Image via WikipediaI saw a patient who wanted a third opinion. She was completely confused. As part of her infertility workup, she had had a HSG ( hysterosalpingogram) done. The X-ray showed that her uterine cavity was normal; the dye filled the fallopian tubes , but the spill into the abdominal cavity was loculated.
When she saw her doctor with the report, he told her that this suggested that there were adhesions around the tubes, and she needed an operative laparoscopy to treat this. Another doctor, to whom she had gone for a second opinion advised her against the laparoscopy. He felt that since the tubes were open, her best option would be to do an IUI, to improves the chances of the eggs and sperm meeting. This patient then sought a third opinion, which is why she came to me !
The first thing I did was to ignore the earlier opinions, and asked to see a copy of the original HSG X-ray films, so I could make up my own mind . Unfortunately, there was only one film, and this was of poor quality . The radiologist had done a sub-optimal study, because he had not taken any delayed films ( perhaps to save some money ?), as a result of which it was hard to draw a firm conclusion based on the HSG films. This meant were now back to square one.
The choices were; repeat the HSG; do a laparoscopy; or assume the tubes were fine and proceed with treatment. Each has advantages and disadvantages, and patients need to think their way carefully through their choices, so they can make the right decision. Unfortunately, most patients are not used to making choices regarding their medical treatment. Even worse, most doctors are not comfortable offering these choices to their patients. "The doctor knows best" is the model most patients ( and doctors) are happy to adopt - which means that often the wrong decision is made ( and usually for the wrong reasons).
We could repeat the HSG in a better clinic and make sure that it was done under fluoroscopic guidance and that delayed films were taken. While this option would give a much better X-ray image of the tubes, she was understandably reluctant to repeat the HSG. This is quite a painful procedure - and few women have the courage to do it again !
Laparoscopy is a surgical procedure, which means it costs more; however, the quality of the documentation is much better, because the surgeon can take videos of the pelvic anatomy. However, it cannot provide information on tubal function - which is really the only thing the patient wants to know - are my tubes working properly or not ?
Doing a laparoscopy was an option - but this is an expensive surgical procedure - and while it provides useful diagnostic information, it often does not change treatment options , which is why we are very reluctant to perform this in our clinic. What's the point of doing a test if it does not impact treatment alternatives ?
So what are patients supposed to do when their doctors disagree ? Some of them get very angry and upset when doctors do not see eye to eye ! I actually feel it's good for patients when doctors disagree. Each doctor will present his point of view and justify why this is better than the alternative proposed by the other doctor . The patient gets to see the pros and cons of both options, so she can make a better-informed decision !