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Infertile couples often come to us for a second
opinion with thick files bulging with the results of numerous medical
tests and investigations. While some of these tests are useful, the sad
fact is that many of these tests are a complete waste of the patient’s
time and money.
Unfortunately, patients have become so used to being
subjected to a battery of tests when they visit their doctor , that they
don’t even stop to question their doctor as to why the tests are being
advised. This means that they often end up having a large number of
tests done, many of which provide no useful information whatsoever in
the treatment of the infertile couple.
Let’s first look at why doctors order so many tests
in the first place . Often, it’s much easier to order a test than to
talk to the patient, which means that many doctors will mindlessly order
a battery of tests in order to make a diagnosis. Also, in many large IVF
clinics, there is a standard “cook-book procotol” of tests which must be
ordered for all patients, irrespective of whether you, as an individual,
actually need the test. Few patients ( or even doctors for that matter)
, question the cost effectiveness or utility of these tests, which are
mechanically performed on a “routine” basis, especially in many US
clinics.
While often this “overtesting” just wastes money,
sometimes it does have more serious consequences. Ordering tests is
easy, but interpreting them intelligently is hard ! Consider the common
example of the presence of “pus cells “ found in a semen analysis. Often
these round cells seen on microscopic examination are actually sperm
precursor cells which are found in normal semen. However, they are very
commonly misreported as “pus cells” and many doctors then promptly label
the man as having a genital tract infection, and treat him with an
endless variety of antibiotics, in order to try to “clear up “ the
infection.
The unreliability of medical tests also poses a
major problem today. The most obvious reason can be attributed to
laboratories whose functioning is marked by factors such as poor quality
control, unskilled manpower and obsolete equipment. There is little
'policing' or retesting, with the result that the needed standards are
not maintained. After all, even a science graduate with a six-month
diploma in laboratory technology can set up a medical lab in some
countries, if he so desires. Most people tend to rush to the nearest
laboratory to get their tests done, but such haste can be a big mistake.
After all, if the laboratory is not reliable, how can you trust its
report? You should try go to the best laboratory possible - your life
can depend upon your test results !
Unfortunately, when infertile patients change their
doctor, many doctors insist on repeating all the tests all over again,
because they do not trust the results of any lab other than their own.
This is very unfortunate, and patients often end up wasting even more
time and money.
Ironically, it is true that sometimes doctors do
tests because the patients demand them. This is very common, for
example, with couples who have unexplained infertility, who often demand
that the doctor continue performing tests till he can accurately
diagnose what the reason for their infertility is. However, while modern
reproductive technology is excellent at solving problems “in vitro “ in
the IVF lab, it’s still not very good at diagnosing them “in vivo “ in
the human body.
What is our approach towards testing our patients ?
We try to simplify testing, by explaining that there are only 4 things
we need to test: eggs, sperms uterus and tubes. The first day the
bleeding starts is called Day 1, and the semen analysis to check the
husband's sperm count and motility can be done can be done on Day 3-4 ,
after requesting him to abstain from ejaculation for at least 3 days .
The wife's blood is then tested for measuring the levels of her four key
reproductive hormones: prolactin, LH ( luteining hormone) , FSH (
follicle stimulating hormone) , TSH ( thyroid stimulating hormone).
Since these levels vary during the menstrual cycle, they should be done
between Day 3-5 of the cycle. We then do a hysterosalpingogram (an
X-ray of the uterus and tubes) for her after the menstrual bleeding has
stopped - between Day 5-7, to confirm her uterus and tubes are normal.
We then see the couple on Day 9 with all these reports and review the
results . These three basic tests allow us to check whether the eggs,
sperm, uterus and tubes are normal.
Here are some of the tests which many doctors will
subject their infertile patients to, which we feel are wasteful and
unnecessary.
1. An endometrial biopsy ( EB ) or D&C (
dilatation and curettage) for endometrial sampling , in order to
“date” the endometrium. This used to be a very popular test, which was
performed routinely in the past, in order to determine whether the wife
was ovulating; and to diagnose a luteal phase defect. This is a painful
and invasive test, which is now considered to be obsolete. The only role
for a D&C today is if the doctor suspects endometrial tuberculosis, a
disease which is now becoming very uncommon.
2. TORCH tests. Certain infections called
TORCH ( which stands for TOxoplasmosis, Rubella, Cytomegalovirus and
Herpes) , may be a cause for a single miscarriage, but are NOT a cause
for repeated miscarriages. While a number of specialists will do these
tests, and even start treatment based on the results, these tests are
not worthwhile for most patients. A positive TORCH test simply means
the patient has positive antibody levels against that particular
infection. Thus, a positive Toxo IgG test means that the patient has
anti-toxoplasmosis antibodies which protect her against a repeat
toxoplasmosis infection. This means a positive test is actually a good
sign and suggests that the patient is protected against that infection
because she has been exposed to that infection in the past.
