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Fertility expert Dr. Sherman Silber gives hope to infertile men and women
By Julia Evangelou Strait
stlbeacon.org, November 12, 2009
As far back as Sherman Silber can remember, his parents told him he wanted to be a doctor.
"They pounded it into me!" said Silber with a laugh. "There was a tremendous parental push. But I'm really happy for it," he said. "I was a Jewish boy in a poor neighborhood on the south side of Chicago," said Silber, describing it as the kind of neighborhood everybody wanted to get out of.
Get out of it he did. Today, Silber, 67, is a world-renowned fertility specialist, leading the Infertility Center of Saint Louis at St. Luke's Hospital. For more than 30 years, he has been at the forefront of developing the latest technologies and surgical techniques that have restored fertility to countless couples.
A focus on the patient
According to colleagues, the needs of his patients keep Silber pushing the boundaries of what can be done to enable infertile women and men to have children. His most recent success is restoring the fertility of a 31-year-old cancer survivor. At 19, she was diagnosed with Hodgkin's lymphoma, a cancer of the immune system. She underwent several years of radiation and chemotherapy as well as two bone marrow transplants. Such treatment can save lives, but it also destroys the ovaries, causing early menopause and sterility. But before her treatment began, Silber removed and froze tissue from one of her ovaries [see video]. In 1998, he could make no promises of success, but explained that this was the only chance she had to preserve her fertility from the ravages of radiation and chemotherapy.
Now, cancer free, the patient has married and would like to start a family. Thawing the tissue that sat frozen for over a decade, Silber returned it to the patient, restoring her ability to ovulate and bear children. She is now pregnant with her first child. A video presented to the American Society for Reproductive Medicine at a meeting in Atlanta, Georgia in October shows the delicate surgery.
A gifted surgeon
"As a surgeon, he's extremely gifted," said David Battaglia, a colleague of Silber and director of the Andrology/Embryology Laboratory at Oregon Health and Science University in Portland. "He just astounds me when I hear about a new case that he has done," Battaglia said. Some of these recent cases include whole ovary transplants between identical twin sisters. In rare instances, one twin can have normal fertility, while the other enters early menopause. Between 2003 and 2009, Silber performed these transplants, which resulted in 12 pregnancies and eight healthy births.
Silber's surgical skills were honed over decades of microsurgical experience, beginning with kidney transplants in rats and continuing with the first consistently successful vasectomy reversals. That success landed Silber on the front page of the New York Times in 1975. Later he performed the first tubal ligation reversals for women and the first sperm retrieval, giving men with zero sperm count in their ejaculate the chance to father children. With these firsts and many others, Silber has a long list of successes. But right now, he says, he is most excited about the ovary transplants.
"I'm riding really high on that because it's very thrilling. We can take the ovary out of cancer patients before they are sterilized by their treatment. And now, 90 percent of these young women are cured of their cancer. We can take the frozen ovary and transplant it back years after they're cured, and it works," he said. "They get pregnant. It's amazingly uneventful."
An unlikely mentor
Such success does suggest an inherent talent for complex surgeries. But Silber himself does not consider his surgical skills a natural gift. Rather, he describes it as the product of hard work and study with a man some might consider an unlikely teacher.
"I had no manual ability whatsoever," said Silber, describing himself as a young medical student at the University of Michigan in the early 1960s. At the medical school's animal research lab, Silber had the good fortune to meet Jimmy Crudup [see video]. Silber credits Crudup for his skill in the operating room. "It all came from Jimmy. He was my teacher and my inspiration," he said.
A former truck driver from Mississippi in the 1950's, Crudup had trouble finding a job. So, like other African Americans in the south at that time, he came north to look for work and eventually landed in the University of Michigan's animal research lab. Lacking a college degree, his job was to care for the animals, keep the lab and instruments clean, and help the surgeons working there. According to Silber, Crudup had an incredible interest in the work done in the lab.
"He would assist some of the surgeons when they needed an extra hand to hold a retractor," said Silber. Independently, Crudup studied anatomy and did his own exploratory surgeries on the already sacrificed animals.
"After about 10 years, they discovered that this guy, who was an amazing mechanic and extremely good with his hands, became basically the best surgeon at the University of Michigan," Silber said. "But he could only operate in the animal lab."
Silber worked with Crudup for years and developed microsurgical techniques to transplant kidneys in rats. He described the instruction Crudup gave and how it differed from the way many surgeons are trained -- by observing surgeries and then performing those surgeries while others observe them.
"We have a country of great surgeons," said Silber, "But Jimmy was extra special because he worked on the basics -- how to get your mind ready for it, how to steady your hand, how to follow the curve of the needle, how to dissect, how to prepare tissue, how to make your knots come down square and flat," he said. Silber compared Crudup to Mr. Miyagi, the wise mentor and teacher from the Karate Kid movies. "You know how he taught the kid 'wax on, wax off'?" said Silber. "That's the kind of thing Jimmy would do. Absolute basics."
It certainly worked for Silber and may be part of the reason he is one of the few people in the world doing procedures like ovary transplants [see video]. Such microsurgeries require the reattachment of blood vessels not much thicker than a thread, the kind that might be used to sew on a button. And that's the outer diameter of the hollow vessel. These tiny tubes must be reattached such that the ovary's blood supply can flow freely through it.
Being the first to do so many new and delicate procedures may cause some to think he's a risk taker. Silber disagrees. "I'm very risk averse," he said. "Almost everything I do has a huge amount of animal research that predates it." For the first ovary transplant, he said,the patient had six months of careful informed consent and that it went through an ethics committee. "I don't like going out on a limb," he said. "Once you've got the idea, you better solidly prepare for it."
