Thursday, October 24, 2013

Everything You Need to Know About Egg Freezing

By Debbie Merryman, Embryology Laboratory Director

Women haven’t always had the choice of freezing their eggs. Now that it’s an option, all women should be well informed on this new assisted reproductive technology. Below is a set of common questions and answers regarding egg freezing to help you better understand the process and how/if it can benefit you.

Q: What’s involved in the process of egg freezing?

·         The ovaries are stimulated to increase the number of eggs available to freeze, much like what happens during in vitro fertilization (IVF).  When the egg sacs on the ovaries appear developed, the eggs are removed.  The eggs are then immediately frozen.

·         Eggs are frozen using an ultra-rapid cooling process known as vitrification.

·         When a woman is ready to use her eggs, they are thawed and inseminated with the sperm of her partner or a donor.  The resulting embryos (fertilized eggs) are cultured in the laboratory and the best one or two are transferred to the uterus.  Remaining embryos can be frozen for later use.

·         This process takes between 2 to 6 weeks to complete.


Q: Who should consider egg freezing?

·         Women diagnosed with cancer that have not yet begun chemotherapy or radiotherapy.  (Women are recommended to talk to their oncologist about the potential for egg freezing.)

·         Women undergoing treatment with IVF who do not wish to freeze embryos.

·         Women who would like to preserve their future ability to have children; either because they do not yet have a partner, they elect to defer childbearing to later in life, or for other personal or medical reasons.


Q: Is there certain criteria to be met in order to be a candidate for egg freezing?

·         Freezing eggs at an early age may increase the chance for a future pregnancy.  Freezing before age 38 gives the best success as there are more eggs to obtain and more are genetically normal.  Some women freeze more than one cycle to obtain enough eggs to increase the chance of having a healthy baby.


Q: What are the benefits of egg freezing?

·         Egg freezing offers women with cancer the chance to preserve their eggs so that they can have children in the future.

·         Women who freeze eggs during an IVF cycle have the opportunity to undergo future IVF attempts without the use of stimulating the ovaries.

·         Egg freezing can be beneficial for women who, for purposes of education, career or other reasons, desire to postpone childbearing.


Q: How long can the eggs remain frozen?

·         Theoretically, the eggs can remain frozen indefinitely.

Q: Is egg freezing covered under insurance?

·         Egg freezing is not typically a covered procedure for most insurance companies.

·         The ART Fertility Program of Alabama participates in Livestrong’s Fertile Hope for Women (and Men) Program (email -, telephone -   855-220-7777).  This program helps to defray the costs of fertility preservation for qualified cancer patients.

·         Should you have questions about the cost of these procedures or insurance coverage, please call the ART Fertility Program of Alabama’s financial department at 205-870-9784. 


Q: How well does the process work?

·         Frozen eggs have resulted in over 2,000 babies born worldwide.  The ART Fertility Program was the first in Alabama to have babies from frozen eggs (2009).

·         No increases in chromosomal abnormalities, birth defects, or developmental defects have been noted in children born from frozen eggs.

·         The success rate with frozen eggs is related to the age of the woman at the time of freeze and the number of eggs frozen.


Q: What is the ART Fertility Program of Alabama’s current success rate?

·         Thus far, 6 patients have received embryos derived from frozen-thawed eggs resulting in 3 deliveries and 1 ongoing (third trimester) pregnancy.



We hope you now have a better understanding of egg freezing, and who can benefit. Should you have additional questions, please do not hesitate to call the ART Fertility Program of Alabama at 205-870-9784.



Monday, October 21, 2013

Initial Results for the Health Care Exchanges

By Colin Luke

It has been a difficult few weeks for Health and Human Services Secretary Kathleen Sebellius and the perhaps inaptly named Affordable Care Act. Since the October 1 rollout of the health care exchange national website,, there have been numerous problems and crashes reported by the national media. Moreover, enrollment in health insurance plans offered through the exchanges has been far less than anticipated and far less than required to sustain the program. According to the website, through October 15, “just 36,000 consumers, or one percent of all those who attempted to register for the federal exchange, successfully enrolled in Obamacare”.

