Low FSH, Low-normal Test, Low libido, ED Problems

Hi Matrix. Was able to send the message, but only so far. It says you've exceeded your private message storage or something of the sort.
 
cleared
 
Update:

This is rather odd and surprising, but the past week or two I've had no problems getting hard without cialis, I've been waking up with good morning erections every morning, and I have a libido again. Orgasms are still slightly weaker than they used to be, but I'm happy to be making progress. Problem is, I have no idea what I did, I don't think I even changed anything. I will continue to only supplement with multi, fish oil, and vitamin d and see if i continue to make progress. I will not be doing another run of clomid soon since I seem to be making progress without it. I will probably retest bloods in another 4 weeks or so.
 
TML499: I am having a very similar issue to yours. After PCT my LH and tes returned to normal but my FSH stayed alarmingly low and I am having symptoms indicative of that. I can't PM yet because I am new to the forum.
 
^ Well actually my LH is low too (usually) and my test is low for my age as well (low-normal). I am not so sure the low FSH is what was causing any of my sexual problems, which have been somewhat alleviated and I'm not really sure why. I'm currently just waiting right now till I see a urologist in July, since my drive was getting better and I don't really feel like **** all the time. Do you have some bloodwork? You should start your own thread, I'll take a look at it and so will others I'm sure.
 
TML499 said:
^ Well actually my LH is low too (usually) and my test is low for my age as well (low-normal). I am not so sure the low FSH is what was causing any of my sexual problems, which have been somewhat alleviated and I'm not really sure why. I'm currently just waiting right now till I see a urologist in July, since my drive was getting better and I don't really feel like **** all the time. Do you have some bloodwork? You should start your own thread, I'll take a look at it and so will others I'm sure.
Click to expand...

Well shortly after you Clomid cycle you stated your LH was up but the FSH remained low. This is my case. My LH is 5.6 and my FSH is .08. My libido has gotten significantly better but I am still have other issues.
 
PHANTOMRIDER said:
Well shortly after you Clomid cycle you stated your LH was up but the FSH remained low. This is my case. My LH is 5.6 and my FSH is .08. My libido has gotten significantly better but I am still have other issues.
Click to expand...

Are you still on the clomid? Near the end of my clomid run my TT was 640 but I had 0 libido, I think it was the clomid itself causing that. Recently I've had a better libido than when I was on clomid and now my TT is probably around 350-400. I don't think low FSH by itself will cause any sexual issues (besides worse sperm production) but I could be wrong.

Update: Still have an existent (but not great) libido, and the ability to get erections without cialis (but not rock hard ones). Orgasms are still slightly weak, energy is OK not great. I am either staying in the same place or improving. I will get bloods done again in late may, and if things look like I expect them too I will schedule the urologist appointment for june.
 
I have a question about varicoceles. By what mechanism would they cause a drop in testosterone? Logically I would think it would cause primary hypo (affecting the nuts functioning) and cause elevated LH. My problem seems to be secondary hypo, so is there any chance varicoceles could potentially decrease my LH leading to the T decrease? Or is this unlikely? I'm going to have my URO check for one when I go in.
 
Went in for bloods checkup yesterday. Numbers are about the same, although I'm not having the ED hardly ever, and libido is still there but not very good. Can anyone guess why my bilirubin might be so high?

Bilirubin: 2.1 (0-1.2)
Test: 341
LH 1.6
FSH 0.6
E2: 26.6
 
TML499 said:
Went in for bloods checkup yesterday. Numbers are about the same, although I'm not having the ED hardly ever, and libido is still there but not very good. Can anyone guess why my bilirubin might be so high?

Bilirubin: 2.1 (0-1.2)
Test: 341
LH 1.6
FSH 0.6
E2: 26.6
Click to expand...

Yep choleostasis is possible
Your not detoxifying bile properly through the liver
Gilberts is common as well
Bottom line your liver needs addressing majorly
 
The Matrix said:
Yep choleostasis is possible
Your not detoxifying bile properly through the liver
Gilberts is common as well
Bottom line your liver needs addressing majorly
Click to expand...


Interesting. I will look into this. My ALT and AST on this blood test were only 20 and 23 respectively, and they always seem to be down there. My bilirubin is sometimes just above the normal range, this was the highest I've seen it even compared to when I would get bloods done at the end of PCT when i cycled.

