When to Question Your Doctor (Part 2)
In Part I of this two-part blog, I discussed the risks of inappropriate fertility testing resulting from a potential conflict of interest. Now I want to present evidence-based practice on infertility evaluation and treatment. The goal is to empower you with knowledge on your problem and assist in efficient and effective decision making. There is no reason to take a backseat in your treatment decisions because you don’t know all the facts.
The following are statements by the American Society for Reproductive Medicine. The titles and verbiage in quotations are from ChoosingWisely.org as well as from their future publication.
1. Don’t perform routine diagnostic laparoscopy for the evaluation of unexplained infertility.
“In patients undergoing evaluation for infertility, routine diagnostic laparoscopy should not be performed unless there is a suspicion of pelvic pathology based on clinical history, an abnormal pelvic exam or abnormalities identified with less invasive testing. In patients with a normal hysterosalpingogram or the presence of a unilaterally patent tube, diagnostic laparoscopy typically will not change the initial recommendation for treatment.” Additionally, the recommendation of laparoscopy due to pelvic fluid seen on sonogram for suspicion of endometriosis is unfounded and inappropriate.
2. Don’t perform a postcoital test (PCT) for the evaluation of infertility
“The PCT suffers from poor reproducibility and its predictive value for pregnancy is no better than chance. Utilizing the PCT leads to more tests and treatments but yields no improvement in cumulative pregnancy rates.” As a result, this is an outdated test that should no longer be offered to evaluate infertility.
3. Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation.
“There is no indication to order autoimmune tests for increased risk of clotting, and there is no benefit to be derived in obtaining them in someone that does not have any history of bleeding or abnormal clotting and in the absence of any family history. This testing is not a part of the infertility workup. Furthermore, the testing is costly, and there are risks associated with the proposed treatments, which would also not be indicated in this routine population.” Additionally, there is often excessive blood testing for patients who experience recurrent pregnancy loss (RPL) but the only autoimmune testing indicated by medical evidence is: Lupus anticoagulant (actually is a misnomer and not indicative of the disease of Lupus); Anticardiolipin antibodies; Anti-beta 2 glycoprotein. Furthermore, a blood test for MTHFR (methylenetetrahydrofolate reductase) and Natural Killer cells have NO causality in infertility or RPL so they should NEVER be tested in this population unless as part of a research study.
4. Don’t perform immunological testing as part of the routine infertility evaluation.
“Diagnostic testing of infertility requires evaluation of factors involving ovulation, fallopian tube patency and spermatogenesis based upon clinical history. Although immunological factors may influence early embryo implantation, routine immunological testing of couples with infertility is expensive and does not predict pregnancy outcome.” As a consequence, unnecessary testing may yield an abnormal result that does not predict infertility yet the physician may prescribe costly and potentially risky treatment such as injections of a blood thinning heparin-like medication.
5. Endometrial biopsy should not be performed in the routine evaluation of infertility.
“Endometrial biopsy performed for histologic dating does not distinguish fertile from infertile women. Chronic endometritis on endometrial biopsy does not predict the likelihood of pregnancy in general nor is it associated with live birth rates in ART cycles. Endometrial biopsy should not be utilized in the routine evaluation of infertility.” Prior considerations of concern for the luteal phase (the two weeks following ovulation) have not provided improvements in outcome of infertility treatment cycles. As a result, progesterone (P4) levels are of no value due to their fluctuations; they begin to rise at ovulation, peak one week later, then fall if no pregnancy occurs. So, a P4 level above 3 ng/mL is all that is needed to presume ovulation; a higher number is meaningless as a measure of a “good ovulation.”
6. Routine serum prolactin testing in a woman with regular menses, ovulation, and lack of nipple discharge is also of no value.
“It has become common practice to obtain prolactin levels in the routine infertility evaluation. However, there is no reason to expect that a woman would exhibit clinically significant, elevated prolactin levels in the presence of normal menstrual cycles and without galactorrhea (milk discharge from breast). Therefore serum testing of prolactin levels in a normally menstruating woman without galactorrhea provides no benefit and would not impact clinical management.”
From my review of the medical literature, there are other inappropriate tests to discontinue:
1. Don’t repeat HSG’s unless a specific indication
Hysterosalpingogram (HSG) are valuable to determine a uterine abnormality and fallopian tube patency but should NOT be repeated on a woman who has not had any of the following since her first HSG: reproductive surgery involving her uterus and/or fallopian tubes; ectopic pregnancy; up to one year of infertility with a new partner; and a pelvic/sexually transmitted infection.
2. Don’t use ovarian age testing to predict live birth rate or the need for egg donation
Ovarian age (such as FSH, antimullerian hormone – AMH) testing should only be utilized by your physician as a guide to the dose of injectable infertility medication (gonadotropins) and an expectation of the number of eggs that will be retrieved from IVF. Transvaginal ultrasound to count the number of small normal cysts on the ovaries is also helpful for ovarian age testing (OAT). However, no OAT has been demonstrated to predict live birth rate and also should not be used to discourage women from attempting IVF with their own eggs.
3. Don’t obtain FSH, LH, estradiol for ovarian age testing
Obtaining routine FSH, LH, estradiol as part of ovarian age testing in a woman with monthly menstruation is NOT indicated for two reasons: 1. FSH levels are unreliable as they fluctuate monthly and LH/estradiol have limited to no value in this circumstance; 2. AMH is a more reliable and earlier predictor of ovarian age and has replaced FSH.
4. Don’t perform estrogen testing during oral infertility medication treatment cycles
There is NO value gained from blood work monitoring of serum estradiol levels during fertility treatment cycles following the five day prescription of clomiphene citrate or letrozole because dose adjustment cannot be performed and the trigger for ovulation (hCG) is not influenced by blood work results. In ovulatory women on these medications, monitoring by ultrasound is valuable and necessary to reduce the risk of multiple births.
All of the above testing, with the exception of AMH and autoimmune testing, have a direct conflict of interest in the infertility clinic where the physician owns the practice including the laboratory. Consequently, the patient must be proactive and vigilant during her infertility journey to find a physician/clinic who is their advocate. If the patient is unclear or uncomfortable regarding the proposed testing or treatment plan, she should always ask questions or seek a second opinion.