitzpatrick skin types I-III at 40 mJ/cm

"Coverage"—the number of microthermal zones of damage required—depends on the condition being treated and the anatomical location, the speakers agreed.

A level 6 setting on the laser translates to 20% coverage, with levels building or declining in 3% increments, Dr. Fitzpatrick explained. A level 7 achieves 23% coverage, for example.

The ease of the system does not negate the importance of being careful, however. The laser's capability of going to extreme depths with a high degree of energy can produce "an intense collimated dermal reaction," which Dr. Fitzpatrick said is unlike any he has ever seen.

Choosing a coverage setting that is too high can be dangerous.

"You will reach the point, if you go too far, where you will risk bulk heating. You will generate thermal necrosis of the area," he said.

On the other hand, significant swelling and erythema are very unusual, and the increased energy delivery makes for better results, Dr. Fitzpatrick said, adding, "High pulse energies are more effective for almost everything."

For mild to moderate photodamage on the face, he performs four treatments using energy in the range of 10–20 mJ/cm

For acne scars, he starts at 25 mJ/cm

"The Fraxel does better with acne scars than any device I've ever used," he said.

Dr. Narurkar agreed, saying that both the first- and second-generation Fraxel lasers are "rapidly becoming the treatment of choice" for this indication.

Across indications, fewer treatments are required with the second-generation Fraxel, although patients can expect more edema when higher settings are used, he said.

"They will see results in three treatments instead of five," Dr. Narurkar said. "It hurts less and my patients are extremely satisfied with the treatment."

Both speakers disclosed that they have received grant or research support from Reliant Technologies Inc., maker of the Fraxel laser. Dr. Fitzpatrick is a paid consultant to the company as well.

'Most other fractional devices are marketingtoys' that are not supported by clinical studies. DR. NARURKAR

LAS VEGAS—Fine wrinkling of the eyelids seemed to respond "quite nicely" to fractional laser resurfacing with a specially designed tip, Dr. Brian S. Biesman said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new 0.25-cm

This innovative approach is "not quite" a lunchtime procedure, requiring an hour for topical anesthetic application prior to each of four sessions and several days of downtime while swelling and erythema subside, he said.

The preliminary results, however, have been "very impressive," Dr. Biesman said following the meeting.

In his study, Dr. Biesman enrolled 20 patients, aged 38–70 years (average age 49), to receive four treatments at intervals of 9–28 days (average interval 14 days). At the time of his meeting presentation, 15 of the 20 patients had completed all four sessions and a 1-month follow-up was available on nine patients. Preliminary results suggest that patients tolerated the procedure well, despite mild to moderate erythema and edema lasting 3–4 days.

"Patients typically returned to their activities in 2–3 days," he said.

For the first patients to complete the treatment and follow-up, improvements in texture and the appearance of wrinkling were rated 2.14 and 1.74, respectively, on a 0–4 scale. Dr. Biesman emphasized that not all patients in the study have completed the follow-up examinations.

"There's definitely something there," he said in an interview. "We're not seeing any regression [in improvement] over time."

Dr. Biesman disclosed that he has received grant and research support from, and is a paid consultant to, Reliant Technologies, manufacturer of the Fraxel laser.

LAS VEGAS—Fine wrinkling of the eyelids seemed to respond "quite nicely" to fractional laser resurfacing with a specially designed tip, Dr. Brian S. Biesman said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new 0.25-cm

This innovative approach is "not quite" a lunchtime procedure, requiring an hour for topical anesthetic application prior to each of four sessions and several days of downtime while swelling and erythema subside, he said.

The preliminary results, however, have been "very impressive," Dr. Biesman said following the meeting.

In his study, Dr. Biesman enrolled 20 patients, aged 38–70 years (average age 49), to receive four treatments at intervals of 9–28 days (average interval 14 days). At the time of his meeting presentation, 15 of the 20 patients had completed all four sessions and a 1-month follow-up was available on nine patients. Preliminary results suggest that patients tolerated the procedure well, despite mild to moderate erythema and edema lasting 3–4 days.

