Friday, November 21, 2008

What Infertility Tests are REALLY Necessary?

Ok, I can't get enough! That radio show was so informative that I had to listen to another one this afternoon. This one is also VERY relavent because we are trying to decide next steps. My first thought was that we try and figure out what test are critical and get them done with our OB now, before moving on to an RE. After listening to the show and what the doctor had to say, I definitely am thinking of things a little differently. Please note that the notes below that I've taken are my (hopefully close) interprutation of the thoughts expressed by Dr. Dlugi and should not be taken verbadem. Please refer to the show to draw your own conclusions on what he has to say. The show can be found here.

Avoiding Unnecessary Testing and Treatments, Hosted by Kim Hahn talks to Alexander Dlugi, M.D., SIRM New Jersey. Dated 3/27/08. (located in the scrollable column on the left-hand side).

Which diagnostic tests are necessary before beginning advanced infertility treatments?

Male Tests
Semen analysis (key because 40% of infertility are male related, 10% combined factor). DNA testing of semen doesn't matter all that much, but costs a lot. FWIW, we don't know a lot about sperm because most types of testing kills the sperm. Infertility centers are probably doing it the same way (rather than a one-off lab), and is of good quality and understands results well. One-off labs are more unreliable. Can a semen analysis change with time? Depends on the situation. Results will fluxuate for sure, but if you find signifigant abnormalities, it will probably still be present. Retesting is sometimes encouraged.

Female Tests - "Old-Fashioned" (thru 80s to early 90s) Standard Testing...

1) HSG (hystosalopingogram - used to look at uterus and tubes).
2) post coidal test (cervical mucus, are sperm getting there)
3) endo bioposy (uterine lining changes) not done much anymore
4) laporsocopy (look inside pelvis and perform surgery if needed). Everyone got testing and then tailored treatment according to results.
5) Basal Body Temps (BBT) - To track ovulation.

Of these, it depends on couples history and what they are willing to consider (IVF, etc). If they're not willing or want to do IVF, then yes, it makes sense to do some of the below.

Thoughts about Diagnostic Testing and What is Actually Helpful

1) HSG: Hystosalopingogram - Used to look at uterus and tubes. Make sense to do.

However, if there is a problem found with an HSG, here are the senerios:
a) Uterus (polip, fibroid, etc) - fix is surgical
b) Tubes - surgery to fix tubes or IVF

10 years ago, recommendation would have been to operate, but because IVF rates are so high these days, that is the way to go. With the surgery, there is recovery time and it takes 1-2 years after surgery to be able to get pregnant, typically, and these problems also will come back. Therefore, surgery doesn't make much sense unless there is a mass or there is pain. Then it's totally different. If for fertility, there isn't much point.

2) Post Coidal Test: Checking cervical mucus to see if are sperm getting to uterus. Not done much anymore.

Problem with this one - you don't really know what the definition of "normal" is. Is a role where a couple uses clomid because it could dimish CM and make it hard to get pregnant. It's good to get one of these done at least to see what findings are. If test is abnormal, you do IVF with clomid, or something else. You will see treatment options come down to trying IUI with fertility meds or move to IVF. So, if you are going to do this anyway, why bother doing the tests if you're going to do the same treatments anyway. If there is a tubal issue, go directly to IVF.

3) Endometrial Bioposy (uterine lining changes) Not done much anymore.

4) Laprosocopy (look inside pelvis and perform surgery if needed). Case by case, but usually not useful.

To check for endo and tubal disease. A lot of people do this before going into something else, but why put people through surgery unless they're having pain. Again, it can take around 2 years before you know if it worked or not. If you're going to turn to IVF anyway, then why mess with it. Probably more successful for people who didn't have much going on, but for people with a lot going on, it's probably not extremely effective.

5) Basal Body Temperature chart and OPK kits - Recommendation to not bother doing those because they are useful for 1-2 cycles, but if you are having regular cycles and you check a chart a couple cycles and if LH surge is fairly consistant, you don't really need to do it. If you do this, you can fall into a trap every month and be more stressed. I'm not sure what his comment would be if you are NOT regular. My feeling is that it can't hurt really to go ahead and do it!

Blood Tests - Used when clinically relevant.

If finding dictates a change in course. A lot of places run the tests purely to get money. Clinically they don't make sense. Where are most blood test applicable? Knowing FSH, Thyroid, Prolactin are important.

Immunological issues should be screened if you have multiple miscarriages
or if you've done 2-3 IVF cycles with no success then you should ask is there something else going on when embryo arrives in the uterus and it is being rejected, this is where immunological test are key. This is very
controversial. This doctor wasn't in agreement when he first started working with the SHER Institute. If you are going with IVF, you might want to rule this out and have this test. But, is it cost effective - how many people do you need to screen to rule things out. $1,000 for
screening usually.

New Procedures - Genetic Testing

Genetic testing of egg and embryos. If there are no sperm issues, the egg is doing most of the work. Now you can biopsy the polar body which is a mirror image of the egg, in terms of the genetic. You can see if the egg has all of its chromosomes. Good for fertility preservation and egg donors - you can go to egg repository and pick out the good ones.

The success rates of IVF depend on
if the 1) embryo is normal 2) is uterus receptive and able to accept an embryo and propagate a pregnancy. So it's basically, do we have a normal embroy. One of the reason why miscarriage happens is that the embryo isn't good.

More on Advantages of Skipping Some Tests
Will now get results quicker because these test might not be necessary. When they do test, they might have a mild male factor. Maybe try a few IUI's and then go to IVF. If you don't ovulate regular, yes then try infertility drugs. But, if you haven't found anything, most people would say to look towards clomid and injectables because it's easy to do and doesn't hurt and some get pregnant. The problem is that we dont' know what that really accomplishes. If you ovulate and have normal sperm, then drugs and IUI don't do much that you aren't already doing. The pregnancy rates for unexplained infertility with clomid IUI is only about 7% or up to 10% with injectables. People do it because they have been told to do so, or are afraid of IVF. A lot of patients ask for it, so it is often done. If IUI and drug induced cycles are done for 3-4 cycles and it hasn't worked, it's probably not going to work so you should move on. For most who choose this route, by the 3rd cycle people are fed up and end up moving to IVF.

For people who don't have mandated coverage for IVF, what do you do then? He would say that then it makes even more sense to go to IVF because if you add up all the potential costs throughout each of the procedures, it easily amounts to $1,500 to 2,000 per cycle if you divide by 7% success rate you get a high number - and then 6-7 K later and still not pregnant, you've already paid a lot and haven't tried IVF yet which yields a MUCH higher success rate of 70% or more.

Increase in pregnancy rates from clomid to clomid with injectables is small. Skip injectables move to IVF is becoming more of the rule.

In Summary
Endless months and money spent doing tons of treatments which might not work and will probably end with IVF anyway is a route that some are beginning to take. In my opinion, this doctor is leaning towards doing less tests and moving to IVF sooner.

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The Swann's November 22, 2008 at 6:57 PM  

Wow! This is REALLY useful information!!!! :-) Since we're seeing a RE come New Year, I want to know what to push for (HSG) and what to say no to (Lap) at initially. Hum... Thanks for the info!

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