Tuesday, July 15, 2014

IVF overtesting in the futile quest for certainty


When I review the medical records of patients who have done IVF in other clinics , I'm quite amazed by the amount of testing which they've undergone . A lot of these tests are extremely expensive  -and many are exotic ; of unproven value; and provide information which is of no clinical use. It’s a long list – and includes: NK cell testing; pregnancy destroying factor; TB PCR testing of the endometrium; and TORCH tests.

Why do doctors do so many unnecessary tests ?

There are multiple reasons.

One is financial. It’s much more profitable to order the test , and it's often easier to do this. One of the reasons doctors order tests is that this is an easy way of terminating the consultation, so they can move on with seeing the next patient. This is much easier than spending 10 minutes explaining why the test is not needed. Not only does this eat into the doctor’s time, they can’t charge for this either. This is because the system doesn’t reimburse doctors for talking to the patient – even though this is often far more useful ( and much less harmful) than ordering tests and doing procedures !

On the other hand, the doctor can order the test, charge the patient, and say –  Please come back and we will discuss treatment options once we get the results !


Lots of doctors crave certainty , and when we come across problems for which we don’t have clear answers ( for example, why a perfect looking embryo did not implant),  the standard knee jerk reflex is – We need more data in order to find out what’s going on, so it's quite logical to order tests to get to the root of the problem. ( Some doctors like to think of themselves as being scientists who are running experiments on their patients).

Unfortunately , more information doesn't always help. Many studies ( across multiple fields ) have shown that more information often just increases the expert’s confidence levels , but does not improve accuracy. Many of these test results don’t actually help to improve clinical outcomes – and these results often just add to the noise, without improving the quality of the signal.

Doctors love doing tests. These are modern, cutting-edge tests ( many use complex genetic analysis,  which is Greek and Latin to most patients, and their doctors as well) , and this is a clever way of signaling to the patient – I am well-informed, which is why I am ordering the latest, newest, state of the art tests for you.  Sadly, your earlier doctor was clueless, and didn’t even know about these tests, and this is why I am better than he was.

Doctors can then present these results at conferences; and dazzle other doctors with their brilliance, by showcasing their findings in order to demonstrate how avant-garde they are. The trouble is that the focus on the outliers – the zebras. This impresses the other doctors, who are then happy to refer even more patients to this specialist, who orders so many tests and discusses their science and results so intelligently

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Patients also contribute to the problem, because they expect the doctor to order tests when they see him. Few patients have the maturity to understand that when a doctor says he doesn’t know (rather than trying to fob you off by ordering more tests in order to cover up how little medical science understands about many complex areas) . this actually means he’s a good doctor because he is sharing the limits of medical knowledge with you . There are still huge areas of ignorance in IVF , and we  need to learn to live with these. While research labs will continue trying to push the frontiers of our knowledge, this is not the right approach in a clinical setting – especially where the patient has to pay out of her pocket to do tests which do not help her to have a baby. Doing more testing is not the right solution .

Sadly, most patients don’t even understand that these tests on experimental and unproven ! Because they are new and expensive and are aggressively promoted with the help of colourful brochures ( and incentives paid to the doctor as well), it’s easy to convince patients that more is better !

Infertile patients are often so desperate , that they are willing to be used as guinea pigs . Patients will often put pressure on the doctor by saying – Doctor, is there anything else you can do for me ? Any other tests you can order ? It’s very tempting for the doctor to buckle down under pressure and order the latest test – often once he has heard about in a medical conference , or read about in a medical journal article – especially if this has been published abroad).

Ordering the test is the easy bit - interpreting the result is extremely hard ! The major issue is the problem of false positives – when the results are abnormal, but are not related to the patient’s clinical problem . These are a major hazard of all tests , and will often lead to more testing , because the doctor then starts chasing red herrings . A lot of time and money is wasted on unnecessary treatments as well , in order to “treat” these abnormal results. The damage done in barking up the wrong tree is often concealed, until the patient gets a second opinion.

A common justification for overtesting is – Lets run the test just to make sure that we aren’t “missing” anything; or we need to rule out a treatable cause, so let’s just order the entire panel of tests. After all, how can it hurt ?

This is one of the reasons good IVF programs have well-defined protocols , which clearly demarcate what tests are acceptable , and which are experimental and unproven . This is especially true when the government pays for IVF treatment in countries such as Scandinavia .

Good doctors  understand that patients are often desperate for answers, but it’s often much kinder to explain that it’s not always possible for us to provide these.

Remember the aphorism - Good surgeons know how to operate, better ones when to operate, and the best when not to operate. This is true for IVF specialists as well. Good doctors know which tests to order, better ones know how to interpret them, and the best know when not to test !

Worried that your doctor is wasting your time and money on doing too may tests ?
Please send me your medical details by filling in the form at
http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?






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