Infertility tests which waste time and money
Being well informed can save you from wasteful and unnecessary Infertility tests that are a drain on resources and time. Here are some of the tests that are often ordered but not required for successful diagnosis, and a checklist of questions you should ask your doctor when a test is recommended.
Infertile couples often come to us for a second opinion with thick files bulging with the results of numerous medical tests and investigations. While some of these tests are useful, the sad fact is that many of these tests are a complete waste of the patient's time and money.
Unfortunately, patients have become so used to being subjected to a battery of tests when they visit their doctor , that they don't even stop to question their doctor as to why the tests are being advised. This means that they often end up having a large number of tests done, many of which provide no useful information whatsoever in the treatment of the infertile couple.
Let's first look at why doctors order so many tests in the first place . Often, it's much easier to order a test than to talk to the patient, which means that many doctors will mindlessly order a battery of tests in order to make a diagnosis. Also, in many large IVF clinics, there is a standard "cook-book procotol" of tests which must be ordered for all patients, irrespective of whether you, as an individual, actually need the test. Few patients (or even doctors for that matter) , question the cost effectiveness or utility of these tests, which are mechanically performed on a "routine" basis, especially in many US clinics. Also, many patients are impressed by a doctor who orders a lot of tests, because they feel that this means the doctor is very thorough !
While often this "overtesting" just wastes money, sometimes it does have more serious consequences. Ordering tests is easy, but interpreting them intelligently is hard ! Consider the common example of the presence of "pus cells " found in a semen analysis. Often these round cells seen on microscopic examination are actually sperm precursor cells which are found in normal semen. However, they are very commonly misreported as "pus cells" and many doctors then promptly label the man as having a genital tract infection, and treat him with an endless variety of antibiotics, in order to try to "clear up " the infection.
The unreliability of medical tests also poses a major problem today. The most obvious reason can be attributed to laboratories whose functioning is marked by factors such as poor quality control, unskilled manpower and obsolete equipment. There is little 'policing' or retesting, with the result that the needed standards are not maintained. After all, even a science graduate with a six-month diploma in laboratory technology can set up a medical lab in some countries, if he so desires. Most people tend to rush to the nearest laboratory to get their tests done, but such haste can be a big mistake. After all, if the laboratory is not reliable, how can you trust its report? You should try go to the best laboratory possible - your life can depend upon your test results !
Unfortunately, when infertile patients change their doctor, many doctors insist on repeating all the tests all over again, because they do not trust the results of any lab other than their own. This is very unfortunate, and patients often end up wasting even more time and money.
Ironically, it is true that sometimes doctors do tests because the patients demand them. This is very common, for example, with couples who have unexplained infertility, who often demand that the doctor continue performing tests till he can accurately diagnose what the reason for their infertility is. However, while modern reproductive technology is excellent at solving problems "in vitro " in the IVF lab, it's still not very good at diagnosing them "in vivo " in the human body.
What is our approach towards testing our patients ? We try to simplify testing, by explaining that there are only 4 things we need to test: eggs, sperms uterus and tubes. The first day the bleeding starts is called Day 1, and the semen analysis to check the husband's sperm count and motility can be done can be done on Day 3-4 , after requesting him to abstain from ejaculation for at least 3 days . The wife's blood is then tested for measuring the levels of her four key reproductive hormones: prolactin, LH (luteining hormone) , FSH (follicle stimulating hormone) , TSH (thyroid stimulating hormone). Since these levels vary during the menstrual cycle, they should be done between Day 3-5 of the cycle. We then do a hysterosalpingogram (an X-ray of the uterus and tubes) for her after the menstrual bleeding has stopped - between Day 5-7, to confirm her uterus and tubes are normal. We then see the couple on Day 9 with all these reports and review the results . These three basic tests allow us to check whether the eggs, sperm, uterus and tubes are normal.
Here are some of the tests which many doctors will subject their infertile patients to, which we feel are wasteful and unnecessary.
- An endometrial biopsy (EB) or D & C (dilatation and curettage) for endometrial sampling In order to "date" the endometrium. This used to be a very popular test, which was performed routinely in the past, in order to determine whether the wife was ovulating; and to diagnose a luteal phase defect. This is a painful and invasive test, which is now considered to be obsolete. The only role for a D & C today is if the doctor suspects endometrial tuberculosis, a disease which is now becoming very uncommon.
- TORCH tests.
- Doppler test To check for a varicocele in the infertile man. In the past, a varicocele was considered to be the commonest cause of a low sperm count. In fact, this is still a very controversial area, and many doctors still believe that varicoceles do cause male infertility, which is why they routinely subject all men with low sperm counts to a Doppler test, to check for a varicocele. However, the fact is that many men with large varicoceles have excellent sperm counts, which is why correlating cause (varicocele) and effect (low sperm count) is very difficult. It is possible that the varicocele may be an unrelated finding in infertile men - a "red herring" so to speak. This means that surgical correction of the varicocele may be of no use in improving the sperm count - after all, if the varicocele is not the cause of the problem, then how will treating it help? In fact, controlled trials comparing varicocele surgery with no therapy in men who have varicoceles and a low sperm count have shown that the pregnancy rate is the same - so that it does not seem to make a difference whether or not the varicocele is treated ! In such a case, why bother to diagnose a condition which does not need to be treated ?