Officials in the Obama Administration have reported that to date there have been approximately 480,000 applications filed for coverage under the national and state exchanges through October 20. No one is able to state accurately how many of these applications will actually be approved and how many individuals will eventually receive health insurance coverage. However, it seems hard to believe that the exchanges will produce the seven million new enrollees forecast by the Congressional Budget Office in the first six month period after October 1st.

Alabama’s experience with the exchanges have also been somewhat mixed. Gov. Bentley decided in November of last year that Alabama would not operate its own health care exchange. He cited projected state operating costs of up to $50 million and the need to avoid creating an additional tax burden on the people of Alabama in opting to go with the federal government’s default plan for operating the health insurance marketplace in Alabama.

The Governor had established the Alabama Health Insurance Exchange Study Commission in November of 2011 by Executive Order to study the various options for exchanges in Alabama. Although the Commission recommended Alabama implement a state-run exchange, no bills were adopted by the Alabama legislature to create such an exchange.

The U.S. Department of Health and Human Services reports that Alabama residents have the lowest number of alternatives among the 36 states participating in the federal exchange. Enrollment options are organized by county, and the number of alternatives may vary across Alabama. On average, Alabamians have seven options for health insurance under the exchange. Nationally, individuals have 53 alternatives on average. According to a report by HHS, the mean monthly premium for a bronze plan health insurance policy for an individual in Alabama is $247. The bronze plan is the lowest level of coverage offered on the exchange.

Several insurance companies are offering plans in Alabama under the federally-run exchange. Blue Cross and Blue Shield of Alabama and Humana are offering individual options through the federal marketplace. Blue Cross and United Healthcare are providing alternatives for small business insurance plans on the exchange for Alabama.

According to Health and Human Services, approximately 650,000 Alabamians are currently without any form of health insurance and eligible to use the exchange. To the extent the website is operational, enrollment under the exchange runs until March 31, 2014 and initial coverage can begin as early as January 1, 2014.

Colin H. Luke is a partner with Bradley Arant Boult Cummings where he advises clients with respect to a variety of healthcare and general corporate matters.

