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Alan H. DeCherney, MD, Chief of Reproductive Biology and Gynecology and Deputy Clinical Director for Academic Affairs of the Division of Reproductive and Adult Endocrinology in the Division of Intramural Research of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)/National Institutes of Health and former Chair of the Department of Obstetrics and Gynecology at Tufts University and the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), is being recognized as a Giant in Obstetrics and Gynecology for his original medical and scientific contributions, innovation, and leadership.
“Imagination is more important than knowledge” — Albert Einstein
The conversation with Alan for this profile began with a dialogue about the relative importance of imagination and knowledge in medicine and science. Having known him for 40 years, I have admired the ways Alan’s quick intellect has allowed him to innovate, execute his vision, and be great company with his legendary sense of humor and wit.
Endoscopic linear salpingostomy for the treatment of unruptured ectopic pregnancy
One of Alan’s major contributions to gynecology took place in the operating room at Yale New Haven Hospital. Forty-five years ago, 90% of ectopic pregnancies were diagnosed after rupture of the fallopian tube. The combined use of ultrasound and the determination of beta-human chorionic gonadotropin in maternal plasma was responsible for the improvement in the diagnosis of ectopic pregnancy and, in particular, a shift toward the identification of unruptured ectopic pregnancies.
Patients with a high index of suspicion for ectopic gestation were typically scheduled for diagnostic laparoscopy, followed by exploratory laparotomy to remove the ectopic pregnancy. In cases of a ruptured ectopic pregnancy, the treatment was salpingectomy, whereas in unruptured ectopic pregnancy, the treatment was linear salpingostomy.
One night, when Alan was the attending physician on call and I was a resident in the gynecology service, a patient with a suspected ectopic pregnancy and a nondiagnostic culdocentesis was scheduled for diagnostic laparoscopy and exploratory laparotomy. The laparoscopy revealed a very small, unruptured, ectopic pregnancy, so small that Alan asked me, “Do you think it would come out through the laparoscope?” Without hesitation, Alan asked the circulating nurse for a unipolar electrocautery, an apparatus used for tubal ligations at that time, and he then performed a linear salpingostomy in the antimesenteric side of the fallopian tube.
With a forceps, Alan successfully removed the ectopic pregnancy through the laparoscope. His ingenuity sparked excitement in the operating room. Alan turned to me as I was looking through the laparoscope and said, “Historical moments in medicine, courtesy of Parke-Davis,” referring to a series of paintings commissioned by the pharmaceutical company featuring breakthroughs in medicine. This was quintessential Alan.
The next day, as some colleagues lauded this novel step in the treatment of ectopic pregnancy, others felt that we should have performed an exploratory laparotomy; nevertheless, preventing open surgery and allowing early discharge was appealing for both us and the patient. After this first case, Alan later reported his experience with 18 such cases in Fertility and Sterility (Figure 1).
He proposed that ectopic pregnancies less than 3 cm could be eligible for laparoscopic removal. This practice went on to change the operative management of ectopic gestation and ignited a conversation as to whether all ectopic gestations required removal and whether the natural history of some would include a tubal abortion or simply involution in situ, not requiring surgery.
“Bring me a resectoscope!”: a novel method to remove a uterine septum
By chance, I witnessed another innovation in surgical treatment, which occurred when a patient with a suspected uterine septum was scheduled for a hysteroscopy to confirm the diagnosis. This common Müllerian duct abnormality was routinely treated with surgery, which was often performed in two stages.
Once Alan confirmed the diagnosis, he mentioned that there was a case report by Frank Chervenak and Robert Neuwirth, which described endoscopic resection of a uterine septum with scissors.
Without skipping a beat, Alan asked for a resectoscope, ordinarily used for treatment of benign prostate hypertrophy. With this instrument, he removed the septum, a technique that rapidly became the standard of practice for the treatment of this condition at Yale (Figure 2).
These two examples of surgical innovation and resourcefulness have led Alan to be recognized as an endoscopic surgeon and prominent member of the American Association of Gynecologic Laparoscopists and the Society of Reproductive Surgeons.
