While modern
infertility treatment has become very effective, the
sad fact is that there are still many dangerous infertility
treatments to which patients are needlessly subjected.
These treatments not only waste time and energy, they
can actually reduce your fertility !
Let’s first take a look at why there are so many
harmful and ineffective treatments still around. Patients
would expect that all good doctors would offer only
safe and effective treatment – so why should useless
and ineffective treatments still exist ?
The reason for this is that infertility is a complex
area, and there is still a lot of confusion about the
best treatment option for many common problems even
amongst doctors . When doctors disagree amongst themselves,
how is a patient to make sense of all the options ?
Most doctors take pride in their own personal experience
, and trust their own clinical judgment. They prefer
doing treatments which have worked in their hands, and
this causes them to become biased. Even though there
is no proof that the treatments are actually helpful,
they remember patients who conceived after taking that
treatment. This is called “anecdotal “ experience,
and create a bias in each individual doctor’s
mind. Few doctors are broad minded enough to study the
scientific literature critically, and few have the objectivity
to practice evidence-based medicine. It’s easy
to get “fooled by randomness” in infertility
medicine, because there are so many variables, and many
patients will get pregnant even inspite of the doctor’s
“treatment” ! Of course, the doctor will
take credit for the pregnancy – and patients too
are quite happy to share the credit with their doctor.
The best way to explain this bias is to consider the
example of a doctor who has performed varicocele surgery
for 10 men with a low sperm count. Of these, only one
succeeds in getting his wife pregnant. ( This success
was not because the surgery helped, but because his
sperm count was not really low in the first place, since
it was done at an unreliable laboratory). This means
that the pregnancy rate for varicocele surgery in this
doctor’s hand is only 10%, and he should his advise
his patients accordingly. However, in real life, what
happens is that the other nine patients who fail to
conceive get fed up , and change their doctor. They
are “lost to follow-up”, and the doctor
only remembers the one patient who did get his wife
pregnant ( since he comes back with a big smile and
a box of chocolates !) Therefore, he continues to imagine
that pregnancy rates after varicocele surgery in “his
clinical experience” are very high.
The second way doctors often delude themselves ( and
their patients) is that even if their patients don’t
get pregnant after the surgery, they still feel the
surgery was justified because the sperm count increased.
Thus, they use an increase in the sperm count as a “surrogate
marker” for success in gauging the effectiveness
of their infertility treatment.
However, since it’s well known that sperm counts
fluctuate considerably in any case, it’s hard
to credit the surgery with the increase in the sperm
count. Also, men don’t want an increased sperm
count – they want a baby, and from the couple’s
point of view, the surgery is still a failure ( even
though the sperm count did
increase !)
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The other complicating factor in assessing the effectiveness
of a treatment is the gullibility of patients, and their
desperation. Infertile couples are so happy to clutch
at straws, that they are willing to pursue any path
which offers a glimmer of hope. This problem has now
been compounded by clever marketing in the “infertility
industry”, which leads patients astray, and misguides
them. Let’s look at the example of a patient who
is doing her third IVF cycle. She starts doing acupuncture,
and conceives in her third IVF cycle. In her mind, the
fact that she failed her first two IVF cycles, and conceived
only after doing acupuncture means that it was the acupuncture
which was responsible for her IVF success. In reality,
it’s well known that chance has no memory, and
IVF treatments have a cumulative conception rate of
about 30% per cycle for the first 4 cycles, which means
she may very well have conceived in her third cycle
even if she hadn’t done the acupuncture. Unfortunately,
patients only have their own personal experience to
go by, and find it hard to be objective. This particular
patient will start swearing by the efficacy of acupuncture,
and recommending it to all infertile couples, thus causing
a myth to spread further. With the advent of the internet,
vocal patients who have succeeded after many IVF attempts
carry a lot of clout on infertility bulletin boards,
and they often end up misleading others ( even though
their intentions are good).
Here’s a list of what we feel are dangerous treatments
of which patients should beware !
1. Varicocele surgery.
The fact that doctors are still uncertain about the
efficacy of varicocele surgery after so many years is
itself is a telling commentary on how unhelpful this
surgery is. While the surgery may improve sperm counts
in some men, objective trials have shown that it is
no better than just watchful waiting.
2. Medical therapy for
low sperm counts. This is another one of those areas
where fashions come and go. The current rage is “antioxidants”
and dietary supplements such as Proxeed. Since they
do not need a medical prescription, they can be sold
directly to unwary patients, but no study has documented
an increase in pregnancy rates after any of these treatments.
Even if you read the Proxeed website, all they claim
is that Proxeed improves “sperm health”
( whatever that means !) and that their clinical trials
only show an increase in sperm count and motility. If
you want “healthier sperm” , or an increase
in your sperm count, then go ahead and take these, but
if you want a baby, then they are just a waste of time
and money.