When I have my first visit with a urologist in June i will be sure to mention the digestion issues I seem to be having based on the bilirubin and my very common morning diarrhea.

Edit: Do you have any input on this question?

"I have a question about varicoceles. By what mechanism would they cause a drop in testosterone? Logically I would think it would cause primary hypo (affecting the nuts functioning) and cause elevated LH. My problem seems to be secondary hypo, so is there any chance varicoceles could potentially decrease my LH leading to the T decrease? Or is this unlikely? I'm going to have my urologist check for one when I go in."
 
TML499 said:
Interesting. I will look into this. My ALT and AST on this blood test were only 20 and 23 respectively, and they always seem to be down there. My bilirubin is sometimes just above the normal range, this was the highest I've seen it even compared to when I would get bloods done at the end of PCT when i cycled.

When I have my first visit with a urologist in June i will be sure to mention the digestion issues I seem to be having based on the bilirubin and my very common morning diarrhea.

Edit: Do you have any input on this question?

"I have a question about varicoceles. By what mechanism would they cause a drop in testosterone? Logically I would think it would cause primary hypo (affecting the nuts functioning) and cause elevated LH. My problem seems to be secondary hypo, so is there any chance varicoceles could potentially decrease my LH leading to the T decrease? Or is this unlikely? I'm going to have my urologist check for one when I go in."
Click to expand...

Those blood results will not show true functionality of liver. Had case where woman was non knowing stage 3 cirrhosis with high normal liver enzymes. Suggest to her to get Ultrasound from Dr. She finally convinced him to do it.Dr was shocked it confirmed my suspections because symptoms where obvious but drs where going by labs instead. This is common what I deal with on daily basis. Since I am not a Dr I just made the recommendations for her to suggest to Dr to.get ultra sound done. Do not let normal blood levels be the be all..
 
The Matrix said:
Yep choleostasis is possible
Your not detoxifying bile properly through the liver
Gilberts is common as well
Bottom line your liver needs addressing majorly
Click to expand...

My guess aswell
Get some UDCA
No orals and GTG

50mg clomid ED for 30days always recovered me fine. From every cycle No sides sept huge loads:)
Tot T always returned to 600-700
 
Neoamerican said:
My guess aswell
Get some UDCA
No orals and GTG

50mg clomid ED for 30days always recovered me fine. From every cycle No sides sept huge loads:)
Tot T always returned to 600-700
Click to expand...
I did that one time made me a crying freak. Times have changed and so has proper jump start procedures. Glad it worked but less is more with. Clomid
 
Neoamerican said:
My guess aswell
Get some UDCA
No orals and GTG

50mg clomid ED for 30days always recovered me fine. From every cycle No sides sept huge loads:)
Tot T always returned to 600-700
Click to expand...

Yeah clomid brings me to 600-700 too but after I stop taking it I drop back down to 3-400. I think I need to sort out everything else first (the liver etc) before i attempt another "restart." I haven't met my urologist yet, but if he isn't proactive in helping me i may use it at 12.5 EOD just to improve overall mood and quality of life until I can get some real solutions.
 
TML499 said:
Yeah clomid brings me to 600-700 too but after I stop taking it I drop back down to 3-400. I think I need to sort out everything else first (the liver etc) before i attempt another "restart." I haven't met my urologist yet, but if he isn't proactive in helping me i may use it at 12.5 EOD just to improve overall mood and quality of life until I can get some real solutions.
Click to expand...

Following this approach has led to greater success rate. You are trying to build a mansion with a crappy foundation and its only going to crumble. One needs to create the optimal environment for a restart to occur by many medical professionals only look at it one sided. I prefer to look at things 3-dimensiob in the approach suggested to drs. This approach is to encompass all the systems working in harmony to get optimal health benefits on a multi level scale.
 
Update: I found out one of my parents has always had bilirubin usually above range as well. I think I might have Gilbert's after hearing this, but my other parent isn't sure if they have it and it sounds like it is recessive. I will be sure to bring this up with the urologist, first appointment is in a couple weeks. Also going to mention the problems I've been having with my digestive system.