Monday, October 14, 2013

The Diabetic Foot Ulcer: How a Wound Care Center Can Help

By: G. Blaine Bishop, Jr., MD
The Centers for Disease Control estimates there are 25.8 million diabetic American as of 2011, with 1.9 million new cases being diagnosed annually.  Medicare FFS data from 2008 showed diabetic foot ulcers in these patients.  20-25% of these patients went on to some form of amputation (toe, foot, or leg).  “Up to 83% of lower limb amputations in diabetic patients are preceded by foot ulcers that fail to heal.”
            Sadly, the 5 year death rate on a diabetic patient following a below-the-knee amputation is 47%! (In contrast, only 28% of Stage III breast cancer patients die within 5 years – American Cancer Society.)  Both the in-hospital and in-home healthcare costs skyrocket after a major amputation.  Surprisingly, virtually all insurers are willing to invest significant monies in order to heal diabetic foot ulcers (DFU’s).
            As most physicians are aware, chronically elevated glucose levels can lead to neuropathy, peripheral vascular disease, and impaired white blood cell function.  It is estimated that 30-50% of diabetics will develop neuropathy in their feet.  Unsurprisingly, 60% of DFU’s occur in patients with neuropathy only, 15-20% in diabetics with peripheral vascular disease, and 15-20% DFU patients with both neuropathy and peripheral capsular disease.
Rare is the physician who hasn’t see a foot ulcer in a diabetic patient whose poorly fitting shoe and lack of sensation have resulted in callus build up, followed by pressure necrosis, followed by infection.  Cellulitis, deep space infections, and even osteomyelitis result all too commonly from this scenario.  Frequently, a multidisciplinary team treating the many components of these lesions will be required.  Such resources often exceed the office capabilities of our hard working primary care physicians.
            The initial patient encounter in a dedicated wound care center (WCC) involves wound measurement, evaluation of blood sugar control, assessment of arterial blood inflow/wound tissue oxygenation, evaluation for infection, as well as determining the correction of the cause of the chronic foot trauma.  Typical initial treatments involve off-loading the ulcer (total contact cast, walking boot, temporary diabetic shoe, and –ultimately- a custom designed orthotic shoe insert to prevent further ulcers). Regular wound debridement that rids the ulcer of callus, dead tissue, and the bacteria-laden biofilm which so often covers the surface of the ulcers.  A specialized wound dressing helps provide enough moisture to promote healing but not so much as to cause wound maceration.
            When these primary therapies aren’t enough (i.e. the wound is less than 40% healed after 4 weeks of these initial treatments), more advanced therapies are indicated.
            Many physicians are familiar with the Wound VAC wound closure system.  Some may not be as familiar with topical vascular endothelial and human platelet derived growth factors. Also human “skin substitutes” from tissue cultured neo-natal foreskin contain a number of growth factors which stimulate ingrowth of the patients own skin calls in order to heal the wound.
            Revascularization via stenting or leg artery bypass can improve oxygen delivery to the wound when peripheral vascular disease is an issue.  Hyperbaric oxygen is another advanced therapy to improve DFU oxygen level.  100% oxygen under 2 atmospheres of pressure for 90 minutes at a time is demonstrated to 1) kill bacteria (even osteomyelitis), 2) stimulate the growth of new arterioles into the ulcer, and 3) stimulate the proliferation of wound healing cells.  Thus, according to the American Diabetic Association, examples of wound patients who should be referred to a Wound Care Center include:
1)      A wound that had failed to show significant progress after 4 weeks of standard care
2)      A wound that involves deep tissue structures or is limb-threatening
3)      A wound complicated by significant comorbidities including peripheral vascular disease, vascular disease, persistent edema, persistent infection, or prior radiation to the area
1)      Bowering; Canadian Family Physician
Vol 47, May 2001 : 1007-16
2)      ADA Consensus Development Conference On Diabetic Foot Wound Care
-          Diabetes Care 22(8) 1345-60, 1999
G. Blaine Bishop, Jr., MD
General Surgeon
Advanced Surgeons, PC
Member of the Medical Staff – Trinity Medical Center

Monday, October 7, 2013

Treatment group at Children’s targets vascular anomalies

By: Dr. Brian D. Kulbersh of Pediatric ENT Associates is director of the Vascular Anomalies Treatment Group at Children’s of Alabama.


About 200 patients are referred every year to Children’s of Alabama for diagnosis, treatment and management of vascular anomalies. These conditions arise when blood or lymphatic fluid vessels develop improperly. They can range in severity from benign birthmarks to painfully swollen malformations of vessels.


To provide the best possible care for these young patients, Children’s of Alabama has formed the Vascular Anomalies Treatment Group. This team brings together seven disciplines: ENT, hematology/oncology, dermatology, interventional radiology, general surgery, plastic surgery and orthopedic surgery.


I lead the team, and members include: Drs. Amy Theos, Joseph Pressey, Ahmed Kamel, Souheil Saddekni and Mac Harmon. We all have developed sub-specialization in the field of vascular anomalies. We meet monthly to review medical histories, photographs, radiological images and pathology slides from patients who have been referred to us.


In general, our team usually sees two major groups of anomalies, hemangiomas and vascular malformations. The more common of the two groups, hemangiomas, are not present at birth. They can be red when they are in the top skin layers and blue if they are deeper. Sometimes they occur in combination. They are usually noticed several days or weeks into life.


Hemangiomas are more common in girls and low birth-weight babies. Eighty percent of them are found near the head and neck. They can grow for up to a year, and then usually begin to slowly fade and disappear when the child is 3 to 9 years of age. Sometimes, families choose surgical intervention.


