Games gynecologists and infertility specialists play

Ideally, the relationship between your gynecologist and infertility specialist should be a synergistic one. Your gynecologist should be your first point of contact ; and she should do your basic tests , so that she can establish a diagnosis and formulate a treatment plan . If it's a simple problem, she should be able to initiate treatment as well ; and make a decision as to when you need a referral to an infertility specialist.

The infertility specialist would treat you; and when you got pregnant , would refer you back to your gynecologist , who would provide you with antenatal care during your pregnancy. In an optimal world, this would be a well oiled machinery , where infertile patients with simple problems can be treated cost effectively by the gynecologist, without having to be referred to an infertility specialist; whereas those who had complicated problems would be referred on straightaway to a specialist, without having to waste time with potentially ineffective treatment with the gynecologist.

However the real world is much messier , and the problem can actually cut both ways. Sometimes gynecologists are reluctant to refer patients onto infertility specialists, because they do not want to lose their patients. This is because many infertility specialists will also deliver babies; and when their patients get pregnant, they will hold on to them and provide them with care during their pregnancy as well, rather than send them back to their gynecologist. This is not an optimal use of resources and medical expertise.

The flip side can be equally bad. Sometimes the relationship between the gynecologist and infertility specialist can get to be too cozy – especially when they work together in the same hospital. Each of them cross refers patients to each other , so that they both end up doing too many unnecessary procedures.

Thus , a lot of IVF specialists , before doing an IVF cycle , will routinely refer their patient to a gynecologist , and will ask them to do a hysteroscopy and/or laparoscopy for them. The purported reason for this is to optimize the endometrial cavity , in order to enhance embryo implantation. This is often done by doing a procedure called metroplasty, which is supposed to increase the capacity of the uterine cavity. This is a procedure which seems to be performed only in India ; and there is no evidence that it actually helps fertility rates at all. After all , the shape of the endometrial cavity has very little bearing on the fertility potential of the woman ; and there are a lot of normal anatomic variants within the fertile population as well. However, when an infertility specialist sees these normal anatomic variants in an infertile women, they tend to over treat them, and refer them to endoscopic surgeons to do procedures which not only are not helpful , but can actually be harmful . They may end up causing scarring and adhesions, and actually reduce the endometrial receptivity.

IVF specialists will also often refer patients prior to IVF for laparoscopy procedures- for example , patients with endometriosis. The rationale for this is that endometriosis can interfere with embryo implantation and that therefore it's best removed prior to the IVF cycle. However, there is no evidence for this , and unnecessary surgical procedures can actually end up reducing ovarian reserve and causing a drop in the IVF success rates.

One of the reasons for this business of excessive referrals is that doctors will often want to maintain collegial relationships amongst each other - it's the “ you scratch my back and I'll scratch yours “ reciprocity principle in play. When an IVF specialist refers his patients to a gynecologist for endoscopy procedures , it's highly likely that this gynecologist will then in turn refer his complicated infertility problem patients back to the IVF specialist. While this back and forth referral will help to increase volumes for both of them, it is unfortunately not in the patient's best interests.

The only solution is that patients need to educate and inform themselves ; and if they immunize themselves with information therapy , they can ensure they are not subjected to unnecessary procedures.