"Patients typically returned to their activities in 2–3 days," he said.

For the first patients to complete the treatment and follow-up, improvements in texture and the appearance of wrinkling were rated 2.14 and 1.74, respectively, on a 0–4 scale. Dr. Biesman emphasized that not all patients in the study have completed the follow-up examinations.

"There's definitely something there," he said in an interview. "We're not seeing any regression [in improvement] over time."

Dr. Biesman disclosed that he has received grant and research support from, and is a paid consultant to, Reliant Technologies, manufacturer of the Fraxel laser.

LAS VEGAS—Fine wrinkling of the eyelids seemed to respond "quite nicely" to fractional laser resurfacing with a specially designed tip, Dr. Brian S. Biesman said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new 0.25-cm

This innovative approach is "not quite" a lunchtime procedure, requiring an hour for topical anesthetic application prior to each of four sessions and several days of downtime while swelling and erythema subside, he said.

The preliminary results, however, have been "very impressive," Dr. Biesman said following the meeting.

In his study, Dr. Biesman enrolled 20 patients, aged 38–70 years (average age 49), to receive four treatments at intervals of 9–28 days (average interval 14 days). At the time of his meeting presentation, 15 of the 20 patients had completed all four sessions and a 1-month follow-up was available on nine patients. Preliminary results suggest that patients tolerated the procedure well, despite mild to moderate erythema and edema lasting 3–4 days.

"Patients typically returned to their activities in 2–3 days," he said.

For the first patients to complete the treatment and follow-up, improvements in texture and the appearance of wrinkling were rated 2.14 and 1.74, respectively, on a 0–4 scale. Dr. Biesman emphasized that not all patients in the study have completed the follow-up examinations.

"There's definitely something there," he said in an interview. "We're not seeing any regression [in improvement] over time."

Dr. Biesman disclosed that he has received grant and research support from, and is a paid consultant to, Reliant Technologies, manufacturer of the Fraxel laser.

SAN FRANCISCO — Ob.gyns. and family physicians play a critical role in educating patients and their partners about infertility, doing a basic workup, and knowing when to refer them without delay to a specialist, according to Dr. Charles Miller.

Receiving factual information from a trusted source will go far to combat deeply entrenched myths and misconceptions about infertility, said the Naperville, Ill., infertility specialist and surgeon during Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“We are not reaching them,” he said. “Despite Redbook and Oprah and Marie Claire … Time magazine, Newsweek, and U.S. News and World Report, we're just not getting there.”

Dr. Miller said he was “shocked” to learn from a recent national survey sponsored by the National Infertility Association RESOLVE that the majority of women could not define infertility and believed the No. 1 cause of the problem was stress.

Among the facts women need to know:

▸ Infertility is defined as failure of a woman 35 or younger to become pregnant in 1 year, or in 6 months if the woman is over 35.

▸ Fecundity rates decline quite precipitously after the first six cycles of attempting to achieve pregnancy.

▸ There are 7.7 million couples experiencing infertility in the United States today.

▸ One in three U.S. couples aged 35–39 years will not be able to achieve pregnancy without treatment.

▸ The risk of Down syndrome and other chromosomal abnormalities increases sharply as women age: estimated to be 1 in 11 live births and 1 in 8 live births, respectively, in a woman who delivers at age 49.

▸ The live-birth rate for in vitro fertilization in women over the age of 40 is approximately 10%–15% at most centers.

Dr. Miller pointed out that the age-related decline in fertility has been documented since the 17th century. “This is nothing new. This is not because of STDs, not because of more fibroids, not because of diet. This is because of egg production.”

Most of the causes of infertility are physical, not psychological, he said.

Among female factors, ovulatory factors are responsible for infertility in about a third of patients, uterine and tubal factors combine to contribute to about 40% of cases, and endocrine factors are responsible for about 17%.