Also, when I go to see the urologist, I am going to bring in the bloodwork done by my primary care doctor, but this is very limited bloodwork (only really shows T, bilirubin, CBC and some other stuff). Should I also bring in bloodwork I have gotten done privately at private md labs/labcorp? Or do they usually frown upon this/discard this? This will show him my depressed LH and FSH levels and even higher bilirubin. I imagine he would do testing soon after and find this stuff out anyways but can it hurt to give the process a jumpstart by bringing in the labcorp labs?
 
TML499 said:
Update: I found out one of my parents has always had bilirubin usually above range as well. I think I might have Gilbert's after hearing this, but my other parent isn't sure if they have it and it sounds like it is recessive. I will be sure to bring this up with the urologist, first appointment is in a couple weeks. Also going to mention the problems I've been having with my digestive system.

Also, when I go to see the urologist, I am going to bring in the bloodwork done by my primary care doctor, but this is very limited bloodwork (only really shows T, bilirubin, CBC and some other stuff). Should I also bring in bloodwork I have gotten done privately at private md labs/labcorp? Or do they usually frown upon this/discard this? This will show him my depressed LH and FSH levels and even higher bilirubin. I imagine he would do testing soon after and find this stuff out anyways but can it hurt to give the process a jumpstart by bringing in the labcorp labs?
Click to expand...

High bilirubin I suggest people to get more sun because it used to help break it down. Probably have bile acid conjugation issues which can result in thicken bile production.
 
Update: So i saw the urologist today. He basically took down all of my symptoms and checked for structural problems (varicocele, etc). I showed him the bloodwork from my primary care doctor showing low testosterone. He referred me to both an endocrinologist and a gastroenterologist for the digestion issues, both of which I will be seeing sometime in the coming month. Frustrating I have to wait again with no additional testing, but I'm optimistic that they are at least looking at my problems from multiple angles.
 
TML499 said:
Update: So i saw the urologist today. He basically took down all of my symptoms and checked for structural problems (varicocele, etc). I showed him the bloodwork from my primary care doctor showing low testosterone. He referred me to both an endocrinologist and a gastroenterologist for the digestion issues, both of which I will be seeing sometime in the coming month. Frustrating I have to wait again with no additional testing, but I'm optimistic that they are at least looking at my problems from multiple angles.
Click to expand...

Gi specialist - good for looking up your ass for structural issues other wise useless.
Endo - going to be waste of time 90% of them are.
 
Good thread. It seems the Clomid did what it was supposed to do in your case. I am using Clomid now at 25mg daily for TRT/HRT as I can't afford test. But it seems to work for people....The "crash" or how your body responds to coming off is the most troubling. I think tapering off will do you fine. Your blood work dictates that the clomid "worked" - which is great.

As for low FSH...I suffer from it too...and hypogonadism.

Maybe Gonadtrophins could be used to help stimulate the production of sperm / FSH?

Chris
 
Another thing I"m curious about is if FSH (although it works directly with sperm production) - if its low or low normal can affect your libido or sex drive (which is the problem I've had going for years....)

My LH and FSH have fluctuated...LH being low normal which in turn will not produce as much TEST.

But I'm curious is anyone with just low / low normal FSH and everything else normal (low test and LH) have problems with sexual function....
 
Bump, have some appointments in the next week or so.

Matrix I do have a question about the relationship between the GI tract and T levels. My LH and T are typically around 1.5 and 350. When my LH goes up (to around 5.0 or so via clomid) my T goes up (to around 650). Would fixing an unfit GI tract just cause my body to produce more T given the amount of LH I have? Because I seem to be producing appropriate amounts of T per the LH available. Or rather, would fixing up the GI tract actually cause my pituitary to secrete more LH? Because if not there may not be a lot to be gained from being secondary and fixing my GI tract.

I assume the benefit in fixing up the gut would be improved nutrient absorption and balance. But does this affect the bodies ability to produce LH and FSH, or does it rather affect the process of making T with your given LH levels?
 
TML499 said:
Bump, have some appointments in the next week or so.

Matrix I do have a question about the relationship between the GI tract and T levels. My LH and T are typically around 1.5 and 350. When my LH goes up (to around 5.0 or so via clomid) my T goes up (to around 650). Would fixing an unfit GI tract just cause my body to produce more T given the amount of LH I have? Because I seem to be producing appropriate amounts of T per the LH available. Or rather, would fixing up the GI tract actually cause my pituitary to secrete more LH? Because if not there may not be a lot to be gained from being secondary and fixing my GI tract.

