Friday, February 17, 2017

When infertile patients start obsessing over their test numbers

I'm a big believer in patient empowerment and feel that patients should do as much homework as possible, so they understand what their options are and can make well-informed decisions for themselves. Yes, this does involve a certain amount of effort, but it is possible for patients to decipher medical jargon and understand their options.

Lots of husband and family members worry when patients spend time on the internet trying to make sense of their results because they feel that half knowledge is dangerous and that these are decisions which are left to the doctor. Because infertility treatment is elective, there are so many variables involved and so many different options, I think patients need to apply their minds so they can express their personal preferences when deciding what to do next. As with everything else, you can carry this too far. Just like being completely ignorant about what's happening and leaving everything up to the doctor is not a good idea, I think looking at numbers out of context also carries its own sets of problems. This seems to be a very uniquely American problem where not only are the doctors completely obsessed with minor variance in test results, so are the patients as well.

Here's an example of a patient who sent me her report and what her concerns were.

Hello. I am 29 years old, my husband is 32. We tried to conceive naturally for around 6 months but due to luteal phase spotting, saw an RE who recommended clomid. We did 4 cycles of clomid with possible chemical pregnancy (highest b-HCG of 5.4). We have now completed fresh cycle of IVF (though we saved all embryos for frozen transfer). I had 32 mature eggs retrieved->19 fertilized->14 made it to day 5 and were frozen. Out of those we had genetic testing done on 8 and 5 are normal. I am preparing for a frozen transfer and noticed that my TSH level was 2.69 with Free T4 of 1.15 after my last cycle with clomid (that day beta hcg was also 2.6). Prior to that i have had my thyroid tested several times throughout the years and TSH has been between 1.1-1.9 with free t4 of 1.3-1.5. Should I be worried about this TSH? Could it be due to clomid? Or could the the b-hcg from trigger or chemical pregnancy have affected the value? Thank you!

Now this poor lady has been over-tested and over-treated and the problem is that he's interpreting her results all wrong. I agree that's not her fault. After all, she's not a doctor and I get that, but she also needs to be far more balanced in her approach and find a reliable doctor who will help to her to make sense of these rather than someone who causes her to worry unduly and creates a lot of anxiety in her head, especially when all these so-called abnormalities are just normal anatomical variance of no clinical importance. Otherwise she's going to drive herself crazy and most probably her husband as well, in her pursuit of the perfect numbers, whether this is a TSH level ... She's obviously been completely over-tested and over-treatment.

Again, this is a very uniquely American phenomenon which, unfortunately, Indian doctors seem to be adopting because it is far more remunerative for them to do as many procedures as possible irrespective of whether these procedures are helpful for the patient or not. The general tendency is this blind belief in technology where the rule seems to be, the more you do the better your results. Without realizing that a lot of these procedures may sound very logical but may actually turn out to be harmful and they've not been proven to improve pregnancy rates. Unless they're subjected to clinical trials, there's no reason for patients to subject themselves to being treated as guinea pigs, especially at their own expense, which is something which makes no sense to me.

As with everything else, do what Gautama Buddha said, "Follow the middle path."

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