Battaglia agrees that Silber does not take unnecessary risks to help his patients. "There's the risk that it might not work," said Battaglia. "But in terms of risking their health, he doesn't do that."
Spreading the word and collaboration
With this concrete success in transplanting ovaries, Silber speaks about his process to help spread the word about this new possibility for young women diagnosed with cancer. Lonnie Shea, a professor of chemical engineering at Northwestern University, met Silber after his keynote speech at a conference focusing on fertility and cancer. "What came across in his talk were a couple of things," said Shea. "One was his enthusiasm and excitement about trying to help patients. The other was his openness and willingness to share what he's done to make this available more broadly."
Shea is part of a team at Northwestern that works on fertility preservation for women with cancer. "Dr. Silber is the most successful person working in the area of transplanting ovarian tissue. That's one of the opportunities that we want to make available to patients here," Shea said.
Visiting St. Louis in July, Shea observed Silber's surgical approach and learned about his cryopreservation techniques, the specific methods Silber uses to freeze ovarian tissue and whole ovaries. "As someone who works with biomaterials and drug delivery, I try to dream of what we might be able to do to make this a surgical procedure that more people can do besides Dr. Silber," said Shea.
The fact that his services are rare perhaps explains Silber's appointments as a visiting professor at other institutions in this country and abroad, including in Brussels, Cambridge, Mass., Tel Aviv, New York City, and Tokyo.
Silber's early career also took him and his wife, Joan, all over the world, from medical school in Michigan to a surgical internship at Stanford, to serving as a gynecology assistant in the U.S. Public Health Service in Alaska. There he treated Native Americans and developed an interest in ancient cultures.
"They taught me about the wilderness. And I realized they seem to be simple, but they have an amazing intelligence. They were just applying it to non-academic issues. When you're with a 10,000-year-old or 40,000-year-old culture, you understand what you are more as a basic human being," said Silber.
After Alaska, they returned to Michigan for his residencies in urology and nephrology. Then, they traveled to the other end of the world, where Silber served as an assistant surgeon at the University of Melbourne in Australia. Returning to the United States, he became vice chairman of the urology department at the University of California, San Francisco.
"We really were traveling minstrels," said Silber. Which begs the question, why did they end up in St. Louis? "My wife is from St. Louis," said Silber with a smile in his voice. And they wanted a family support system for the kids. Silber and his wife, Joan, raised three sons.
Silber met Joan when he served as the teaching assistant in a Shakespeare class she took as an undergraduate at the University of Michigan. Silber's undergraduate degree was in English. "Don't get the wrong idea," he said. "I avoided any kind of fraternization until the class was over," he said. "Then I asked her out."
They were engaged two weeks after their first date. Before the engagement, Joan remembers calling home and telling her parents that she thought she'd met the man she would marry. Having never heard their daughter talk about this man, her parents asked her his name. Joan told them -- Sherman. "They asked for his last name and I said... I'm not sure," said Joan with a laugh.
Joan remembers that their early dates involved Silber drawing diagrams on a napkin to explain a procedure he was doing in the lab and inviting her to visit the lab and observe a surgery. "He was just extremely excited and enthusiastic about the science and the impact it could have," she said. "I loved that. I still love that."
Among the penguins: Silber blends in with the locals in Antarctica.
Work hard, play hard…
When the family moved to St. Louis, Joan set up and ran Silber's office full time for the first 10 years. "We're a very workaholic family," she said. But they also worked hard to spend time together. "We always had family dinner together," said Silber. Afterward, he would return to the hospital, sometimes staying late to get his work done. Silber also coached his sons' soccer teams (see sidebar).
This family may work hard, but that doesn't mean they don't know how to have a good time. On a trip to Antarctica that Silber used to observe the reproductive habits of penguins, the family decided it would be funny for Silber to wear a white tie and tails, in an effort to blend in with the locals. "It wasn't a tuxedo," said Silber, explaining that a tux doesn't have quite the right look. "I wanted to really look like a penguin. I thought it would be an easier way to mingle among them."
Joan laughs when reminded of the adventure. "You couldn't bundle up with it," she said of wearing such fancy clothes in the Antarctic. "You put the underwear on, then the tails, then the snow suit on. It was a whole deal. We had a lot of fun," she said.
…and maintain an inquisitive mind
Silber says he enjoys the outdoors, fly fishing and skiing, as well as traveling to remote locations and meeting with people of ancient cultures, a continuation of the interest he developed when working with the native peoples of Alaska.
Even as he pursues his hobbies, he can't help but ponder issues of fertility. The concept of infertility does not exist among the Hadzi Bushmen in Tanzania, explained Silber. The people of these ancient cultures marry and have their children so young that infertility due to the aging of the woman's eggs is not an issue.
The primary cause of the infertility epidemic in today's modern society is that people are waiting longer to start families, Silber said. "In teenagers, the risk of infertility is 0.2 percent. By the time woman are in their 20s, about 2 percent are infertile." That's quite low, explained Silber, but it's still a 10-fold decline in fertility. By the early 30s, Silber explained, it's at 20 percent.
"I think we're intrinsically born with a desire to have children," Silber said. "In the modern world, we may not realize it until we're in our 30s or 40s. Because of all the opportunities in life, we're putting it off," he said. But as long as doctors like Silber and his collaborators continue their work, there remains hope for child-bearing both after cancer treatment and into later years.