I assume the benefit in fixing up the gut would be improved nutrient absorption and balance. But does this affect the bodies ability to produce LH and FSH, or does it rather affect the process of making T with your given LH levels?
Click to expand...

By addressing GI tract you address vast majority of the immune system and neuotransmitters in the body which addresses the adrenal glands all the way up the chain. By reducing inflammation on the HPTA in general is important for over all health in general..
 
Update: So I had appointments with a GI doctor and an endo.

GI doctor started with stool samples, ruling out parasites/bacteria. He ordered these tests:
Celiac's Disease (I didn't have a wheat allergy)
Sedimentation Rate (ESR)
Comprehensive Metabolic Panel (My Glucose was low, 54 out of 70-100 this time. Last time when I wasn't fasted it was over 100)
TSH 0.73
C-Reactive Protein
CBC
Heliobacter AG, stool
culture, stool
clostridium difficile A & B Toxin
Leukocytes, fecal smear
Giardia AG

Everything came back negative. I think next I'm going to have a GI scan or something.

The endo ran new bloodwork to see my test levels in the morning and see my LH and FSH levels which weren't on the first text my primary doctor did.
TT: 278
FT: 81
LH: 1.8
FSH: 0.6
Prolactin: 16.7 (2-17)

Testosterone was about 50-100 points lower than usual but I think it might be because the bloods were drawn a week after a long vacation that involved much more drinking than normal for me. The only time I ever got prolactin tested before it was 9. He also tested iron, iron binding, and iron saturation, which were all fine.

He says the next step is a pituitary MRI and a sleep study. He says my hemoglobin is elevated (16.7, always around the upper range), so he thinks I may have sleep apnea.

Edit: I also have noticed that as of late I am getting restless leg syndrome more frequently than I have in the past.
 
Update: Results from the sleep study. I don't have sleep apnea. I did mention that I had been getting restless leg syndrome at night. I have a pituitary MRI coming up in the next week or so.

PROCEDURE:
This attended polysomnogram montage using Compumedics Profusion 3
Software included recorded video, 6 EEG electrodes for frontal,
central, and occipital monopolar recordings, 2 EOG electrodes,
ECG, and chin EMG electrodes, snoring microphone, thermistor,
airflow pressure, thoracic, and abdominal respiratory effort,
pulse oximetry, leg movement, body sleeping position, and body
movement. The 30 sec. epochs were scored according to The AASM
Manual for the Scoring of Sleep and Associated Events: Rules,
Terminology and Technical Specifications (2007).

SLEEP SCORING DATA:
Lights Out / On (clock times): 22:59:45 / 05:09:46
Total Recording Time (TRT) (min): 370.0
Total Sleep Time (TST) (min): 250.5
Sleep Efficiency: 67.7%
Sleep Latency (min): 59.5
Stage REM Latency (min): 77.0
Wake after sleep onset (WASO) (min): 60.0

Stage N1 Sleep (min, % of TST): 10.0 (4.0%)
Stage N2 Sleep (min, % of TST): 106.0 (42.3%)
Stage N3 Sleep (min, % of TST): 88.0 (35.1%)
Stage R Sleep (min, % of TST): 46.5 (18.6%)
Supine Sleep (min): 128.5
Arousals (index, #): 10.5 (44)

RESPIRATORY ANALYSIS: (index = #/hr)
Apnea/Hypopnea Index (AHI): 0.2
NREM AHI: 0.3
REM AHI: 0.0
Non-Supine AHI: 0.0
Supine AHI: 0.5

Respiratory Disturbance Index (RDI): 2.6
NREM RDI: 1.8
REM RDI: 6.5

Apneas (index, #): 0.2 (1)
Obstructive Apneas (index, #): 0.0 (0)
Mixed Apneas (index, #): 0.0 (0)
Central Apneas (index, #): 0.2 (1)
Hypopneas (index, #): 0.0 (0)
RERAs (index, #): 2.4 (10)

Mean Awake SpO2: 96%
Mean Sleep SpO2: 96%
Minimum Sleep SpO2: 92%
Sleep Time with SpO2 < 88% (min, % of TST): 0.0 (0.0%)

Cheyne Stokes breathing: No
Snoring:

CARDIAC ANALYSIS:
Mean Awake HR: 58
Mean Sleep HR: 58

Bradycardia: No
Asystole: No
Sinus tachycardia: No
Narrow Complex Tachycardia: No
Wide Complex Tachycardia: No
Atrial Fibrillation: No
Other: None

LIMB MOVEMENT ANALYSIS:
Periodic Limb Movements of sleep (PLMS) (index, #): 22.5 (94)
PLMS with arousals (index, #): 1.2 (5)

OTHER ABNORMALITIES:
No other unusual body movements were demonstrated and no seizure
activity was noted.


