December 12, 2017

Case of the month Apr '08: Episode #2

Click here for episode 1

RECAP: Aimee and Boyd have been infertile for three years. They’ve finished basic testing under the care of their regular OB. They’ve also been tried unsuccessfully on six cycles of Clomid. Their only significant findings include minimal endometriosis and periods that are just a tiny bit longer than average.

What additional testing would you do?

Before we answer that, let’s think about the basic principles of medical testing. This applies to infertility testing as well as to ANY general medical testing. Here are the factors to consider before deciding on whether or not to get particular test.

USEFULNESS: This is defined by whether or not the test results will affect your decisions. Some tests fall in the category of "gee, that’s nice to know", but since it does not change management, there is little reason to do it.
LIKELIHOOD OF POSITIVE FINDING: How likely is it that the test result will come back abnormal? For example, if there is some tropical parasite that is the cause of infertility in one out of a million couples, is it really worth testing?
COST: How much will doing the test cost you in terms of $$$, as well as inconvenience and/or suffering and/or danger? If we want to get really fancy, we can even factor in the cost of following up a false positive. This is a huge issue in general medicine. The only way for doctors to safely defend against frivolous lawsuits in this country today, is to do a lot of testing, much of it unnecessary from a medical point of view, but crucial to do from a medico-legal point of view. Sometimes, the testing will falsely end up showing something that is not really a problem, sort of a false alarm (better known as a false positive). However, once you have that positive result in front of you, you are forced to address it, even if it means sometimes putting the patient through unneeded invasive surgery. This is not a big problem in infertility, but my heart goes out to my fellow physicians in other specialties who have to deal with this on a regular basis.

There are hundreds of possible tests that I can order, but for Aimee and Boyd, AT THIS TIME BASED ON WHAT WE KNOW NOW, there is no pressing reason to order anything else. This might change in the future as the situation evolves and we learn more things, but for now, it’s better to focus our energy and resources on treatment rather than testing.

Often, patients come to my office with an article printed out from the internet asking me to order this test that they read about. Most of the time, I will explain the rationale behind NOT doing it. Other times, I will explain the pros and cons and leave it to the patient to individually decide if she wants it or not.

I’ll give an example. There is a common blood test used to get a general idea of a woman’s ovarian reserve (to sort of get an idea of how old her ovaries are). This test is called a day #3 FSH. For reasons I won’t go into here, it is only accurate if done in conjunction with a day #3 estradiol (E2). So we abbreviate this combination of tests as a D3 FSH/E2.

So should we do this test on Aimee? Wouldn’t it be nice to get a better idea of her ovarian age?
Let’s analyze the logic using the principles mentioned above.

COST: This is a pretty cheap test, easily done for under $200. It consists of one poke to get the blood. It’s non-invasive and has virtually no risk associated with doing it, unless perhaps you pass out while getting your blood drawn and bonk your head. So cost isn’t much of a factor.
LIKELIHOOD OF ABNORMALITY: At Aimee’s age, it is highly unlikely she is menopausal or even near menopause, especially since she has regular periods, has positive ovulation testing, does not get hot flashes and has ovaries which are normal-sized. This fact alone makes me very unexcited about ordering this test on her.
USEFULNESS: If her FSH comes back sky-high (indicating she is menopausal), that would be a shock and would not make sense. But still, would it change our management? Do you think that if a test claimed she was menopausal, we would all just nod our heads sadly and agree to give up, or to move on to using an egg donor, all on the basis of a blood test? Of course not. Most likely, Aimee would not believe it and would still like to try with her own eggs anyway.

Therefore, if someone comes to me waiving a printout and screaming, "This website says all infertile women should have their FSH checked. When are you going to check my FSH?", next time I can just give them a printout of this article for them to read first.

In summary, there is no absolute MUST-DO testing to perform for Aimee. I will concede that anyone can try and make an argument for this test or that test, but it will fail to be overwhelmingly convincing if you consider the balance of cost, usefulness and likelihood of a positive. Again, this strongly applies to where we are NOW.  That may change, so that we might get some more tests on Aimee in the future, as things unfold. But I wouldn’t get anything just yet, which brings us to the next issue, that of choice of treatment options…

Click here for episode 3