Varicocele is most commonly behind male infertility, but idiopathic factors, obstruction (14%), and other causes, including infections, medications, and immunologic problems, are also factors.

Debate rages about whether immunologic concerns are a major contributor to infertility. Dr. Miller called the issue “probably the raciest part of our field.”

He said he believes anticardiolipin antibodies probably do hamper fertility, but the role of other antiphospholipid antibodies is less clear.

“There are physicians who will work this up to the hilt, and there are groups of physicians who will ignore it,” he said.

SAN FRANCISCO — Ob.gyns. and family physicians play a critical role in educating patients and their partners about infertility, doing a basic workup, and knowing when to refer them without delay to a specialist, according to Dr. Charles Miller.

Receiving factual information from a trusted source will go far to combat deeply entrenched myths and misconceptions about infertility, said the Naperville, Ill., infertility specialist and surgeon during Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“We are not reaching them,” he said. “Despite Redbook and Oprah and Marie Claire … Time magazine, Newsweek, and U.S. News and World Report, we're just not getting there.”

Dr. Miller said he was “shocked” to learn from a recent national survey sponsored by the National Infertility Association RESOLVE that the majority of women could not define infertility and believed the No. 1 cause of the problem was stress.

Among the facts women need to know:

▸ Infertility is defined as failure of a woman 35 or younger to become pregnant in 1 year, or in 6 months if the woman is over 35.

▸ Fecundity rates decline quite precipitously after the first six cycles of attempting to achieve pregnancy.

▸ There are 7.7 million couples experiencing infertility in the United States today.

▸ One in three U.S. couples aged 35–39 years will not be able to achieve pregnancy without treatment.

▸ The risk of Down syndrome and other chromosomal abnormalities increases sharply as women age: estimated to be 1 in 11 live births and 1 in 8 live births, respectively, in a woman who delivers at age 49.

▸ The live-birth rate for in vitro fertilization in women over the age of 40 is approximately 10%–15% at most centers.

Dr. Miller pointed out that the age-related decline in fertility has been documented since the 17th century. “This is nothing new. This is not because of STDs, not because of more fibroids, not because of diet. This is because of egg production.”

Most of the causes of infertility are physical, not psychological, he said.

Among female factors, ovulatory factors are responsible for infertility in about a third of patients, uterine and tubal factors combine to contribute to about 40% of cases, and endocrine factors are responsible for about 17%.

Varicocele is most commonly behind male infertility, but idiopathic factors, obstruction (14%), and other causes, including infections, medications, and immunologic problems, are also factors.

Debate rages about whether immunologic concerns are a major contributor to infertility. Dr. Miller called the issue “probably the raciest part of our field.”

He said he believes anticardiolipin antibodies probably do hamper fertility, but the role of other antiphospholipid antibodies is less clear.

“There are physicians who will work this up to the hilt, and there are groups of physicians who will ignore it,” he said.

SAN FRANCISCO — Ob.gyns. and family physicians play a critical role in educating patients and their partners about infertility, doing a basic workup, and knowing when to refer them without delay to a specialist, according to Dr. Charles Miller.

Receiving factual information from a trusted source will go far to combat deeply entrenched myths and misconceptions about infertility, said the Naperville, Ill., infertility specialist and surgeon during Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“We are not reaching them,” he said. “Despite Redbook and Oprah and Marie Claire … Time magazine, Newsweek, and U.S. News and World Report, we're just not getting there.”

Dr. Miller said he was “shocked” to learn from a recent national survey sponsored by the National Infertility Association RESOLVE that the majority of women could not define infertility and believed the No. 1 cause of the problem was stress.

Among the facts women need to know:

▸ Infertility is defined as failure of a woman 35 or younger to become pregnant in 1 year, or in 6 months if the woman is over 35.

▸ Fecundity rates decline quite precipitously after the first six cycles of attempting to achieve pregnancy.

▸ There are 7.7 million couples experiencing infertility in the United States today.