CLINICAL INTERPRETATION:

1. Periodic Limb Movements of Sleep. These limb movements,
however, did not occur throughout the night. Instead, they
occurred during two blocks of time, one at 2 AM and another at 5
AM. The patient was sleeping on his right side during both of
these periods.


RECOMMENDATIONS:

1. Clinically significant obstructive sleep apnea was not
observed on this night

2. During this recording, periodic leg movements of sleep (PLMS)
were noted. After adequate management of patient’s
sleep-disordered breathing, clinical correlation is recommended
to determine whether he might benefit from treatment of the PLMS.
Screening for the restless legs syndrome (RLS) could be
beneficial (as the patient endorsed limb symptoms on the patient
questionnaire). Serum ferritin levels ( < 50 ng/ml are
associated with RLS/PLMD), BUN, creatinine, and TSH may be
evaluated to exclude subclinical iron deficiency, thyroid
dysfunction or renal disease contributing to RLS/PLMS/PLMD.
Antidepressant medications can also worsen PLMS. An empiric
trial of a dopamine agonist (e.g. ropinirole or pramipexole) can
be considered for primary RLS/PLMD.

3. Unless we have instructions to the contrary, we usually
recommend that the patient discuss the results and treatment
options with the referring physician.
 
Update: MRI scan shows that my pituitary is normal. The scan also showed some cysts/polyps in my sinuses, which makes sense, i feel like i am chronically stuffy.

The gastro stool results came back normal, and now he wants to do a colonoscopy. I really doubt that will "reveal" anything or help at all.

Anyways, my endo messaged me after the results came in. He suggested I go visit him again to discuss beginning testosterone treatment. I assume this means TRT. I also assume it is quite understandable that I do not want to yet jump on TRT at my age (22) without exploring other areas besides just a sleep study and pituitary MRI (GI, etc). I will tell him this at the appointment, and if he does not have another direction to go in... well matrix you may be receiving that call from me soon.
 
Update: Had a follow up to sleep study and MRI with my endo. He was surprised I didn't have sleep apnea since my hemoglobin was high, and wants to send me to a hematologist consult (he wrote the word polycythemia, I don't know what that is.) He also wants me to do a bone density test, I think he is having me do these things because they are issues that TRT can cause.

I mentioned to him that at this point I was more concerned for looking for a cause than hopping on TRT at a young age. He said that most causes actually are of the unkown variety. I told him about my concerns with my diet (not very many fruits or veggies), but he says something like that can't cause low testosterone. Starting to feel like im running in place now.
 
Bump: Well I have moved away for school again, and I decided to do a privatemdlabs blood draw to see where I was at, since my last draw showed 275 or so test, and first thing am i am usually 340-380. I basically wanted to see if the last draw was a fluke due to a vacation beforehand, or things were getting worse. Some numbers:

Test: 381
Estradiol: 25
LH: 1.1
FSH: 0.6

So basically, it seems things are not getting worse which is comforting.

BUN: 24 (6-20)
Creatinine: .75 (.76-1.26)
BUN/Creatinine Ratio: 32 (8-19)

Don't know if that means anything? I think I was actually taking creatine less frequently when this blood was drawn.

Anyways, since I'm probably going to go on 12.5mg clomid EOD for this quarter of school now to improve how I feel, although I am not feeling "terrible" per say I definitely don't feel close to 100%.

Anyone still checking in on this thread? Matrix you still here? I think I'm planning to call you soon, if it's still ok with you.
 
TML499 said:
Bump: Well I have moved away for school again, and I decided to do a privatemdlabs blood draw to see where I was at, since my last draw showed 275 or so test, and first thing am i am usually 340-380. I basically wanted to see if the last draw was a fluke due to a vacation beforehand, or things were getting worse. Some numbers:

Test: 381
Estradiol: 25
LH: 1.1
FSH: 0.6

So basically, it seems things are not getting worse which is comforting.

