Tuesday, April 20, 2010
Do you need a hysteroscopy before doing IVF ?
In order for an IVF treatment cycle to succeed, the embryos need a healthy uterus in which they can implant. There are many tests to evaluate the uterine cavity and the endometrial lining. These include noninvasive tests such as ultrasound scans ( including 3-d vaginal ultrasound scans) and a HSG ( hysterosalpingogram); and invasive tests such as hysteroscopy. The most accurate method for evaluating the uterine cavity is a hysteroscopy, because it allows the doctor to actually look inside the uterus . However, because it involves a surgical procedure, it is expensive; and while this is a reason why many doctors what to do this, many patients are not keen on getting it done !
It's quite interesting to analyse the attitude of IVF clinics towards hysteroscopy. Some doctors will routinely perform a hysteroscopy for every patient prior to doing an IVF cycle. They consider this to be a part of their basic pre-IVF evaluation, along with the semen analysis and the testing for ovarian function.
Others will perform a hysteroscopy only selectively. Both these options have pros and cons, so let's look at these.
Doctors who routinely perform a hysteroscopy justify this by saying that it allows them to pick up ( and correct) problems which would otherwise be missed by other techniques such as ultrasound scanning , because these noninvasive tests are not as reliable or sensitive as a hysteroscopy. They remember all the patients in whom they identified a small polyp or adhesion prior to doing the IVF - a finding which was missed on the HSG or the ultrasound scan. They feel that if patients are going to spend so much money on an IVF, it makes sense to make them spend a little bit more, if this will improve their chances of having a baby. They feel a hysteroscopy is a simple , office-based procedure which can be done very easily; and that even if it is normal, it can still be justified, because it can provide additional reassurance to the patient that her uterus is normal. The big ( often unstated) benefit for doctors is that it is a great additional source of revenue.
So why don't all IVF doctors do hysteroscopy routinely prior to doing IVF ? Many doctors are quite conservative and feel that it is not justified to make the patient spend money on invasive procedures - especially if this information can be obtained less expensively and easily by non-invasive tests. It is possible that the hysteroscopy can pick up abnormalities which are missed by the ultrasound, but is it justified to subject hundreds of patients to a procedure in order to pick up a problem in only a few of them ? And is identifying these minor abnormalities of any clinical use ? Does correcting them actually improve IVF pregnancy rates ?
This is a vexed issue; and there is still no consensus on what the right approach is.
In fact, IVF doctors often find themselves in a bind. If you make patients do lots of tests, then patients feel that you are greedy and are making them waste their time and money on medical testing . On the other hand, if you do not do the test, then patients feel you are sloppy and your workup is incomplete and shoddy !
We try to take a balanced approach in our clinic. For the three critically important tests prior to IVF - semen analysis; blood tests for ovarian function ( FSH,LH,PRL,TSH,AMH); and the ultrasound scan, we will insist that patients do these from labs we can trust, as our entire treatment depends upon these results. These tests are easy to perform and inexpensive.
However, for expensive and invasive tests, we will take conservative attitude ; and do these ( or repeat them) only if our simple screening tests suggest there is a problem.
I have learned that there is no "one size fits all" solution. We try to tailor our approach to each patient and try to factor in the patient's preference when making these decisions. Thus, for patients who are fed up of tests, we will try to minimise these. However, for patients who have failed multiple IVF cycles or who demand a "complete checkup ", we will be more liberal with ordering tests. We do not have a rigid policy and try to involve the patient in these important decisions, so the patient is well-informed about the pros and cons of both approaches !