On the other hand, vascular malformations are abnormal clusters of blood vessels that form during fetal development, although they may not be visible at birth. Symptoms include pain, swelling or bleeding. They, too, grow during the first year of life, but without treatment, they will not diminish or disappear.  


For example, arteriovenous malformations are abnormal connections between arteries and veins. They are present at birth, developing in the absence of a normal network of tiny capillaries that is needed to properly connect arteries and veins. These malformations slowly progress, and become larger, darker, warmer and more painful.

We also care for patients with lymphatic malformations, conditions that are often present at birth and cause swelling in the neck and face. These malformations do not involve blood vessels, but instead involve defective vessels that carry lymph, a fluid that is critical to the body’s immune system.  Some lymphatic malformations can interfere with eating and breathing. Treatment includes surgical intervention, sclerotherapy via interventional radiology and some new medical treatments such as Rapamycin.


Vascular anomalies, and some of conditions that cause them, include:

--Common birthmarks are the most familiar vascular anomalies, with names like “stork bite” and “strawberry mark.” These areas of discolored and/or raised skin are apparent at birth, or shortly thereafter. About 1-in-10 babies have a vascular birthmark. Most are benign and require no treatment.


--Hereditary hemorrhagic telengiectasia. Children with this syndrome tend to form blood vessels that lack capillaries between arteries and veins. Without tiny capillaries, arterial blood under high pressure flows directly into a vein and can rupture vessels, causing bleeding. This occurs mostly on the nose, facial skin, hands, mouth, GI tract, lungs and brain.

--Klippel-Trénaunay syndrome. This rare, congenital condition is marked by a large number of abnormal blood vessels. It is a complicated condition, and affects different children in different ways. It requires the skills of several specialists using a variety of interventions, including surgery.

--Sturge-Weber syndrome. This syndrome involves a vascular birthmark and neurological abnormalities. Between 75 to 90 percent of afflicted children develop seizures, which start before age 1, and may worsen. About a third of afflicted children are born with glaucoma on the side of their facial birthmark.

--Port wine stains. These birthmarks begin as flat areas of skin that are pink to dark red. They usually follow nerves on the face, arms or legs. A port wine stain on an eyelid of the forehead is sometimes associated with Sturge-Weber Styndrome, and similar lesions may be found in the brain, causing neurological problems.

--Venous malformations. These are collections of dilated veins usual present at birth as a painless, purple mass. They grow slowly, and tend to get larger during adolescence, especially if they are located below heart level.
--PHACE syndrome. This rare syndrome is marked by large hemangiomas and birth defects of the brain, heart, eyes head or neck.

For more information send an email to

Thursday, October 3, 2013

Diabetes and Colorectal Cancer: Shared risk, Shared Screening


By Ashley Vice

FITway Alabama Colorectal Cancer Prevention Program

Completing the screening and rescreening cycle for colorectal cancer is a daunting task for medical practices across the state. The U.S. Preventative Services Task Force recommends colonoscopy every 10 years or a flexible sigmoidoscopy every 5 years or an annual stool test for average risk patients.  Identifying patients that need screening, encouraging compliance with recommended screening methods,  and repeating FIT/iFOBT tests annually (when used as the primary screening option) are just a few of the necessary, but challenging steps in reducing incidence and mortality of Alabama’s second-leading cancer killer.

The ideal patient panel for annual screening with FIT/iFOBT is average risk, compliant and in the provider’s office multiple times per year. That population exists in Alabama and it has a 30 percent higher risk for colorectal cancer: people with diabetes (1-2).

One in 10 Alabamians have been diagnosed with diabetes, an illness that negatively impacts quality of life and lifespan and brings with it a host of other health issues (3).  Those at risk for type 2 diabetes often mirror those at risk for colorectal cancer: patients over 50 years old or African Americans, for example.  Many of the risk factors for colorectal cancer also overlap with diabetes including obesity, sedentary lifestyle, and western diet (1-2, 4).

In addition to sharing risk factors and at-risk populations, diabetes may also cause or contribute to colorectal cancer through chronic insulin treatment, increased production of bile acids, and slower bowel transit (1,4-6). 

