Fertility treatments: why haven’t you recommended it before?

By Dr. Raúl Olivares.

This is one of the questions that fertility consultants hate the most. But unfortunately this question is made too often. Infertility has one major problem, it may take long to get to the diagnosis and sometimes you only can get it after the couple has undergone several treatments and you’ve gathered enough information to conclude what’s going wrong. It’s really time-demanding, and most of the time the couple has almost run out of time, or simply they’ve decided that they want a child… now!

Moreover, we deal with the problem that some tests can only be done during certain moments of the cycle, which can make the waiting for the couple unbearable.

But our responsibility as doctors is to recommend those tests that are going to provide useful information and to avoid unnecessary (and most of the time expensive) tests.

And these recommendations should be made according to the principle that in medicine “the most common is the most frequent”. Therefore the set of tests that are initially done are very well known to most of the patients (blood tests to check hormones, scans, spermiograms and tests to asses the tubal patency). If you’re “lucky” one of these tests will turn out abnormal and you’ll have the diagnosis and the treatment that should get rid of the problem. But, what happens if all are normal? Then you’ll have to decide whether it’s time to start treatments or to search further.

Obviously the decision has to be made based on one’s own experience and on the odds of getting useful information. For example, should we recommend tests to assess the genetics of sperm if the spermiogram is normal? We have evidence that even though normal sperm can carry meiotic errors, the chances are less than 1%. So don’t dare to tell the man that you’re going to perform a small biopsy in his testicles during the first appointment unless it’s absolutely necessary. But after two unsuccessful IVF cycles in which everything has been normal (oocyte quality, fertilization rates, embryo morphology…) the chances of having those genetic abnormalities in the same sperm grow up to 40%. Then is when it’s worth recommending the test, though the patients may ask you why haven’t you recommended it before? They’ve spent time and money only to undergo a new diagnosis test.

(At this point I’d like to comment that sometimes an IVF cycle itself should be considered as a diagnosis test. It gives us information about the quality of the eggs, the fertilization rate and the embryo characteristics. We don’t have any other way to gather this information. Besides, it can be successful in a good percentage of cases.)

So, how can all these situations be avoided? It is easy; spending time discussing the options with the patients, even those ones that you think are unnecessary right now. Give information. Tell them that there are more tests that can be done but not at that moment. Explain why those tests should be done later. Take the lead and try to cover the maximum possibilities. This investment of time is going to save you from a later loss of confidence on your expertise. If you give couples a route-sheet of what this journey can be, they are going to feel fully informed, and when you later recommend the necessary tests, they are going to be already aware of that possibility and there won’t be any conflict at all.

I think that there are two main streams regarding what doctors think that the patients want us to do. Some of us think that they want us to decide any aspect of the treatment because we’re the experts. We belong to the other stream. And luckily the number of doctors who provide the patients with enough information, allowing them to share with us the decision of what they want to do, is constantly growing. And believe me, if you belong to this group, if you take your time to make the couples understand the whys and wherefores of your decisions, you’ll seldom have to answer to “the same old question”. 

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