Like many of my patients, my life revolves around information. Personally, I use the same technology as most of you to keep track of obligations and loved ones. Professionally, the Houston Fertility Center team uses technology and constant communication to manage our patients' treatment plans. In this era of digital info, we can all feel more empowered, more often, more quickly. It seems like there's always room for more information, doesn't it?
Is it possible we sometimes actually don't help things with our "more is better" attitude toward information?
It's quite common in my office to hear, "Dr. Kristiansen, we want a baby so badly, we'll submit to any test that exists to find out the problem." I applaud their desire to get to the root of the situation and make it better. For many patients, the "not knowing" is nearly as difficult as not having a baby.
Ironically, even when I have strong reasons to suspect a particular cause of a patient's infertility, some may feel very unsettled if I order only those tests that I know will hone in on that cause. I understand -- they want to cover every single realm of possibility, right up front, leave no stone unturned (so to speak), even if it means performing tests that have a low chance of being applicable in their situation.
Recently, an organization published fact sheets called "Five Things Physicians and Patients Should Question" authored by nine medical specialty societies such as the American Academy of Family Physicians and others. The point of this public information campaign: to encourage patient-doctor communication about eliminating unnecessary tests and procedures. The campaign was first started by the National Physicians Alliance and then further supported by the ABIM Foundation with a focus on evidence-based medicine.
There are two recommendations that are pertinent to gynecology:
1) Don't perform Pap smears on women younger than 21 or who have had a
hysterectomy for non-cancer disease.
2) Don't recommend follow-up imaging for clinically inconsequential adnexal cysts.
However, there are no similar recommendations specific to fertility treatment.
If a woman is trying to get pregnant and is worried that there may be a problem, here are the tests that I recommend for virtually any fertility patient:
• Medical history: Not exactly a "test" but a good review of a patient’s health and even a little about the immediate family's health history can give us a lot of clues.
• Semen analysis: It really does take two, so there's almost no point in only looking for infertility causes in half of a couple.
• Pelvic exam: Even if a patient has had annual well-woman exams for years, it's possible that something's been missed or that things have changed in terms of the reproductive structure.
• HSG, unless you're using IVF: Hysterosalpingogram is the best way to determine tubal patency. If there's not a definite plan for in vitro fertilization (which is a very successful workaround for tubal factor infertility), then we need to know the pathway for the eggs is clear.
• AMH & Day 3 FSH: Simple blood tests, testing these two hormones give us a wealth of information about the quantity and quality of eggs, for patients of all ages, and enables us to start your treatment plan most appropriately. There's no point being caught by surprise later down the line by an ovarian reserve that was in decline all along.
Of course, there are more diagnostic tools at our disposable if necessary. And that's my point: Simply having a wider array of tests and procedures does not make them all necessary. So why go through the expense of both time and money, not to mention additional anxiety, by submitting to every test -- unless we find, one step at a time, that the initial tests aren't revealing enough information to optimize your treatment path.
Can we have too much information? Not really, especially when it comes to our comfort level. We've all become very accustomed to the sense of control over our lives that comes from having all that data. But there are costs to being inundated with data, both financially and emotionally. Part of my job as a fertility specialist is helping patients find what's necessary and truly helpful from among the abundant but sometimes confusing options.