Too Many Fertility Tests?
Going beyond these tests is where the controversy sets in. In the fertility field, it often seems as if a new test or procedure is being announced every minute . . . but the scientific proof to back up the claims lags behind. Some fertility tests routinely recommended just a few years ago are now being abandoned. For instance, when the results of a hysterosalpingogram suggest blockage in the fallopian tubes, many doctors routinely advise having a laparoscopy, a surgical procedure in which a lighted telescope is inserted through a tiny incision within or just below the navel. Now a growing number of experts feel these invasive procedures, usually done under general anesthesia, are being overdone in the name of fertility testing.
“If the goal is getting pregnant, a laparoscopy won’t help you get there,” says Sandra Carson, M.D., M.P.H., professor/medical director, Baylor College of Medicine Assisted Reproductive Technology in Houston. “The fact is that if the procedure confirms tubal blockage, the most successful ‘treatment’ to try to get a baby is via IVF. Well, guess what? If the laparoscopy shows your tubes are open, the possible ‘treatment’ for your unexplained infertility would still be the same.”
Other tests that may be suggested to couples with unexplained infertility include endometrial biopsy (to check for luteal phase defects—problems with the menstrual cycle between ovulation and menstruation) and/or postcoital tests (literally taken just after having sex) to evaluate cervical mucus, sperm, and the interaction between the two. The verdict on these two tests, according to top experts in the field, is “DON’T BOTHER.” In fact, the American Society of Reproductive Medicine’s online patient guide, “Infertility: An Overview,” specifically discourages both of these tests. “Endometrial biopsy to look for luteal phase defect is not routinely done by most infertility specialists because the information has not usually been helpful in improving pregnancy rates,” it says of the first. And of postcoital tests: “ . . . many physicians are not currently recommending this test because it has not been shown to be of value in increasing pregnancy rates.”
What about doctors who claim that they have new tests and treatments enabling them to lower the percentage of unexplained infertility cases in their practices to well below 15 percent? (One internet site claims their clinic’s sophisticated testing shows just 1 percent of cases are truly unexplained!) Much-ballyhooed research often shows an association between a certain lab test result and unexplained infertility, but doesn’t prove a cause or bring you any closer to pregnancy, cautions Dr. Carson, who is also past president of the ASRM. Case in point: Testing a woman for sperm antibodies, touted as an immunological reason for her body to “reject” a pregnancy. A well-respected study now suggests that while the test may work in the lab, it isn’t really helpful in providing information of practical use, says Dr. Leppert.
“If a doctor is researching a particular connection, there’s often a bias toward a specific test,” Dr. Carson notes. “It’s vital for a couple to ask, ‘Who’s giving this test? Who’s paying for it? Will it change what fertility treatment is recommended?’ And, most important of all, ‘What is the evidence for that treatment?’”
Various tests are now available, for example, to look at the chromosomal and DNA integrity of men’s sperm. While a recent review by doctors at Yale concluded that “the exact mechanisms by which these factors affect reproduction are unknown,” one new test, called the sperm chromatin structure assay (SCSA), is being touted as a much more precise measure of sperm “health” than any existing technique. “But only a few others have been able to replicate the inventor’s results. The fact that only one lab has been licensed to do this measurement begs the question of why everyone isn’t using it,” notes Jon Pryor, M.D., chair of urologic surgery at the University of Minnesota Medical School in Minneapolis. “That doesn’t mean that a decade from now, similar tests may not be routine, but we’re just not there yet.”
When Patience is What the Doctor Orders
Ironically, while doctors may not be able to find the cause of a couple’s infertility, they can offer advice—and even possible fertility treatments—to help. The least invasive, one-word potential solution: time. One major review of medical studies revealed that while 90 percent of healthy, fertile couples conceive in the first year of regular unprotected sex, and another 5 percent get pregnant in the second year, in the first three years of unexplained infertility, one in three couples will have a successful pregnancy with no treatment at all.
“Some of these couples may simply be normal people at the extremes of the statistics,” explained Dr. Santoro. They may have what is being dubbed “subfertility”—a delay in getting pregnant that may be due to a relatively minor glitch somewhere along the line to producing a baby. We have all heard tales, for example, of couples who adopted a child and then “miraculously,” some years later, had conceived a child. Or of women who had stopped using birth control because they assumed they would never get pregnant only to find (surprise!) that they’re suddenly expecting.
When both partners are young, say under 30 or 35, simply waiting a while longer is a totally realistic option that should be discussed with the couple, says Dr. Santoro. Increasingly, though, say doctors, couples don’t want to wait—and are willing to take the expensive gamble—physically, emotionally and financially—on fertility treatments and IVF.