Unfortunately, many doctors do not know how to interpret these results
and scare the patient into thinking that the positive test result means
she has an active infection which can cause her to miscarry again. In
fact, some doctors will even attempt to "treat" the "infection" ! This
wastes time and causes needless distress. If your doctor asks you do a
TORCH test after a miscarriage, you should refuse and find a better
doctor !
3. Doppler test to check for a varicocele in
the infertile man. In the past, a varicocele was considered to be the
commonest cause of a low sperm count. In fact, this is still a very
controversial area, and many doctors still believe that varicoceles do
cause male infertility, which is why they routinely subject all men with
low sperm counts to a Doppler test, to check for a varicocele. However,
the fact is that many men with large varicoceles have excellent sperm
counts, which is why correlating cause (varicocele) and effect (low
sperm count) is very difficult. It is possible that the varicocele may
be an unrelated finding in infertile men - a "red herring" so to speak.
This means that surgical correction of the varicocele may be of no use
in improving the sperm count - after all, if the varicocele is not the
cause of the problem, then how will treating it help? In fact,
controlled trials comparing varicocele surgery with no therapy in men
who have varicoceles and a low sperm count have shown that the pregnancy
rate is the same – so that it does not seem to make a difference whether
or not the varicocele is treated ! In such a case, why bother to
diagnose a condition which does not need to be
treated ?
4. Sperm function tests. Since all doctors
are aware of the limitations of a conventional semen analysis (there is
often poor correlation between the results of a semen analysis and male
fertility potential) , many tests have been devised to assess the
fertilising potential of the sperm. Many of these tests become
“fashionable “for a few years, and then they disappear when doctors
learn how useless they are. There is a lot of overlap in the results of
these tests in both fertile and infertile men , and many fertile men
will also have abnormal results when subjected to these tests, even
though they have fathered babies ! This is because while these tests do
provide useful information for groups of men in a research study, they
do not provide any useful prognostic information for the individual
patient. This means they often end up confusing a perplexed issue even
more. While tests like the zona-free hamster egg assay were popular a
few years ago, the currently fashionable tests for sperm function are
the Sperm Chromatin Structure Assay (SCSA) and the sperm DNA
Fragmentation assay. These test the integrity of the DNA in the sperm
nucleus, and thus the ability of the sperm to fertilise the egg. Thus,
we know that men with a higher degree of DNA fragmentation have a higher
chance of being infertile. However, they do not provide any useful
information for the individual patient, which means their utility in
clinical practise is very limited.
5. Laparoscopy. Many doctors routinely
perform a laparoscopy for infertile women, and we used to do so
ourselves until a few years ago. However, we have now stopped doing so,
for the simple reason that we do not think it is cost effective to
subject all infertile women to this invasive surgical procedure. We use
a HSG ( hysterosalpingogram, X-ray of the uterus and tubes) to determine
if the fallopian tubes are normal or not, because this is much less
expensive and does not involve surgery. What about the argument that we
may miss the diagnosis of mild endometriosis or peritubal adhesions on
the HSG ? This is true, but since there is no evidence that treating
mild endometriosis or removing peritubal adhesions at the time of
laparoscopy helps to increase fertility, we feel we are justified in our
decision not to subject our patients to this surgical procedure on a
“routine “ basis. Moreover, since the next step in our treatment of
women with a normal HSG is IUI ( intrauterine insemination) , the
results of the laparoscopy do not affect our treatment plan at all. The
fact is that the “yield “ of routine laparoscopies in infertile women
is very low, since the vast majority are normal, and this should also
cause doctors to re-think their old-fashioned approach to performing
laparoscopies mindlessly for all infertile women.
6. PCR for endometrial TB. This test has
become very fashionable in India, where endometrial tuberculosis ( TB)
is still a cause of female infertility. The gold standard for making a
diagnosis of endometrial TB is culturing the tubercle bacilli from the
endometrial curettings; or finding tubercle granulomas on
histopathological examination of the endometrial curettings. However,
it’s easy to miss the diagnosis of TB with these conventional tests, as
a result of which doctors were very excited when the technology of PCR
was introduced to aid in the diagnosis of TB. PCR ( polymerase chain
reaction) is a genetic technologic tool, which allows the lab to amplify
very small quantities of DNA fragments which are unique to the tubercle
bacillus, thus allowing doctors to make an early diagnosis of TB.
Unfortunately, the test is still not robust, reliable or standardized,
with the result that there are many “false positives” – women who do NOT
have endometrial TB, but still have a positive PCR test, because it was
done improperly. Many of these women are then even subjected to 9 months
of unnecessary anti-TB treatment , messing up their unhappy lives even
more !