▸ One in three U.S. couples aged 35–39 years will not be able to achieve pregnancy without treatment.

▸ The risk of Down syndrome and other chromosomal abnormalities increases sharply as women age: estimated to be 1 in 11 live births and 1 in 8 live births, respectively, in a woman who delivers at age 49.

▸ The live-birth rate for in vitro fertilization in women over the age of 40 is approximately 10%–15% at most centers.

Dr. Miller pointed out that the age-related decline in fertility has been documented since the 17th century. “This is nothing new. This is not because of STDs, not because of more fibroids, not because of diet. This is because of egg production.”

Most of the causes of infertility are physical, not psychological, he said.

Among female factors, ovulatory factors are responsible for infertility in about a third of patients, uterine and tubal factors combine to contribute to about 40% of cases, and endocrine factors are responsible for about 17%.

Varicocele is most commonly behind male infertility, but idiopathic factors, obstruction (14%), and other causes, including infections, medications, and immunologic problems, are also factors.

Debate rages about whether immunologic concerns are a major contributor to infertility. Dr. Miller called the issue “probably the raciest part of our field.”

He said he believes anticardiolipin antibodies probably do hamper fertility, but the role of other antiphospholipid antibodies is less clear.

“There are physicians who will work this up to the hilt, and there are groups of physicians who will ignore it,” he said.

SAN FRANCISCO — Many young infertility patients can be worked up and started on a course of therapy without referral to a reproductive endocrinologist or fertility clinic, said Dr. Charles E. Miller at Perspectives in Women's Health, sponsored by OB.GYN. NEWS.

Others, however, deserve an immediate referral for in vitro fertilization, since their chances of pregnancy may be fading fast, said Dr. Miller, director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.

Patients to refer include all women over 40 years, patients with hypogonadotropic hypogonadism, tubal blockage, inadequate ovarian function, and those in whom simple treatments have failed, as well as males with severe semen deficiencies, including problems with sperm morphology.

In remaining couples, a simple work-up can be launched, but it should be done correctly, preventing the need for repeat examinations.

For example, a day 3 follicle-stimulating hormone (FSH) level below 10 mIU/L is an important marker of impaired ovarian reserve, but it should not be interpreted in isolation, said Dr. Miller.

Estrogen counts, too.

“If I see an FSH of 8 and an estradiol of 90, that looks every bit as abnormal to me as an FSH of 15 and an estradiol of 50,” he said.

The age of the patient also provides context with regard to her FSH levels, which can fluctuate. Low FSH rates are less of a problem in women under 35, as are many signals of impaired fertility.

Even in vitro fertilization success rates decline precipitously in the mid- to late third decade.

“At my lab we do very, very well until age 37 and there is a dramatic decline. If you look at most peoples' results in the good clinics around the U.S. at the present time, by 37 things get to be a little bit funky,” he said.

A basic work-up begins by taking a focused history, including a history of surgical or medical events, illnesses such as thyroid disease or diabetes, sexual development, use of birth control, previous pregnancies, current health status, and sexual practices.

Tests and examinations concentrate on exploring potential ovulatory dysfunction/failure, tubal uterine or peritoneal abnormalities, or cervical, immunologic, or infectious contributors to why a couple has been unable to get pregnant for a year (6 months in a woman over 35).

Both partners should be asked about possible lifestyle contributors, including substance use, said Dr. Miller.

“You have to talk to your patients about this. If a male is doing marijuana three or four times a week, that is not going to be helping his sperm, I can assure you,” he said. Even cigarette smoking is a “real concern, so much so that when we do studies … we exclude women who smoke.”

Among infertility tests and procedures that may be performed by general ob.gyn. and family physicians:

▸ Laboratory tests. For day 3 of a woman's cycle, Dr. Miller orders an FSH, estrogen, luteinizing hormone (LH), thyroid-stimulating hormone (TSH), fasting prolactin.

