Infertility diagnosis and treatment: How to gain maximum benefit with minimum physical, emotional and economical costs.

After 15 years of dealing exclusively with diagnosis and treatment of infertility I would like to share my findings on the subject.

As a researcher, I hope that my scientific data and clinical results communicated through peer review publications and conferences over the years, contributed to a better understanding of the complex nature of infertility. I also hope that from a social perspective, the information provided here will help couples to achieve the desired result in a way that will allow them to save not only money, but also spare them from both physical and emotional grief.

Dr. Tsilivakos Vassilis MD, PhD, Immunologist and Pathologist, Researcher of Reproductive Immunology


The objective of this effort is clear: To gain maximum benefit possible with minimum consumption of physical and mental health, time and money.


During recent years in the fields of reproductive healthcare and assisted reproduction, two areas demonstrated considerable progress. The first, was the improvement of IVF technology. In this area, progress was achieved through continuous improvement of stimulation protocols and stricter regulations of standardized work in the embryology laboratory. Competition brought about by the increase of the number of IVF centers played a key role to that effect. Also important was the improvement of embryo, sperm and ova freezing methods.

The second area that significantly evolved over the last 15 years, was the development of etiological (causal) approaches to the diagnosis and treatment of infertility.

Admittedly, the likelihood a successful IVF attempt in later years has been increased due to the gradually applied etiological approach of infertility and to the individualized assessment of reproductive health problems of couples undergoing treatment. This is a highly complicated medical field, where the sum effect of the interaction of a large number of factors can ultimately lead to fertility problems. In spite of the great heterogeneity of infertility-contributing factors, we can now target each one in a more precise and effective way compared to previous years. These recent developments in the field have led to successful pregnancies even by means of natural conception rather than IVF.

Natural conception should be the primary goal of every couple. At the same time however the continuation of a pregnancy all the way through term must be ensured in advance, especially since miscarriages are more likely to occur in couples with a history of infertility.


The first objective should be the definition of factors contributing to the couple’s infertility.


 

Simply put, the couple should learn the reason(s) behind their difficulty in conceiving. Under no circumstances should any kind of treatment or assisted reproduction attempt be started before an assessment of all possible factors which contribute to the problem has been made. The only exception to this rule is the treatment of infection (microbial, fungal or viral), which is also a matter of good healthcare in general. Needless to say, consideration of IVF options, before the above investigation has been completed is considered premature. 

In most cases however, the procedure described above is not followed. Unfortunately, after a spermiogram and  a salpingography most couples are directed towards a series of assisted reproduction attempts. What's more, if in spite of multiple IVF attempts, conception is still elusive, these cases are classified as “infertility of unknown cause”! To avoid this eventuality, one must persist in the first question of "what are the reasons that prevent conception?". The answer to this question should be convincing to the couple according to their common sense and logic. If not, this should be clarified by more questions (a doctor’s ability to clearly explain an answer to the couple often reflects his expertise on the subject).

Apart from discovering the primary causes for their infertility, the couple should also ask themselves - when conception occurs, how can we be sure that we have done everything possible to avoid a miscarriage?

In this case too, the doctor should provide the couple with a convincing answer. Keep in mind, however, that infertility is a highly complex medical chapter that spans through many clinical, laboratory and research disciplines of medicine. Even for a doctor very well-versed in reproductive medicine it is sometimes difficult to assess a case. Specialization, experience and investigative thinking are essential qualities a medical reproductive health specialist must possess. Unfortunately, a large number of physicians who are not experts on the subject of infertility, in order to live up to their patient’s expectations, rather than referring them to a specialist, they resort to prescribing extended lists of diagnostic tests which are not aiming at answering specific questions. To make things worse, the results of these tests are often misinterpreted. 

The field of gynecology and obstetrics is very extended. A gynecologist is not obligated to have a deep understanding  of all fields of andrology, immunology, hematology, endocrinology, genetics and medical laboratory technology which are needed for handling  complex and highly specialized infertility cases.