Embryo biopsy and painting chromosomes: fostering collaboration
With a keen insight into human nature, Alan’s knack for identifying who might work well together has led to the assembly of teams and encouraged countless collaborations. The success of in vitro fertilization in New Haven had sparked Alan’s interest in assessing the embryo.
Among the brightest stars of the Yale reproductive endocrinology and fertility training program was James Grifo, a physician-scientist with a PhD in genetics (now a professor of obstetrics and gynecology at New York University). David Ward of the Department of Human Genetics had developed a method for painting chromosomes to help identify their number and rearrangement. Sensing a common interest and the potential for synergy and aware that this collaboration represented a frontier, Alan asked Jamie and David to work together. They assembled a team and developed a method for performing a biopsy of preimplantation mouse embryos and human blastomeres (Figure 3).
Progesterone for luteal support and improved outcome of in vitro fertilization
Steptoe and Edwards reported the first successful in vitro fertilization, accomplished by monitoring the luteinizing hormone surge that accompanies ovulation during natural menstrual cycles. Investigators in Canada decided to enhance the likelihood of success by inducing superovulation with clomiphene.
The next innovation came from the group at Norfolk, who used mild stimulation with gonadotropin to induce superovulation. Alan and his group at Yale, which included Florence Haseltine and Neri Laufer, decided to use high-dose gonadotropin (4 to 6 ampules) when other physicians were using 1 to 2 ampules (1 ampule = 75 mIU).
Of the five groups working on in vitro fertilization at the time in the United States, all but Yale’s had been successful: Anne Wentz at Vanderbilt, Richard Marrs at the University of Southern California, Martin Quigley at the University of Texas-Houston, and Howard and Georgeanna Seegar Jones in Norfolk. At a meeting in Norfolk, the four successful teams criticized Alan’s choice of high-dose gonadotropin. Their argument was that high-dose gonadotropin would lead to high estrogen production, and this would have an adverse effect on the endometrium by altering the implantation window.
Alan realized at the meeting that there was another difference among the US teams: he was not using progesterone for luteal support. He had reasoned that if one follicle produced enough progesterone to support a pregnancy, 10 to 12 follicles generated by high-dose gonadotropin would produce enough progesterone to sustain gestation. When Alan returned to New Haven, he decided to add progesterone to his protocol, and this led to Yale’s first in vitro fertilization success.
Prophylactic antibiotics and cesarean delivery
While at the University of Pennsylvania, Alan worked with Ronald Gibbs and Richard Schwarz, both of whom had an interest in infectious diseases. Together, they conducted one of the first studies to demonstrate that the use of perioperative antibiotics could reduce morbidity.
As the story goes, the immediate motivation was to find a way to address the problem of puerperal fever and to make postpartum rounds more interesting.
At the time, several studies had shown that antibiotics could reduce infection-related morbidity in gynecological procedures, such as vaginal hysterectomy. Ron, Alan, and Richard undertook a double-blind, placebo-controlled study to determine whether a short high dose of perioperative broad-spectrum antibiotics could decrease morbidity in high-risk patients. The results supported their hypothesis: the incidence of infection was 27% lower in patients allocated to antibiotics than in the placebo group.
This led to a series of studies that culminated in the current practice of administering antibiotics to women undergoing cesarean deliveries.
A lineage of physicians: family background and early life
Alan’s family emigrated from Eastern Europe at the turn of the 20th century. It was Alan’s great-uncle, Matthew S. Ersner, a longtime Chair of the Department of Otorhinology at Temple University School of Medicine, who persuaded the family to move to Philadelphia and who later encouraged his nephews to attend medical school at Temple. Two nephews did: Alan’s father, William DeCherney, and one of his three brothers, who became a prominent psychiatrist.
William was a family practitioner and delivered many babies who remained his patients into adulthood. He lived in his old neighborhood, and many of his patients were people he had grown up with. After half a century, more than 400 of his patients threw a party to celebrate the 50th anniversary of his practice. He retired at age 86 years at his wife’s request.
