Diagnosing via the Internet? Not the best use for the information highway.
It’s not to say that a patient’s fine research abilities can’t be utilized to help themselves, but the most important initial step in this process is to establish a diagnosis for a given patient so that only the information that applies to them will be evaluated. For example, suppose a patient reads about another infertility patient who had tried to conceive for years and finally was helped by a new drug for ovulation enhancement. She asks her physician if she can try this since it helped another person and they agree to use it without having done a semen analysis for her husband. After six months of failure, the man finally has his semen analysis only to find that he has a very low sperm count.
An infertility evaluation is quite simple and mostly non-invasive. Three areas need to be evaluated which include male factor, structural problems for the female, and eggs (hormonal) factors for the female. By default, when nothing is found the diagnosis is unexplained if the female is younger than 38 and advanced maternal age if the female is over 37.
The basic workup includes a semen analysis, an ultrasound, an evaluation of the uterine cavity and fallopian tubes (usually done with a hysterosalpingogram), and early cycle hormonal testing. Many physicians will do additional testing but the above is a bare minimum to establish a diagnosis for the couple. Many couples will find that there are problems in more than one area and by simply correcting a number of small problems they will be successful. Unfortunately, some couples will find that there is a significant problem which may require extensive therapy, if a treatment is indeed available at all.
The role of the physician is to help the patient to resolve in the best manner possible the patient’s fertility issues. Based upon the diagnosis, the physician can then predict the success of various strategies available to the patient. The physician becomes an educator about the probabilities of success thereby allowing the patient to determine which options are best for that particular patient in that situation. The purpose of the infertility evaluation is to assign diagnostic categories for a patient rather than explain in depth the reason for the infertility. For example, suppose a patient undergoes a hysterosalpingogram (HSG). If the test determines that the fallopian tubes are open, it is correct approximately 96% of the time. When the test determines that there is bilateral proximal obstruction, it will be correct less than 40% of the time. Either result does not permit the physician to tell the patient with certainty that the tubes are either open or closed.
Assignment of diagnostic categories permits the physician to predict two sets of outcomes. Knowing the diagnosis permits the physician to predict the treatment independent pregnancy rate. This is an extremely important statistic for a patient since it sets the baseline pregnancy rate when no intervention is undertaken. Assigning a diagnosis also permits the physician to define therapeutic interventions which might increase the odds of achieving a pregnancy. Treatments can be organized as hierarchies based upon a risk-benefit evaluation allowing the patient to make an informed decision about what plan of action, if any, the patient finds acceptable.
A couple armed with a correct diagnosis, can then began to decide which treatments are best for them and will be able to most effectively solve their infertility problem utilizing the expertise of their physician and even the input of Dr. Google.