Thursday, January 05, 2012

How too much testing can reduce your fertility

One of the first things medical students learn to do is to order tests . Medicine is supposed to be scientific, and test results are supposed to provide doctors with objective data which they can use to treat their patients.

It's easy ( and profitable !) to order tests - but few doctors learn how to interpret them properly. They just blindly follow what the medical text book suggests. Wise doctors know that the patient's body does not always read the text book - and good doctors know which test results to ignore - and how to make sense of the outliers !

The danger is that we are becoming overdependent on tests and this causes us to practise bad clinical medicine. Many tests are untested and unreliable and give results which are difficult to interpret. An excellent example of this is the sperm DNA fragmentation tests.

Explaining this fact to patients can take too long, which is why most doctors don't bother to educate patients that most test results rarely provide answers in black or white - they are usually shades of grey ! Interpreting them in the context of the individual patient's clinical presentation requires skill and clinical judgment and experience - something which all doctors do not possess in equal measure.

The trouble with overtesting is that this fools patients. Many naively believe that a doctor who orders many tests is more thorough; better informed and more knowledgeable - after all, he has ordered tests which the earlier doctors did not have the sense to ask for ! Doesn't this prove that he is a better expert ?

Sadly, more is not better - and newer tests are often more harmful ( and more expensive) than older tests, because they are still untested themselves ! Doctors like to play with new toys - but patients need to remember that tests are not benign ! They can be harmful and cause anxiety and worry. Even worse, they can lead to overtreatment and wrong treatment.

This situation is unlikely to change, given today's reality. Doctors find it easier ( and more lucrative) to order tests rather than to sit down and explain to patients why they don't need the tests in the first place!

Too many physicians still do not understand test interpretation. The patient's clinical presentation provides the context for any diagnostic test interpretation, not the other way around. Today, it is testing which often defines the problem , rather than serving its appropriate function as a diagnostic aid.

Thus, rather than treat the patient's infertility, many doctors end up treating the chocolate cyst diagnosed on the ultrasound scan. They advise surgery, which is beautifully performed technically - but this just ends up reducing the patient's ovarian reserve , so she now needs donor eggs ! The tests and the treatment did not help the patient at all ! Doctors need to treat patients - not just test results - and patients need to remind their doctors this basic fact !

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