▸ Ultrasounds. Obtain a baseline ultrasound to examine the follicles on day 3 of the cycle to assess the presence of small “resting” antral follicles less than 9 mm in each ovary. Fewer than six total antral follicles (in both ovaries) is a predictor of poor outcome; these patients should be referred. Then have the patient start a urine ovulation predictor kit at midcycle (day 11 if the patient has a 28-day cycle, but day 13 if her cycle is 30 days). Immediately following a positive color change, have the patient come in for another ultrasound to assess follicle production. A mature follicle that contains a mature egg should be 15–20 mm. Look again at the patient's estrogen level, since a mature follicle may produce a serum estrogen of 200 pg/mL.

▸ Ovulation induction. Use oral medications or injections with the goal of establishing a normal ovulatory cycle for timing of intercourse or inseminations.

▸ Male work-up. This should include a physical examination, laboratory tests (testosterone, TSH, prolactin, FSH, and LH). Sperm analysis should be calculated using a formula of volume (greater than 2.0 mL), concentration (greater than 20 million/mL), and motility (greater than 50% with forward progression), and morphology (greater than 30% normal forms). Considered together, fewer than 10 million total motile sperm is an indicator of a fecundity problem.

Furthermore, “morphology counts,” said Dr. Miller. “Males with abnormal sperm morphology should be referred to a male infertility specialist.”

▸ Postcoital test. Aspirate mucus from the surface of the cervix 2–6 hours after the couple has had intercourse at midcycle. A color change is seen just as in the ovulation predictor test. Primary care physicians still use this as a general screen to evaluate the viscosity of the mucus and the activity of the sperm, indicating that the patient should be referred if either is abnormal. (This test is generally not used by reproductive endocrinologists, who move directly on to insemination if there is an indication of sperm dysfunction.)

▸ Hysterosalpingogram. Schedule the test for day 6–12 to assess the structure and patency of the fallopian tubes.

▸ Midluteal serum progesterone levels. Timing is everything with this test, said Dr. Miller. “I see clinic after clinic after clinic … getting a day 21 progesterone [in a] patient with a 35-day cycle. You want to get that progesterone level a week after ovulation and a week prior to menstruation. Time it based on cycle length.”

▸ Clomiphene challenge test. Draw a day 3 FSH and estradiol, and order clomiphene citrate, 100 mg daily on days 5–9. Draw FSH again on day 10. A poor prognosis is associated with either an abnormal day 3 FSH or day 10 FSH, or if the sum of the day 3 and day 10 FSH is less than 26.

▸ Surgery. Consider with caution performing minimally invasive surgery to correct anatomic problems, scarring, adhesions, endometriosis, or fibroids, although the cost of surgery and the potential advantages of in vitro fertilization should be considered.

▸ Fertility drugs with insemination. If the woman's follicles do not develop to a mature size or her estrogen or progesterone levels are low, Dr. Miller considers several courses of clomiphene citrate at low doses (50 mg for 5 days on days 3–7 or days 5–9.) Ovulation will occur in 80%–85% of women, and over four cycles, 40% of women will become pregnant.

However, pregnancy rates are much lower in older patients.

“I can tell you that [40% pregnancy rate] does not happen in my 38-year-olds. I do not use this medication in women over 40. I feel that we are just wasting time.”

However, in well-selected young patients, the strategy is worth a try, since it is inexpensive, easy, and not associated with an unacceptable rate of multiple births.

“For a generalist, this is a safe drug to use for 3–4 cycles, particularly in younger patients. Then move that patient on,” Dr. Miller said.

SAN FRANCISCO — Many young infertility patients can be worked up and started on a course of therapy without referral to a reproductive endocrinologist or fertility clinic, said Dr. Charles E. Miller at Perspectives in Women's Health, sponsored by OB.GYN. NEWS.

Others, however, deserve an immediate referral for in vitro fertilization, since their chances of pregnancy may be fading fast, said Dr. Miller, director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.

