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Infertility is always an important problem for the patient but never
an urgent one. The general attitude is one of “let’s wait and watch”
and let “Nature take its own course”. Since many couples and doctors
know of patients who have conceived naturally after many years of
previously fruitless marriage, they commonly adopt this attitude.
This
approach was acceptable in the past, when there was so little we
could offer in any case for these couples. However today with
recent advances in reproductive medicine, it is no longer acceptable
for many reasons.
1.
Couples
today
marry at an older age. Their biological time clock is running out
and we often need to accelerate events – we cannot sit back and wait
and watch.
2.
Effective treatment is available today to enhance Nature’s
efficiency (or rather its inefficiency in the case of these
couples). This treatment must be judiciously employed, to give
couples their best chance.
It is
worthwhile drawing an analogy to the current management of labour
and childbirth. In older days, when no drugs were available,
doctors were often forced to wait and watch. They could do little
to intervene and it was common for labours to last for over 2-3 days
often resulting in stillbirths and even maternal deaths. With the
advent of drugs like oxytocin and prostaglandins, all that has
changed! Obstetricians now take an active approach to provide a
favourable outcome in a quicker time frame.
Today, unfortunately, the investigation and management of
infertility still leaves a lot to be desired. It is often slow,
time-consuming and costly. The infertile couples are seldom seen
together. Investigations are performed in a piecemeal fashion
rather than as part of an overall strategy. Doctors are also keen
to “do something” and repeated curettages and laparoscopies (done
unnecessarily) are a common feature in the medical history of these
hapless couples. Also, myomectomies may be performed for small
fibroids; ovarian cystectomy and wedge resections done for simple
ovarian cysts which should have been left well alone; as well as
“uterine ventrisuspension” when all else fails. These procedures
commonly induce adhesions and damage a previously normal pelvis.
Both
patient and doctor suffer from the inefficient treatment of this
problem. The doctor feels inadequate and unable to help his
patient, and trust between the doctor and patient breaks down. The
temptation to try many empirical, possibly useless medical
treatments is considerable; and patients often end up spending large
sums of monies at the hands of quacks and “spiritual healers”.
This
is why taking an active success-oriented approach to infertility is
important today.
The
couple must be seen together and treated as a unit. The workup to
establish a diagnosis should be completed in 1 months. The timing
of the procedures is important, and we have found the following
strategy cost-effective.
Semen analysis (during the wife’s
menstrual period)
Blood
tests (Prolactin, LH, FSH, TSH) – Day 3-5;
Hysterosalpingogram-Day 5-7;
Ultrasound for ovulation monitoring and assessing endometrial
thickness and texture – Day 11-16;
Serum progesterone level- Day 21 (7days after
ovulation)
With
this strategy, we can tell patients that we will be able to find out
what the problem is in 1 month and then start treatment.
As
regards the treatment, it is easy not to do anything (“planned
relations” or as the Americans call it, “well-timed intercourse”),or
to continue repeating the same treatment month after month.
Remember that not doing anything is hell for the patient-the waiting
can be agony. You need to keep on progressing to more aggressive
treatment! For example, a reasonable plan for patients with
unexplained infertility may be:
Timed
intercourse, 6 cycles;
Intrauterine insemination (IUI)- 4 cycles;
Superovulation with HMG plus IUI-3 cycles;
then
IVF or GIFT. Don’t waste time! As a rule of thumb, if a treatment
is going to work, it should work in 4 cycles.
While
no one can predict what the out-come of treatment is going to be for
any infertile couple, at the end of it all, they should at least
have the satisfaction of knowing that they tried everything that was
possible.
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