Monday, October 25, 2010

Unexplained infertility vs incompletely evaluated infertility

Many patients are diagnosed with having unexplained infertility. This means that all their fertility tests - semen analysis; hormonal blood tests ( FSH,LH,PRL,TSH and AMH) for egg quality; HSG ( hysterosalpingogram) for tubal patency; and ultrasound scanning for ovulation monitoring are normal.

This can be a very frustrating diagnosis for patients. " But doctor, if everything is normal, then why aren't I getting pregnant ? " Patients are never happy with doctors who honestly answer - We do not know ! Patients expect a scientific definitive answer from their doctor who is meant to be an expert - and if a doctor cannot provide this, then be mustn't be very competent at his job is the natural conclusion many of them jump to . The truth is that our technology for identifying problems is still very crude. Thus , while we can check if the fallopian tubes are open or closed , we still cannot determine if the tubes are functioning properly or not. Similarly, while we can count the number of sperm in the lab and grade their motility, we still cannot find out if they are capable of fertilising an egg !

In actual fact, patients should be relieved that the diagnosis is one of unexplained infertility. This means that all their test results are normal; and that their basic reproductive apparatus ( eggs, sperms, tubes and uterus) are working fine !

However, the major fear in their minds is that if the doctor cannot find a problem, how will he able to fix it ? Does this mean that I will never get pregnant ?

The truth is that while we are not very good at identifying problems, we are very good at bypassing them !

A better term for unexplained infertility would be undiagnosed infertility - and this says a lot more about the limitations of our diagnostic technology, rather than anything about the patient !

However, when patients are told their diagnosis is "unexplained infertility" they are so hell-bent on finding the explanation ( because how can a doctor provide treatment without first making a diagnosis ?) , that they pressurise doctors into running a further battery of tests. In their mind, unexplained infertility means incompletely evaluated infertility - that the doctor is not been meticulous in completing all the tests . Some doctors are happy to pander the patient's hankering for a diagnostic label ! They start doing all sorts of unnecessary tests ( such as laparoscopy or endometrial biopsy to test for TB). When they finally find a problem ( which is just a matter of time because it is a mathematical certainty that the more the tests you do, one of them will turn out to be abnormal), the doctor then triumphantly proclaims that he has found the elusive diagnosis - which the earlier ( presumably incompetent) doctor had missed because he was not diligent enough.

The danger with this approach is that a lot of these "abnormalities" are just incidental red-herrings, which do not affect the patient's fertility at all. However, now that a problem has been "found", it needs to be treated ! This wastes a lot of time and money while the doctor and patient are barking up the wrong tree. Patients finally end up getting fed up and frustrated - and then refuse to explore treatment options such as IVF which would have allowed us to bypass the problem and achieve success in a much more timely and cost effective fashion !

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