Patients to refer include all women over 40 years, patients with hypogonadotropic hypogonadism, tubal blockage, inadequate ovarian function, and those in whom simple treatments have failed, as well as males with severe semen deficiencies, including problems with sperm morphology.

In remaining couples, a simple work-up can be launched, but it should be done correctly, preventing the need for repeat examinations.

For example, a day 3 follicle-stimulating hormone (FSH) level below 10 mIU/L is an important marker of impaired ovarian reserve, but it should not be interpreted in isolation, said Dr. Miller.

Estrogen counts, too.

“If I see an FSH of 8 and an estradiol of 90, that looks every bit as abnormal to me as an FSH of 15 and an estradiol of 50,” he said.

The age of the patient also provides context with regard to her FSH levels, which can fluctuate. Low FSH rates are less of a problem in women under 35, as are many signals of impaired fertility.

Even in vitro fertilization success rates decline precipitously in the mid- to late third decade.

“At my lab we do very, very well until age 37 and there is a dramatic decline. If you look at most peoples' results in the good clinics around the U.S. at the present time, by 37 things get to be a little bit funky,” he said.

A basic work-up begins by taking a focused history, including a history of surgical or medical events, illnesses such as thyroid disease or diabetes, sexual development, use of birth control, previous pregnancies, current health status, and sexual practices.

Tests and examinations concentrate on exploring potential ovulatory dysfunction/failure, tubal uterine or peritoneal abnormalities, or cervical, immunologic, or infectious contributors to why a couple has been unable to get pregnant for a year (6 months in a woman over 35).

Both partners should be asked about possible lifestyle contributors, including substance use, said Dr. Miller.

“You have to talk to your patients about this. If a male is doing marijuana three or four times a week, that is not going to be helping his sperm, I can assure you,” he said. Even cigarette smoking is a “real concern, so much so that when we do studies … we exclude women who smoke.”

Among infertility tests and procedures that may be performed by general ob.gyn. and family physicians:

▸ Laboratory tests. For day 3 of a woman's cycle, Dr. Miller orders an FSH, estrogen, luteinizing hormone (LH), thyroid-stimulating hormone (TSH), fasting prolactin.

▸ Ultrasounds. Obtain a baseline ultrasound to examine the follicles on day 3 of the cycle to assess the presence of small “resting” antral follicles less than 9 mm in each ovary. Fewer than six total antral follicles (in both ovaries) is a predictor of poor outcome; these patients should be referred. Then have the patient start a urine ovulation predictor kit at midcycle (day 11 if the patient has a 28-day cycle, but day 13 if her cycle is 30 days). Immediately following a positive color change, have the patient come in for another ultrasound to assess follicle production. A mature follicle that contains a mature egg should be 15–20 mm. Look again at the patient's estrogen level, since a mature follicle may produce a serum estrogen of 200 pg/mL.

▸ Ovulation induction. Use oral medications or injections with the goal of establishing a normal ovulatory cycle for timing of intercourse or inseminations.

▸ Male work-up. This should include a physical examination, laboratory tests (testosterone, TSH, prolactin, FSH, and LH). Sperm analysis should be calculated using a formula of volume (greater than 2.0 mL), concentration (greater than 20 million/mL), and motility (greater than 50% with forward progression), and morphology (greater than 30% normal forms). Considered together, fewer than 10 million total motile sperm is an indicator of a fecundity problem.

Furthermore, “morphology counts,” said Dr. Miller. “Males with abnormal sperm morphology should be referred to a male infertility specialist.”

▸ Postcoital test. Aspirate mucus from the surface of the cervix 2–6 hours after the couple has had intercourse at midcycle. A color change is seen just as in the ovulation predictor test. Primary care physicians still use this as a general screen to evaluate the viscosity of the mucus and the activity of the sperm, indicating that the patient should be referred if either is abnormal. (This test is generally not used by reproductive endocrinologists, who move directly on to insemination if there is an indication of sperm dysfunction.)

