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The Pragmatic approach in treating patients with unexplained infertility

April 02, 2014

The following examples tell you how clinicians take a pragmatic approach whilst managing cases of unexplained infertility.

In unexplained infertility, if we know that there will be some hidden cause, why don’t we continue investigating until we know the answer?

As purists all fertility experts would like to go to the root cause of the infertility and conduct as many tests as possible to find out what’s the problem. However we have to be pragmatic about this and look at the cost-benefit ratio of continuing investigations to find out unusual or less common causes. Most often clinicians takes the practical pragmatic approach of getting on with the treatment which covers many factors and corrects them even without being sure that they need correction. Let’s take a few examples on the limitations of investigations and the reason for starting treatment before you are 100% sure about the cause.

Pragmatism Rules

Example 1

The fallopian tube is where the egg meets a sperm to make a baby. We routinely check for tubal patency checks using echo-songraphy or HSG (X ray test with a radio-opaque dye pushed from the cervix). Laparoscopy uses similar technique wherein blue dye is pushed from the cervix and the tubes are observed through the laparoscope to check that the flow of the dye is smooth and easy. These tests will confirm that the tubes are patent i.e. open. However the Fallopian tubes are functioning organ and actually secret essential nutrients and provide the environment for egg and sperm to meet. Whether the endothelial lining of the fallopian tubes can perform this job is difficult to be sure about by a routine laparoscopic test. There aren’t many tests to confirm that the tubal lining (endothelium) is working correctly.

So we declare the tubes to be working normally when in effect we only know that they are physically open or patent. If there is a problem with the functioning of the lining of the tube, it is not something we have tested for or it is not something that can be tested easily. Such a problem couple be a cause of unexplained infertility. If we were to choose to do IVF for unexplained infertility, such problem would be super seeded because IVF bypasses the need of the fallopian tube. This is a classical example of how going add with the treatment helps in cases of unexplained infertility.

Example 2 – mild to moderate endometriosis.

Endometriosis is the deposition of spots of endometrial in the peritoneal cavity typically around the uterus and ovaries which causes sub fertility. Treatment of endometriosis using electro-diathermy or laser diathermy during laparoscopy is said to improve the chances of fertility. However endometriosis doesn’t cause infertility in all women who have it. As a matter of fact most gynecologists will have seen mild, moderate or even severe endometriosis in women who were being operated for tubal ligation as a part of sterilization for contraception. That endometriosis surely didn’t affect that particular woman’s fertility. But in other cases, seeing no other reason for infertility, if we find endometriosis it ends up getting blamed for it. If we were to find endometriosis on laparoscopy, IVF as a treatment for the patient might circumnavigate the entire issue. Again IVF has allowed us to go directly to the treatment without having to worry too much about defining the exact cause or how responsible what’s nay cause that was found.

Example 3 -Oligospermia or moderately low count

This could be around 5 mil to 10 mil sperm per ml. this again is a typical example wherein lower than normal sperm seems to be the only cause of infertility. We could spend a fortune and lot of time trying to identify as to why the man has a low sperm count. It could mean hormone tests, antibody tests, infective screens, and test for varicoel and a few other expensive tests that not only cost money but hold back the treatment for a long time. Focusing on improving the sperm count by giving injections of human chorionic gonadotropin or other medicines etc. is expensive (in terms of time and money) and most often futile. By taking such patients directly for IVF plus ICSI, we are simply getting to the solution rather than pondering about the problem.

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