Moving to working-class south Philadelphia for her husband’s practice was difficult for Alan’s mother, who grew up in an affluent family. Her family’s move from Vienna to Philadelphia occurred in the 1860s. Alan recalls that he enjoyed living in the home that housed his father’s practice. Although his father worked from 6 AM to 11 PM, having the office in their home made it possible for them to share meals and to see each other a great deal. Literally living with the practice, observing how hard his father worked, and accompanying him on Sunday rounds at Doctor’s Hospital kindled Alan’s love for medicine from early childhood.
When Alan was looking for someone to help with an important report, he met Deanna (DeeDee), who had offered her assistance. Alan and DeeDee had lived on the same street and attended the same large high school, but the two had never met. Within a few months after successfully completing the manuscript, Alan asked DeeDee for a date, and four years later, they were married. They celebrated their golden anniversary in 2015.
DeeDee is an artist: a talented ceramist, sculptor, and interior designer. She has been a teacher of interior design and served as the editorial director of Design Times magazine. DeeDee is also a trustee of her alma mater, The University of the Arts, in Philadelphia.
Alan describes DeeDee as intelligent, intuitive, and kind. He approves of her sense of humor in that “she laughs at all my jokes.” Alan praises DeeDee as a loving, supportive mother, and he says that he and his family have benefited from her design skills in creating the ideal environment for the family’s needs each time they moved, adapting the decor to the location. Their home in New Haven reflected a young family’s lifestyle; later, she created a minimalist, open-concept design, California style, in Los Angeles. Now, they live in a stunning, art-filled home in Potomac, Maryland.
Together, the DeCherneys have engaged in charitable works. For example, they received a Community Leadership Award for humanitarianism and commitment to the education of all children by Friends of the Fulfillment Fund, which provides at-risk Los Angeles school district students with mentors and financial assistance to help them complete high school and attend college.
Finding a specialty: “Life isn’t about finding yourself; it is about creating yourself” — George Bernard Shaw
From the start of his career, Alan had a clear idea of his strengths and goals. After attending Muhlenberg College, he chose Temple University Medical School, appreciating that the school was geared toward clinical medicine. Then, two months into an internship in medicine at the University of Pittsburgh, Alan realized that although he missed surgery, he liked the continuity of patient care that he had observed in his father’s practice. Obstetrics and gynecology was the ideal venue for him. Even the prospect of staying up all night appealed to him.
Alan completed his residency in obstetrics and gynecology at the University of Pennsylvania, where he had originally hoped to attend medical school before bowing to family tradition. There, he worked with exceptional colleagues, many of whom later became department chairs. His closest friends at Penn, Ron Gibbs and Michael Menutti, became like family. The three physicians served on the American Board of Obstetrics and Gynecology together and traveled the world. Their ties endure to this day.
The atmosphere at Penn consisted of individuals who wanted to make progress and took pride in being creative. They were competitive, Alan recalls, but not with each other. The late Luigi Mastroianni Jr, who chaired the department when Alan was a resident, was considered to be distant, but in truth, he actively nurtured Alan and those working under him. As the years passed, Alan says, he appreciated Luigi even more.
In Alan’s second year of medical school, he signed up for the “Berry Plan.” Under this program, medical students could defer military service by agreeing to serve in the Army for two years after completing their education. By the time Alan had finished his residency, the Vietnam War was over. Although most participants were not required to enter the Armed Services after all, Alan was drafted and assigned to Tokyo, Japan, where he practiced general obstetrics and gynecology for two years. For the last six months of his tour, he served as the Commanding Officer of the hospital on base.
During that time, Alan developed his leadership skills and a deep, abiding respect for the military and the discipline that it imposes. Alan also met Nathan Kase, and when his Army tour ended, Alan joined Nate in New Haven and began his career in earnest.
Yale, Tufts, and UCLA
During Alan’s first months as an assistant professor at Yale, he listened closely during morning rounds, yet said nothing. Once Donald Coustan arrived, the two became directors of the residency program and began to hold rounds in an open, collegial way. They made a point of answering all questions posed by residents. Alan compares the situation to a game in which the players enjoy themselves and no one is injured. I had the opportunity to witness the repartee between Alan, Don, and the residents for three years and consider it one of the most educational experiences of my professional life.