3. Surgery for fibroids.
Fibroids are very common benign tumours found in the
uterus of many young women. Some of these women who
have fibroids will also have the misfortune of being
infertile, and some of them will then end up falling
in the hands of an enthusiastic knife-happy surgeon
who will advise them to get the fibroids removed. However,
most fibroids are silent bystanders in an infertile
woman’s uterus, and do not need to be removed.
The only fibroids which need to be removed are submucous
fibroids, and these can be removed by doing an operative
hysteroscopy. Think many times before agreeing for myomectomy
surgery if you are infertile. You may get your fibroids
removed, but you may also end up with adhesions, which
will reduce your fertility even further ! Often, getting
a second opinion also does not help, because even the
next surgeon may still advise surgical removal –
after all, surgeons are happiest when doing surgery
!
4. Surgery for removing
an ovarian cyst. Ovarian cysts are very common in young
women, which is why they are very common in infertile
women. Because of the frequent use of ultrasound scanning
in treating infertile women, many of these small ovarian
cysts are diagnosed and reported by the sonographer.
Once an infertile woman knows she has an ovarian cyst
( a term she may never have heard of before), her mind
starts playing tricks with her, and she feels that it
is the cyst which is responsible for her infertility.
Sooner or later, she will fall into the hands of an
unscrupulous doctor who agrees with her, and offers
to remove the cyst with “minimally invasive surgery”.
The vast majority of ovarian cysts are of no clinical
importance, and do not need to be touched. They usually
regress on their own, and rarely affect fertility. However,
unnecessary surgery to remove a cyst will often cause
infertility, because normal ovarian tissue is also removed
at the time of the cyst removal. No surgery is far less
invasive than “minimally invasive surgery”
!
5. Hysteroscopic metroplasty.
This has become a very popular operation in some parts
of India. While doing a hysteroscopy, some over-enthusiastic
surgeons will make cuts on the lateral walls of the
uterus, to “broaden” the uterine cavity.
The truth is that fertile uterine cavities come in various
shapes and sizes, and there is no need to change the
shape of the cavity. Not a single study in the medical
literature has been published which shows this procedure
helps , and this gratuitous surgery can often cause
intrauterine adhesions and damage the uterus ! Beware
of trigger happy surgeons out to make money.
6. D&C for pregnancy
termination . Many doctors still perform a surgical
evacuation of the uterine cavity when a patient suffers
a missed abortion. This used to be a standard surgical
treatment in the past, but leads to intrauterine adhesions
in some women. It is far safer and better to medically
terminate this pregnancy using RU-486
( mifegest) and prostaglandins, as this leaves the uterine
cavity intact.
7. Medical therapy for
endometriosis. A diagnosis of endometriosis is very
commonly made in infertile women when a laparoscopy
is performed for them. In fact, the chances of finding
minimal endometriosis are as high as 60%, depending
upon how carefully the doctor looks ! Of course, once
the endometriosis is found, this is then labeled to
be the “cause” for the infertility, when
often it is just an innocent “red herring”
of no clinical importance. The damage really starts
when doctors treat the endometriosis by trying to suppress
it with Danazol or GnRH agonists. Medical therapy of
endometriosis has been shown to be useless, and just
wastes time and money because you cannot conceive while
you are taking this “treatment”.
8. Immune therapy for
repeated pregnancy losses. Patients who suffer repeated
pregnancy losses present one of reproductive medicine’s
most frustrating problems. We usually cannot pinpoint
the reason for the miscarriage, which means that patients
are often desperate in their search for solutions. They
are emotionally very vulnerable, and are willing to
try anything under the sun, in the hope that it will
work for them. They intuitively believe that their body
is “rejecting” their embryos, which is why
immune therapy for these patients has become so popular
and fashionable. Unfortunately, not only is it extremely
expensive, there is no evidence to show it helps. For
every patient who has a healthy baby after taking IVIg
after suffering three miscarriages (and who is considered
to be a shining example of the success of immune therapy)
, there are at least another five patients who go on
to have a healthy baby after three miscarriages, with
the help of only TLC – tender loving care !
9. Physical therapy and
massage therapy to remove adhesions. “Clear passage”
at www.clearpassage.com claims to achieve excellent
success rates with “site-specific” massage,
which they believe “decreases adhesions and increases
function of the organs.” This is an excellent
example of quack therapy ( to learn how to identify
quackery read www.quackwatch.com). However, it’s
all just clever marketing ( what a lovely name they
have selected !) . Their claims that their “medical
studies “ were “recently honored with induction
into the US Library of Medicine” will unfortunately
mislead naïve patients into believing that this
therapy works, when every surgeon know that it’s
impossible to remove adhesions without surgery –
after all, scar tissue does not melt because you knead
it !
Not only do all these treatments waste time, money
and energy, they also cause patients to get fed up and
frustrated, so that they end up losing confidence in
doctors - and in themselves ! The worst kind of hope
is false hope – and these treatment offer unsuspecting
patients just that, and nothing else. The only antidote
against this is information and education, so you can
protect yourself from such harmful treatments.
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