7. Immune testing for patients with repeated IVF
failures and repeated miscarriages .Patients who have failed
repeated IVF cycles even though apparently perfect embryos were
transferred, are understandably upset, frustrated and distressed. They
are looking for answers as to why they are not getting pregnant, and a
plausible reason is that their body is “rejecting” their embryos. This
is why immune testing for patients with reproductive failure has become
very fashionable recently. There is a long list of expensive tests which
many labs now perform – and these include: DQ Alpha, Leukocyte Antibody
Detection, Reproductive Immunophenotype, ANA (Antinuclear Antibody),
Anti-DNA/Histone Antibodies, APA (Antiphospholipid Antibodies), Natural
Killer Cell Assay and TJ6 Protein. This mind –boggling range of catchy
acronyms conceals the fact that no one knows whether the immune system
is really responsible for the failure of the embryos to implant in these
women. Many labs use different protocols to carry out these tests, which
are still poorly standardized. This means that results for the same
test from different labs vary widely, making interpretation very
difficult. Also, intelligently interpreting these tests in individual
patients is virtually impossible, because of the considerable overlap in
the results in normal fertile women and those who are infertile, since
many fertile women will also have abnormal results when subjected to
these tests. Sadly, most labs do not bother to standardize their test
results by doing them on normal fertile women. This means that if a
woman who has had an IVF failure is subjected to these tests and has an
abnormal result, her doctor happily jumps to the erroneous conclusion
that he has now “diagnosed “ the reason for the IVF failure, little
realizing that the abnormal result could just be a “red herring”, since
“abnormal “ results are often found in “normal “ fertile women as well.
( These are called “ false positives “ - test results which are
abnormal ('positive'), even though the patient has no disease. ) A false
positive result causes needless anxiety, and will often lead to a
situation in which the patient will have to undergo even more tests to
prove or disprove the previous results. Remember that if your doctor
performs enough tests on you, it is a mathematical certainty that he
will find something wrong with you. And if he finds something wrong with
you, he'll usually end up treating you - whether you need treatment or
not !
Interestingly, just like over-testing can lead to
problems, we have also noted that under- testing can be equally
problematic ! Thus, we have seen many men who have been advised to
undergo IVF treatment, based on the report of just a single semen
analysis report, which was abnormal. It is essential that the semen
analysis be repeated, after a period of 4- 6 weeks, to confirm that the
abnormality is persistent, because sperm counts do vary considerably,
even in normal men.
You should also make sure that your doctor examines your original scans
and X-rays, and not just the reports, because his interpretation may be
different from the radiologist's. If you have undergone a series of
scans, they should be arranged in chronological order, so that the
doctor can compare them easily.
Here's a checklist of questions you should ask your doctor when a test
is recommended:
· Why is the test being ordered?
· How definitive is the test? Is it the 'gold standard' for making the
diagnosis? Will it reveal for sure that a condition is present or not,
or must it be repeated or followed by more sophisticated tests?
· What precisely will the doctor be looking for in the results of these
tests? What does he hope to learn from the tests? How accurate are they?
Other relevant questions are as follows:
· Is there any pain? What are the side-effects? What
are the risks?
· Is this the best test for your problem? Tests are big money spinners
today, because of which many doctors have fallen victim to 'testitis';
(a disorder in which doctors go in for all the tests available instead
of the most appropriate one!)
· What is the risk of not having the test done, and what are the
alternatives?
The single most important question you must ask is –
“ How will the result of the test change the course of my
treatment? “ And if the answer is that it really won't, then
maybe you don't need the test at all !
In the final analysis, remember that medical tests
can be very helpful in pinpointing your problem, but they need to be
used wisely and well; after all, doctors do not treat abnormal test
results, they treat patients !
Here is a checklist which highlights the important factors you need to
consider before in for a medical test.
Medical Test checklist
Test name _____________________________________________
Description ____________________________________________
Purpose ______________________________________________
To confirm diagnosis?___________ Diagnosis _______________
To exclude diagnosis? ___________ Diagnosis ______________
Where will the test be done? Clinic? _________
Independent lab?________ Hospital? _________
Cost of test in: Clinic _______ Independent lab ________
Hospital _______
Are there risks associated with the test (i.e., is the test invasive)?
___________
If yes, what risks? _____________________________________
Are there less invasive tests that might give the same
information? ___________________________________________
If the test result is abnormal what will be done next? __________
If the rest result is normal what will be done? _______________
COMMENTS ______________________________________
________________________________________________
__________________________________________________
You should fill out this checklist for every medical
test suggested.
The more invasive or expensive a test is, the more important this
checklist becomes.
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