| 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
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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
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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:
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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.
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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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