▸ Hysterosalpingogram. Schedule the test for day 6–12 to assess the structure and patency of the fallopian tubes.

▸ Midluteal serum progesterone levels. Timing is everything with this test, said Dr. Miller. “I see clinic after clinic after clinic … getting a day 21 progesterone [in a] patient with a 35-day cycle. You want to get that progesterone level a week after ovulation and a week prior to menstruation. Time it based on cycle length.”

▸ Clomiphene challenge test. Draw a day 3 FSH and estradiol, and order clomiphene citrate, 100 mg daily on days 5–9. Draw FSH again on day 10. A poor prognosis is associated with either an abnormal day 3 FSH or day 10 FSH, or if the sum of the day 3 and day 10 FSH is less than 26.

▸ Surgery. Consider with caution performing minimally invasive surgery to correct anatomic problems, scarring, adhesions, endometriosis, or fibroids, although the cost of surgery and the potential advantages of in vitro fertilization should be considered.

▸ Fertility drugs with insemination. If the woman's follicles do not develop to a mature size or her estrogen or progesterone levels are low, Dr. Miller considers several courses of clomiphene citrate at low doses (50 mg for 5 days on days 3–7 or days 5–9.) Ovulation will occur in 80%–85% of women, and over four cycles, 40% of women will become pregnant.

However, pregnancy rates are much lower in older patients.

“I can tell you that [40% pregnancy rate] does not happen in my 38-year-olds. I do not use this medication in women over 40. I feel that we are just wasting time.”

However, in well-selected young patients, the strategy is worth a try, since it is inexpensive, easy, and not associated with an unacceptable rate of multiple births.

“For a generalist, this is a safe drug to use for 3–4 cycles, particularly in younger patients. Then move that patient on,” Dr. Miller said.

SAN FRANCISCO — Many young infertility patients can be worked up and started on a course of therapy without referral to a reproductive endocrinologist or fertility clinic, said Dr. Charles E. Miller at Perspectives in Women's Health, sponsored by OB.GYN. NEWS.

Others, however, deserve an immediate referral for in vitro fertilization, since their chances of pregnancy may be fading fast, said Dr. Miller, director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.

Patients to refer include all women over 40 years, patients with hypogonadotropic hypogonadism, tubal blockage, inadequate ovarian function, and those in whom simple treatments have failed, as well as males with severe semen deficiencies, including problems with sperm morphology.

In remaining couples, a simple work-up can be launched, but it should be done correctly, preventing the need for repeat examinations.

For example, a day 3 follicle-stimulating hormone (FSH) level below 10 mIU/L is an important marker of impaired ovarian reserve, but it should not be interpreted in isolation, said Dr. Miller.

Estrogen counts, too.

“If I see an FSH of 8 and an estradiol of 90, that looks every bit as abnormal to me as an FSH of 15 and an estradiol of 50,” he said.

The age of the patient also provides context with regard to her FSH levels, which can fluctuate. Low FSH rates are less of a problem in women under 35, as are many signals of impaired fertility.

Even in vitro fertilization success rates decline precipitously in the mid- to late third decade.

“At my lab we do very, very well until age 37 and there is a dramatic decline. If you look at most peoples' results in the good clinics around the U.S. at the present time, by 37 things get to be a little bit funky,” he said.

A basic work-up begins by taking a focused history, including a history of surgical or medical events, illnesses such as thyroid disease or diabetes, sexual development, use of birth control, previous pregnancies, current health status, and sexual practices.

Tests and examinations concentrate on exploring potential ovulatory dysfunction/failure, tubal uterine or peritoneal abnormalities, or cervical, immunologic, or infectious contributors to why a couple has been unable to get pregnant for a year (6 months in a woman over 35).

Both partners should be asked about possible lifestyle contributors, including substance use, said Dr. Miller.

“You have to talk to your patients about this. If a male is doing marijuana three or four times a week, that is not going to be helping his sperm, I can assure you,” he said. Even cigarette smoking is a “real concern, so much so that when we do studies … we exclude women who smoke.”

