Active Management Of Infertility

Times have changed and so has our approach to infertility. Today, an active success-oriented approach to the investigation and management of infertility is essential to get the best out of the wide variety of modern fertility treatments available to you.

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.