While data show that diabetic patients in Alabama are more likely to be screened for CRC than the general population, approximately 29 percent of the diabetic population in Alabama is not up to date on CRC screening (7).

Tracking screening within the chronic patient pool:

One way to target diabetic patients and other chronic disease sufferers for colorectal cancer screening is through electronic health records (EHR). By choosing colorectal cancer screening as one of your clinical quality measures (NQF 0034/PQRI 113) you can improve patient care, earn incentives up to $44,000 for Medicare or $63,750 for Medicaid depending on your patient population, and achieve three EHR objectives at once.

Providers can achieve the professional core objective by reporting ambulatory clinical quality measures. Two eligible professional menu objectives can be achieved by generating a list of patients by specific condition to use for quality improvement and sending patient reminders as needed for preventative and follow-up care.

A recent study published in the Annals of Internal Medicine showed that patients completed recommended screening more often when EHR-linked reminders and fecal occult blood testing kits were sent to them (9). Primary care facilities in the study created a registry through EHR which tracked when screening was due and automatically generated mailings. Patients who received automated reminders and mailouts were 26.3 percent more likely to be screened even without direct contact from a nurse or physician. The study also showed drastic increases in screening rates for patient groups who received automated information and staff follow-up.

For help setting up clinical decision support rules and patient alerts for colorectal cancer screening, physicians can contact the Alabama Regional Extension Center at (251) 414-8170.

Screening more patients overall:

Screening with a FIT test is a great way to increase screening in your practice by offering an easier, convenient method of screening for your patients. Patients offered a choice between colonoscopy and a stool test are more likely to be screened (8). Patients often have barriers to colonoscopy like fear and aversion, lack of adequate insurance coverage, inability to provide transportation or time off from work. Those barriers can be overcome with take-home stool tests.

Only high-sensitivity tests, like the FIT/iFOBT and high-sensitivity guaiac are recommended by the USPSTF as acceptable stool tests. Older, low-sensitivity  guaiac FOBT should no longer be used.

Take-home FIT/iFOBT screening is also covered by major insurers in Alabama including Blue Cross and Blue Shield of Alabama, Medicaid, and Medicare. Medicare reimburses $21.86 for a completed test (CPT Code: G0328QW).

To get more information on screening with the FIT contact the Alabama Department of Public Health Cancer Prevention Program: Ashley Vice 334-206-3336,

1.       Gioleme O, Diamantidis M, Katsaros M. Is diabetes a causal agent for colorectal cancer? Pathophysiological and molecular mechanisms. World Journal of Gasteroenterology 2011, 17, 444-448.

2.       Larsson S, Orsini N, Wolk A. Diabetes Mellitus and Risk of Colorectal Cancer: A Meta-Analysis. Journal of the National Cancer Institute 2005, 97, 22.

3.       Centers for Disease Control and Prevention. Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department for Health and Human Services; 2012.

4.       Will J, Galuska D, Vinicor F, Calle E.E. Colorectal Cancer: Another Complication of Diabetes Mellitus? American Journal of Epidemiology 1998, 147(9).

5.       Sun L, Shiying Y. Diabetes Mellitus Is an Independent Risk Factor for Colorectal Cancer. Digestive Diseases and Sciences, Springer 2012, 57, 1586-1597.

6.       Coughlin S.S., Calle E.E., Teras T.R., Petrelli J, Thun M.J. Diabetes Mellitus as a Predictor of Cancer Mortality in a Large Cohort of US Adults. American Journal of Epidemiology 2004, 159(12).

7.       Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2012.

8.       Inadomi J.M., et al. Adherence to Colorectal Cancer Screening a Randomized Clinical Trial of Competing Strategies. Arch Intern Med. 2012, 172(7), 575-582.

9.       Green B.B., Wang C.Y., Anderson M.L., et al. An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening; a randomized trial. Annals of Internal Medicine. 2013, 158(5 pt 1): 301-311.