- Sperm function tests Since all doctors are aware of the limitations of a conventional semen analysis (there is often poor correlation between the results of a semen analysis and male fertility potential) , many tests have been devised to assess the fertilising potential of the sperm. Many of these tests become "fashionable "for a few years, and then they disappear when doctors learn how useless they are. There is a lot of overlap in the results of these tests in both fertile and infertile men , and many fertile men will also have abnormal results when subjected to these tests, even though they have fathered babies ! This is because while these tests do provide useful information for groups of men in a research study, they do not provide any useful prognostic information for the individual patient. This means they often end up confusing a perplexed issue even more. While tests like the zona-free hamster egg assay were popular a few years ago, the currently fashionable tests for sperm function are the Sperm Chromatin Structure Assay (SCSA) and the sperm DNA Fragmentation assay. These test the integrity of the DNA in the sperm nucleus, and thus the ability of the sperm to fertilise the egg. Thus, we know that men with a higher degree of DNA fragmentation have a higher chance of being infertile. However, they do not provide any useful information for the individual patient, which means their utility in clinical practise is very limited.
- Laparoscopy Many doctors routinely perform a laparoscopy for infertile women, and we used to do so ourselves until a few years ago. However, we have now stopped doing so, for the simple reason that we do not think it is cost effective to subject all infertile women to this invasive surgical procedure. We use a HSG (hysterosalpingogram, X-ray of the uterus and tubes) to determine if the fallopian tubes are normal or not, because this is much less expensive and does not involve surgery. What about the argument that we may miss the diagnosis of mild endometriosis or peritubal adhesions on the HSG ? This is true, but since there is no evidence that treating mild endometriosis or removing peritubal adhesions at the time of laparoscopy helps to increase fertility, we feel we are justified in our decision not to subject our patients to this surgical procedure on a "routine " basis. Moreover, since the next step in our treatment of women with a normal HSG is IUI (intrauterine insemination) , the results of the laparoscopy do not affect our treatment plan at all. The fact is that the "yield " of routine laparoscopies in infertile women is very low, since the vast majority are normal, and this should also cause doctors to re-think their old-fashioned approach to performing laparoscopies mindlessly for all infertile women.
- PCR for endometrial TB This test has become very fashionable in India, where endometrial tuberculosis (TB) is still a cause of female infertility. The gold standard for making a diagnosis of endometrial TB is culturing the tubercle bacilli from the endometrial curettings; or finding tubercle granulomas on histopathological examination of the endometrial curettings. However, it's easy to miss the diagnosis of TB with these conventional tests, as a result of which doctors were very excited when the technology of PCR was introduced to aid in the diagnosis of TB. PCR (polymerase chain reaction) is a genetic technologic tool, which allows the lab to amplify very small quantities of DNA fragments which are unique to the tubercle bacillus, thus allowing doctors to make an early diagnosis of TB. Unfortunately, the test is still not robust, reliable or standardized, with the result that there are many "false positives" - women who do NOT have endometrial TB, but still have a positive PCR test, because it was done improperly. Many of these women are then even subjected to 9 months of unnecessary anti-TB treatment , messing up their unhappy lives even more !
- Immune testing for patients with repeated IVF failures and repeated miscarriages Patients who have failed repeated IVF cycles even though apparently perfect embryos were transferred, are understandably upset, frustrated and distressed. They are looking for answers as to why they are not getting pregnant, and a plausible reason is that their body is "rejecting" their embryos. This is why immune testing for patients with reproductive failure has become very fashionable recently. There is a long list of expensive tests which many labs now perform - and these include: DQ Alpha, Leukocyte Antibody Detection, Reproductive Immunophenotype, ANA (Antinuclear Antibody), Anti-DNA/Histone Antibodies, APA (Antiphospholipid Antibodies), Natural Killer Cell Assay and TJ6 Protein. This mind -boggling range of catchy acronyms conceals the fact that no one knows whether the immune system is really responsible for the failure of the embryos to implant in these women. Many labs use different protocols to carry out these tests, which are still poorly standardized. This means that results for the same test from different labs vary widely, making interpretation very difficult. Also, intelligently interpreting these tests in individual patients is virtually impossible, because of the considerable overlap in the results in normal fertile women and those who are infertile, since many fertile women will also have abnormal results when subjected to these tests. Sadly, most labs do not bother to standardize their test results by doing them on normal fertile women. This means that if a woman who has had an IVF failure is subjected to these tests and has an abnormal result, her doctor happily jumps to the erroneous conclusion that he has now "diagnosed " the reason for the IVF failure, little realizing that the abnormal result could just be a "red herring", since "abnormal " results are often found in "normal " fertile women as well. (These are called " false positives " - test results which are abnormal ('positive'), even though the patient has no disease.) A false positive result causes needless anxiety, and will often lead to a situation in which the patient will have to undergo even more tests to prove or disprove the previous results. Remember that if your doctor performs enough tests on you, it is a mathematical certainty that he will find something wrong with you. And if he finds something wrong with you, he'll usually end up treating you - whether you need treatment or not !