At this point one must consider the financial implications of fertility testing. The prescribed tests should be personalized, few in number and very focused. If the financial costs are very high, this will eventually impact the couples psychology resulting in aggravation of the problem. Patients should always perform a market research beforehand and when the couple is referred to a specific laboratory or medical center for diagnostic testing, the doctor should be able to explain that choice. Higher prices should always be justified by higher quality of information made available by the tests’ results. 

The patients must ask questions and should expect convincing answers. They must always be able to understand where their money is spent. Keep in mind of course, that the problems of each couple are different. Some face more complicated problems than others. However, a good specialist can inform the couple in such way that the patients understand the complexity of their problem which will explain the costs of the prescribed tests and therapies.


The second objective for the couple is taking the appropriate therapeutic measures aimed specifically at each cause contributing to the problem.


 

The couple should be able to understand the correspondence between treatment and each individual factor that contributes to their infertility. In this way, they will be able to clarify any questions regarding their treatment in order to minimize the chance of making a mistake.

Etiological therapies begin by treatment of microbial infections. Treatment of the rest of the factors then follows according to the way that the couple wants to attempt a conception. After achieving the first goal, (diagnosing the cause of the problem) the couple should think about the way of conception that they want to try. In cases of Fallopian tube obstruction, severe sperm problems, advanced age or in cases where for some reason is imperative for the couple to achieve conception as soon as possible, the answer is simple: Completion of etiological treatment should be followed be an IVF attempt. In fact many of the etiological therapies are temporally adapted to the expected date for oocyte- or embryo-transfer.

On the other hand, when the conditions are less severe, when even one doctor can suggest that conception is possible with ways other than IVF, then the couple should set their deadlines. According to their age, psychological condition, financial status, jobs, relationship and the advice of their family doctor, the couple should allow a number of months (cycles) for natural conception to occur in which case they will have avoided the expenses and pharmaceuticals associated with IVF.  During the stage of waiting for a natural conception to occur, etiological therapies should continue correctly during every cycle (except from antibiotics). One should be extremely careful to maintain a continuous and accurate treatment regime since, with the exception of antibiotics administered early during treatment to remove infection, all other treatments have temporary effects and must be repeated in order to remain effective. 

At this point via assisted reproduction or through natural conception most couples would have achieved pregnancy. The treatment received not only helped achieve a conception, but will also help to maintain the pregnancy provided the doctor’s instructions are followed correctly during 1st trimester. If during this time the couple did not achieve a conception then a consultation with their doctor must take place in order to decide whether a more strict regime of diagnostic testing should be performed or whether the couple should proceed with some method of assisted reproduction, intrauterine insemination (IUI) or IVF.


The third objective is to reach week 12 of pregnancy without problems.


 

At this point the couple should refrain from excessive excitement and preparations. Keep in mind that, unfortunately, spontaneous abortions mainly occur during the first trimester and are more frequent in couples with a history of difficult conceptions.

This period requires much patience, optimism but also a good understanding of the state of pregnancy. In the first trimester, particularly women that had a hard time trying to conceive should not ignore the possibility of a bad outcome for the pregnancy. The reason for this, is to minimize the later psychological repercussions of a possible miscarriage. The attempt that will follow will require the woman to be in a good psychological condition. A new attempt cannot begin if the woman has already resigned psychologically.

Furthermore, the couple should not commit to their friend, family and working environment through impulsive disclosure and "advertising" of their pregnancy. Depending on their temperament and character, the couple may feel badly when a widely known pregnancy does not end successfully. The right way to go about this, is for the couple to disclose the news of the pregnancy in a controlled manner keeping in mind all possible outcomes, both good and bad.

At the end of the 1st trimester, if all fetal signs are normal, then we can allow ourselves to safely say that we are well on the road of achieving our final objective - to take a healthy baby home after another 6 months.