BUN: 24 (6-20)
Creatinine: .75 (.76-1.26)
BUN/Creatinine Ratio: 32 (8-19)

Don't know if that means anything? I think I was actually taking creatine less frequently when this blood was drawn.

Anyways, since I'm probably going to go on 12.5mg clomid EOD for this quarter of school now to improve how I feel, although I am not feeling "terrible" per say I definitely don't feel close to 100%.

Anyone still checking in on this thread? Matrix you still here? I think I'm planning to call you soon, if it's still ok with you.
Click to expand...

Yes I see a few factors which are red flags.
Low creatine --> methylation issues BIG TIME..
Bun being elevated that high not so good unless you where dehydrated.
I agree it was secondary, but you need to back fill metabolic pathways address immune system, GI, other detoxifcation pathways.
If you can not properly detox you will decrease inflammation ....end of story..
 
First off, sorry, I try to separate this into paragraphs and the board keeps bunching everything up.Ok guys first update in a while, I've been focusing on studies this fall but I do have an update.I decided to run clomid at 15mg EOD this quarter to see if it could improve mood/wellbeing etc. I am about to stop the clomid and I decided to get some bloods done to see if it did much, since it didn't exactly feel like it did. Results:Test: 679LH: 3.6FSH: 0.9 (low still)Estradiol: 45 (a little high)So it seems that running at a lower dose (as opposed to a higher dose like I have done before) results in my LH and FSH numbers not being boosted as high, but my test still falls right around the 600-800 range that is the target. The bad news is that I did not expect to see numbers that high. Just like when I ran clomid at a higher dose, I did not notice much improvement in the ED or Libido departments (still needed a little cialis to get/maintain good erections), and I again did not feel like I had high testosterone.It is frustrating because it seems the main problem is that my pituitary doesn't make quite enough LH (boosting from 1.5 to 3.6 raises test from 350 to 680), yet clomid for some reason does not provide me with the tangible benefits of high test (have heard about it interacting with estrogen receptors in brain, etc). I wonder if it would be worth trying out nolva or torem? Or maybe add in an AI like erase or aromasin? This is not a long term solution, just something I've been self administering to try to improve my condition while I wait for proper/better care. Or would it be just as fine to jump on TRT (the androgel my doc was proposing) until being properly evaluated? When I head home for the holidays, I have several more doctor appointments scheduled, one with hematology because my endo wants to look into why my blood is thick (high hematocrit, but usually still in range, he already ruled out apnea), as well as do a bone density test. However I believe both of these tests are to determine if TRT is safe/optimal to use on me, and I do not know if this is the road I want to go down yet at only 23 years of age. That being said I plan to give matrix a call when I'm home and have the time. I am tired of running in place and want some answers.Edit: Should I look into getting my fertility looked at with such terrible FSH numbers? I have no idea why it is so low, can something cause this?
 
i feel you man, hope you can finally find out the cause...

i think a lot of people can commiserate with what you're going through
 
TML499,
I now have capability to have Dr run blood work through insurance for further evaluation not a diagnosis. It has helped target nutritional recommendations and findings to present to an.open minded medical professional for.proper treatment if.needed
 
Well I had a very frustrating doctor appointment recently. I had to visit a new PCP thats related to my current health insurance and he was condescending and trying to argue with me that I didn't actually have a problem without even having my medical records yet. He cited that I had a beard and muscles, what a joke. Although my endo seems to be pretty clueless himself, at least he was concerned and trying to help.

BTW, Matrix could you check your PMs? Been trying to contact you but haven't gotten a response.
 
TML499 said:
Well I had a very frustrating doctor appointment recently. I had to visit a new PCP thats related to my current health insurance and he was condescending and trying to argue with me that I didn't actually have a problem without even having my medical records yet. He cited that I had a beard and muscles, what a joke. Although my endo seems to be pretty clueless himself, at least he was concerned and trying to help.BTW, Matrix could you check your PMs? Been trying to contact you but haven't gotten a response.
Click to expand...
TML499 try me again..
 
Well I met with a new doctor today and it went much better. He was very open minded into looking for root causes. Matrix I'll be PMing you shortly with more information.
 
Awesome. I.am also.doing peer to.peer consults with doctors on.cases
 
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