To prepare for his board examinations in reproductive endocrinology and infertility, Alan went to the home of Nathan Kase and studied while proofreading the galleys of the second edition of Clinical Gynecologic Endocrinology and Infertility by Leon Speroff, Nathan Kase, and Robert Glass.
After Alan had been in New Haven for six months, Leon Speroff moved to Case Western Reserve as Chair, leaving Alan to inherit his many patients with endocrine disorders. Shortly thereafter, Nathan Kase left for Mount Sinai, and Alan inherited his patients as well, establishing an exceptional practice in New Haven.
After 17 years at Yale, Alan went to Tufts University in Boston as Chair of the Department of Obstetrics and Gynecology, where he remained for five years. He subsequently became Professor and Chair at the David Geffen School of Medicine at UCLA, where he was to stay for nearly 10 years. He then joined NICHD, where he is the Program Head of Reproductive Endocrinology and Gynecology.
Alan has written or edited 50 books and some 900 original and review articles and book chapters, and he has served on the editorial boards of 25 clinical journals. He was the Editor-in-Chief of Fertility and Sterility for 15 years and Associate Editor of the New England Journal of Medicine for five years. During his career, he has been President of the American Society for Reproductive Medicine, the Society for Reproductive Endocrinology and Infertility, the Society of Reproductive Surgeons, the Society of Assisted Reproductive Technology, and the Society for Gynecologic Investigation. In 2004, Alan was elected to the Institute of Medicine (now the National Academy of Medicine).
Books, movies, and other interests
Alan is a voracious reader of both fiction and nonfiction. Rarely, if ever, have I been able to recommend a book to Alan that he has not already read. A current favorite is Duty: Memoirs of a Secretary at War by Robert M. Gates, who served six US presidents while at the CIA and National Security Council. Gates addresses the issue of leadership: how to assess people and accomplish goals. Gates’ view resonated with Alan, who believes that the most important attribute of a leader is to get things done. Gates also emphasized the value of loyalty, which Alan considers to be an important quality in leadership and in life.
Among Alan’s favorite movies are The Philadelphia Story, for its depiction of old American class at its finest, and Annie Hall, for its New York sensibility and comic appeal. His favorite poems are “The Road Not Taken” by Robert Frost; “Ozymandias” by Percy Bysshe Shelley; and “The Love Song of J Alfred Prufrock” by T S Eliot.
With his intelligence and wit, Alan is in demand as a speaker and master of ceremonies. During the 1980s, he was a memorable guest on the Phil Donahue Show. Alan, part of a panel of advocates and experts on reproduction, was asked whether it would be possible for a man to bear a child. Donahue was excited that Alan hinted at a theoretical pathway for such a pregnancy, given that pregnancy did not require a uterus. After reeling Donahue into the possibility, Alan dashed the host’s hopes for newsworthy discussion when he followed with, “Of course, the man would have to agree to have his testicles removed.” The audience laughed, and Donahue knew that Alan had set him up.
The legacy of an academic physician
At the end of Alan’s residency in obstetrics and gynecology, Alan said to his mentor, Dr Mastrioianni, “Your immediate legacy is your patients; your long-term legacy is your research; but the only legacy that really counts is the people you have trained.” Those words spoken many decades ago are still relevant to Alan, and he remembers with pride all of the superb clinicians he has trained. Since 1994, the DeCherney Society, comprised of more than 100 of Alan’s mentees, gathers annually at the American Society for Reproductive Medicine meeting.
Impatience, innovation, wisdom, and wit
As our conversation for this piece came to a close, I asked Alan what he considered his shortcomings. “Impatience,” he said. “In the rush to get things done, I have been impatient.” Perhaps this emanates from Alan’s decisiveness: when Alan is faced with a problem and makes a decision, he proceeds without doubt. It is Alan’s other attributes — innovation, wisdom, and wit — that make him unique and a Giant in Obstetrics and Gynecology.
Surgical management of unruptured ectopic pregnancy.