Among infertility tests and procedures that may be performed by general ob.gyn. and family physicians:

▸ Laboratory tests. For day 3 of a woman's cycle, Dr. Miller orders an FSH, estrogen, luteinizing hormone (LH), thyroid-stimulating hormone (TSH), fasting prolactin.

▸ Ultrasounds. Obtain a baseline ultrasound to examine the follicles on day 3 of the cycle to assess the presence of small “resting” antral follicles less than 9 mm in each ovary. Fewer than six total antral follicles (in both ovaries) is a predictor of poor outcome; these patients should be referred. Then have the patient start a urine ovulation predictor kit at midcycle (day 11 if the patient has a 28-day cycle, but day 13 if her cycle is 30 days). Immediately following a positive color change, have the patient come in for another ultrasound to assess follicle production. A mature follicle that contains a mature egg should be 15–20 mm. Look again at the patient's estrogen level, since a mature follicle may produce a serum estrogen of 200 pg/mL.

▸ Ovulation induction. Use oral medications or injections with the goal of establishing a normal ovulatory cycle for timing of intercourse or inseminations.

▸ Male work-up. This should include a physical examination, laboratory tests (testosterone, TSH, prolactin, FSH, and LH). Sperm analysis should be calculated using a formula of volume (greater than 2.0 mL), concentration (greater than 20 million/mL), and motility (greater than 50% with forward progression), and morphology (greater than 30% normal forms). Considered together, fewer than 10 million total motile sperm is an indicator of a fecundity problem.

Furthermore, “morphology counts,” said Dr. Miller. “Males with abnormal sperm morphology should be referred to a male infertility specialist.”

▸ Postcoital test. Aspirate mucus from the surface of the cervix 2–6 hours after the couple has had intercourse at midcycle. A color change is seen just as in the ovulation predictor test. Primary care physicians still use this as a general screen to evaluate the viscosity of the mucus and the activity of the sperm, indicating that the patient should be referred if either is abnormal. (This test is generally not used by reproductive endocrinologists, who move directly on to insemination if there is an indication of sperm dysfunction.)

▸ Hysterosalpingogram. Schedule the test for day 6–12 to assess the structure and patency of the fallopian tubes.

▸ Midluteal serum progesterone levels. Timing is everything with this test, said Dr. Miller. “I see clinic after clinic after clinic … getting a day 21 progesterone [in a] patient with a 35-day cycle. You want to get that progesterone level a week after ovulation and a week prior to menstruation. Time it based on cycle length.”

▸ Clomiphene challenge test. Draw a day 3 FSH and estradiol, and order clomiphene citrate, 100 mg daily on days 5–9. Draw FSH again on day 10. A poor prognosis is associated with either an abnormal day 3 FSH or day 10 FSH, or if the sum of the day 3 and day 10 FSH is less than 26.

▸ Surgery. Consider with caution performing minimally invasive surgery to correct anatomic problems, scarring, adhesions, endometriosis, or fibroids, although the cost of surgery and the potential advantages of in vitro fertilization should be considered.

▸ Fertility drugs with insemination. If the woman's follicles do not develop to a mature size or her estrogen or progesterone levels are low, Dr. Miller considers several courses of clomiphene citrate at low doses (50 mg for 5 days on days 3–7 or days 5–9.) Ovulation will occur in 80%–85% of women, and over four cycles, 40% of women will become pregnant.

However, pregnancy rates are much lower in older patients.

“I can tell you that [40% pregnancy rate] does not happen in my 38-year-olds. I do not use this medication in women over 40. I feel that we are just wasting time.”

However, in well-selected young patients, the strategy is worth a try, since it is inexpensive, easy, and not associated with an unacceptable rate of multiple births.

“For a generalist, this is a safe drug to use for 3–4 cycles, particularly in younger patients. Then move that patient on,” Dr. Miller said.