Why it's a pleasure treating well informed patients !

A patient sent me this email

We are considering embarking upon IVF to have our 4th living child . We have a history of successful pregnancies (births 2008, 2010, 2012) mixed with miscarriages (3 in 2007, one in 2017). We want to expedite conception rather than trying for years more on our own. My AMH appears reasonable (21.6 pmol/l) and my CD3 FSH was 8.3; LH and estradiol, prolactin etc. were in normal range). We have approached two fertility clinics (one in Greece, one in the Czech republic, both well known) who have both recommended a hysteroscopy before proceeding. I do not feel that this is evidence-based practice. I have received recent serial ultrasounds, which showed normal uterus and ovaries - on CD14 endometrium was 10.6mm, trilaminar and had good blood flow; 22mm follicle to RHS (LH surge was later that day and CD21 progesterone confirmed ovulation). To my mind, the value of hysteroscopy is negligible in my specific case, despite having had 2 D&Cs for miscarriage in my past. I feel that any major issues are likely to have shown up in the ultrasounds - but I am interested to see if you agree! I also wish I could ask you my chances of having a baby - but I suspect that is far too complex a question. Moreover, with 3 previous successful pregnancies and just over a year trying for this one (with one miscarriage), decent AMH etc. I am going to remain very quietly optimistic on that front. Very best wishes,  This is a patient who has done her homework and is clearly aware of all her options. She has used Information Therapy, so she can Say No to unnecessary procedures, such as hysteroscopy. She is not a doctor, but is very well read, and wants answers to her questions. Many IVF doctors would not want her patient like her, because they would think she is too "demanding" - but she is the best kind of patient to treat, because she has realistic expectations of what an IVF doctor can do for her, and will not put up with an BS !