Wednesday, July 16, 2014

Infertile Patient query - IUI versus laparoscopy ?

Physicians perform laparoscopic stomach surger...

Hi, Dr Malpani.

I have been reading your blog and have found it to be very helpful. My husband and I have started infertility treatments and options. Briefly, this is what has happened: -We have been trying for a year naturally (both 29 years old) -Did blood work to check all hormonal levels and everything is normal -Husband did semen analysis and that is better than normal -PCT was done twice (wish I had known this is kind of outdated and most doctors don't do this but oh well, what is done is done!) and both showed that sperm were not swimming like they should at all -Doctor/OBGYN had recommended using mucinex but cervical mucus seemed "perfect" for each PCT

After we Visited Infertility Clinic: -Vaginal Ultrasound completed: Showed that my uterus was slightly tilted; Right ovary looked great and easy to find; Left ovary difficult and painful to find -Completed HSG and one tube the "spill" was great, the other seemed tangled - due to scarring? endometriosis? something else? -Tried 1 unsuccessful IUI (follicles on the "open" tube seemed good, so IUI seemed like a good option) Now the doctor has two options, and after reading some of what you have written and what he has suggested it seems like Option 1 would be the best choice:

Option 1: Use drugs such as Clomid to increase egg development and use IUI as an intervention to see if that helps. Option 2: Laparoscopy My Dr. things it might be best to do Option 1 which is less invasive and easier. I guess I just worry, will my issues - whatever they may be - make it hard to get pregnant again later? Will they keep me from getting pregnant right now? I'd hate to do a bunch of IUIs and then find out surgery would have helped the whole thing. Three of my friends who have infertility issues all got laparoscopy, and two got pregnant after, one did not and did IVF. Both my husband and I are healthy - it's just such tough decisions. I think we will go with Option 1 but I would love to hear your opinion and other information you could give me that would help me to be better informed going through this difficult process.
Thanks, A

A is a well-informed patient – my model of an expert patient. She has done her homework, and is now on the horns of a dilemma.

 Her question is simple – Should I have a laparoscopy or not ?

This is a deceptively simple question, but there is no easy answer.
Actually, there is no one right answer, because both the answers are correct.
Each has pros and cons, and she needs to think through these rationally, to make the right decision.  However, it’s important she does not  use the experience of her friends  as a guide – every infertile woman, is different, and their case is not the same as hers

Many doctors will advise doing a laparoscopy routinely for all infertile women. They position it as being a simple diagnostic test, with the added advantage that the doctor can “fix” problems if there are any at the same time of the laparoscopy.  They tell the patient that a laparoscopy is the only way of making the diagnosis of subtle diseases such as peritubal adhesions and endometriosis, which is why it’s compulsory to perform this.

It’s fairly easy to convince patients, because the laparoscopy is described as being a “ minimally invasive” surgery . “ No cut or scar – just a bandaid”. It seems temptingly easy to do, and since patients are hungry to find out what the problem is,  many will sign up without even realizing that this is not always a good idea.

While laparoscopy may be “minor” surgery for the doctor , the truth is that for the patient, every surgery is  major ! Also, the focus should never be on finding problems – it should be on finding solutions. While it’s true the doctor may find a few minor lesions , this does not mean that these were the cause of the infertility; or that “treating” them will improve her chances of having a baby ! In fact, sometimes overenthusiastic laparoscopy can end up actually reducing the patient’s fertility. Thus, the doctor may find a small chocolate cyst which is of no clinical importance. However, now that the doctor has a laparoscope in his hand ( and can also charge more for doing an operative intervention, as compared to doing only a diagnostic procedure), he  goes ahead and removes the cyst. The patient  is  also very happy. She feels the doctor was smart, because he has diagnosed the problem, and treated it.

However, 6 months after the laparoscopy, when she fails to get pregnant , she realizes her hopes were misplaced and she is back to square one ! In fact, this surgery may end up reducing her fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing her ovarian reserve.
Most good doctors prefer being conservative. After all, the first rule of medicine is – “ Do No Harm”.  They prefer using non-invasive tests to make a diagnosis, rather than doing a laparoscopy.

The question should NOT be “Why am I not getting pregnant ? “
Rather, it should be – What can I do in order to get pregnant ?”
After all, no one cares about problems – we only care about results – about having a baby !

This is my advise.

The fact that you are not getting pregnant means that the eggs and sperm are not meeting in your fallopian tubes when you are trying naturally.
The next step would be IUI. We prefer HMG/IUI, as this has a higher pregnancy rate than clomid/IUI. If 3 cycles of IUI don’t work, then we suggest IVF.

This “stepped-care” treatment plan does not need a laparoscopy, as the laparoscopy does not affect the treatment options at all.

Finally, patients should remember that while the process is in their control, the outcome is not. The should follow their personal path of least regret, so they have peace of mind they did their best.

Need your query solved ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

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