- Hysteroscopic metroplasty to enlarge the size of the uterus and correct its shape We are now seeing a virtual epidemic of this unnecessary surgical procedure. The size of a normal uterus varies from woman to woman, and many fertile women have a small uterus (a normal anatomic variant) when they not pregnant. The uterus enlarges normally during pregnancy, allowing them to give birth to a healthy baby. However, when a doctor notes a "small uterus" in an infertile women on vaginal ultrasound scanning, they diagnose this as a case of " uterine hypoplasia " and propose hysteroscopic surgery, to increase the size of the uterine cavity. This "minor surgery" called a hysteroscopic metroplasty, is supposed to improve the uterus's ability to "hold the baby" - and since it's such a simple procedure, and seems so logical, many patients agree to it. Many doctors also overuse this procedure to correct minor anatomic variants of the shape of the uterine cavity, as " diagnosed " by a HSG (hysterosalpingogram). Unfortunately, not only does this surgery not help to improve fertility, it can actually reduce fertility, by causing endometrial scarring, and preventing embryo implantation. If your doctor suggests hysteroscopic metroplasty, please say No !
Certain infections called TORCH (which stands for TOxoplasmosis, Rubella, Cytomegalovirus and Herpes) , may be a cause for a single miscarriage, but are NOT a cause for repeated miscarriages. While a number of specialists will do these tests, and even start treatment based on the results, these tests are not worthwhile for most patients. A positive TORCH test simply means the patient has positive antibody levels against that particular infection. Thus, a positive Toxo IgG test means that the patient has anti-toxoplasmosis antibodies which protect her against a repeat toxoplasmosis infection. This means a positive test is actually a good sign and suggests that the patient is protected against that infection because she has been exposed to that infection in the past. Unfortunately, many doctors do not know how to interpret these results and scare the patient into thinking that the positive test result means she has an active infection which can cause her to miscarry again. In fact, some doctors will even attempt to "treat" the "infection" ! This wastes time and causes needless distress. If your doctor asks you do a TORCH test after a miscarriage, you should refuse and find a better doctor !
Just like over-testing can lead to problems, we have also noted that under- testing can be equally problematic ! Thus, we have seen many men who have been advised to undergo IVF treatment, based on the report of just a single semen analysis report, which was abnormal. It is essential that the semen analysis be repeated, after a period of 4- 6 weeks, to confirm that the abnormality is persistent, because sperm counts do vary considerably, even in normal men.
You should also make sure that your doctor examines your original scans and X-rays, and not just the reports, because his interpretation may be different from the radiologist's. If you have undergone a series of scans, they should be arranged in chronological order, so that the doctor can compare them easily.
Here's a checklist of questions you should ask your doctor when a test is recommended:
- Why is the test being ordered?
- How definitive is the test? Is it the 'gold standard' for making the diagnosis? Will it reveal for sure that a condition is present or not, or must it be repeated or followed by more sophisticated tests?
- What precisely will the doctor be looking for in the results of these tests? What does he hope to learn from the tests? How accurate are they?
Other relevant questions are as follows:
- Is there any pain? What are the side-effects? What are the risks?
- Is this the best test for your problem? Tests are big money spinners today, because of which many doctors have fallen victim to 'testitis'; (a disorder in which doctors go in for all the tests available instead of the most appropriate one!)
- What is the risk of not having the test done, and what are the alternatives?
The single most important question you must ask is -" How will the result of the test change the course of my treatment?"And if the answer is that it really won't, then maybe you don't need the test at all !
In the final analysis, remember that medical tests can be very helpful in pinpointing your problem, but they need to be used wisely and well; after all, doctors do not treat abnormal test results, they treat patients !
Here is a checklist which highlights the important factors you need to consider before in for a medical test.
Medical Test checklist
Test name _____________________________________________
To confirm diagnosis?___________ Diagnosis _______________
To exclude diagnosis? ___________ Diagnosis ______________
Where will the test be done? Clinic? _________
Independent lab?________ Hospital? _________
Cost of test in: Clinic _______ Independent lab ________
Are there risks associated with the test (i.e., is the test invasive)? ___________
If yes, what risks? _____________________________________
Are there less invasive tests that might give the same information? ___________________________________________
If the test result is abnormal what will be done next? __________
If the rest result is normal what will be done? _______________
You should fill out this checklist for every medical test suggested. The more invasive or expensive a test is, the more important this checklist becomes.