The initial step when we see patients at InVia is to get a complete history and perform a physical examination or ultrasound. This is followed by a few simple tests that help with diagnosing the cause of infertility. There are however, several tests that are not indicated and/or are not cost-effective if done routinely. The American Society for Reproductive Medicine (ASRM) recently partnered with the “Choosing Wisely” campaign, an initiative of the ABIM Foundation, and came up with a list of common, but often unnecessary tests and procedures that physicians and patients should talk about. Here is a summary of the list.
Five Things Physicians and Patients Should Question
1) Don’t perform routine diagnostic laparoscopy for the evaluation of unexplained infertility.
In patients undergoing evaluation for infertility, routine diagnostic laparoscopy should not be performed unless there is suspicion of pelvic pathology based on clinical history, an abnormal pelvic exam or abnormalities identified with less invasive testing. In patients with a normal hysterosalpingogram or the presence of a unilaterally patent tube, diagnostic laparoscopy typically will not change the initial recommendation for treatment.
2) Don’t perform advanced sperm function testing, such as sperm penetration or hemizona assays, in the initial evaluation of the infertile couple.
Studies document that extreme variability exists among these tests, with very little correlation between results and outcomes. They have also been shown not to be cost-effective and often lead to more expensive treatments.
3) Don’t perform a postcoital test (PCT) for the evaluation of infertility.
This is a test where the cervical mucus is examined around the time of ovulation for sperm about 8 hours after intercourse. The PCT suffers from poor reproducibility and its predictive value for pregnancy is no better than chance. Utilizing the PCT leads to more tests and treatments but yields no improvement in cumulative pregnancy rates. I have not performed a postcoital test for mare than 25 years now!
4) Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation.
There is no indication to order these tests, and there is no benefit to be derived in obtaining them in someone that does not have a history of bleeding or abnormal clotting and in the absence of any family history. This testing is not a part of the infertility workup. Furthermore, the testing is costly, and there are risks associated with the proposed treatments, which would also not be indicated in this routine population.
5) Don’t perform immunological testing as part of the routine infertility evaluation.
Diagnostic testing of infertility requires evaluation of factors involving ovulation, fallopian tube patency and spermatogenesis based upon clinical history. Although immunological factors may influence early embryo implantation, routine immunological testing of couples with infertility is expensive and does not predict pregnancy outcome.
How this list was created
The Practice Committee of the American Society for Reproductive Medicine (ASRM) reviewed evidence from ASRM’s practice documents to identify possible topics along with suggestions for possible topics from the ASRM Board of Directors. By consensus, the Practice Committee narrowed the list to the top five most overused tests within specified parameters. Additional input was sought from the ASRM Board of Directors and incorporated. The final list was reviewed and approved by the ASRM Board of Directors. The ASRM Board of Directors and Practice Committee are comprised of representatives from every aspect of reproductive medicine through our five affiliated societies including the Society for Assisted Reproductive Technology, the Society of Reproductive Surgeons, the Society for Reproductive Endocrinology and Infertility, the Society for Male Reproduction and Urology and the Society of Reproductive Biologists and Technologists.
Clomiphene citrate (Clomid, Serophene) is a common medication used to treat infertility. It has been used in the United States since 1967. In patients that do not ovulate, clomiphene citrate is used to make them ovulate (ovulation induction). In patients that do ovulate (unexplained infertility), it can be used to induce the growth of multiple follicles (superovulation). It is often used as a first-line treatment since it has few side effects. The usual starting dose is from 50 – 150 mg. However, sometimes the starting dose can be as low as 25 mg or as high as 250 mg.
Clomiphene citrate is generally taken orally daily starting on cycle day-5 for five days (days 5 – 9 of cycle). About 5-12 days after the last dose of clomiphene citrate is taken, a woman can expect an LH surge, which signifies a subsequent ovulation. The physician will monitor the patient during this time or have the woman use an at-home ovulation predictor kit. This was to either prepare for timed intercourse or an insemination procedure.
Why is day-5 the magic number? Is it that important to start it on that day? What happens if clomiphene citrate is started earlier or later? Read on.
Typically a woman’s ovaries recruit a “dominant” follicle early in her cycle (days 5 – 7 of the cycle). This is the follicle that will subsequently grow to a size of 16 – 22 mm and ovulate. Once the “dominant” follicle is selected, other follicles will not grow.
If clomiphene citrate is started after day-5, it will not be effective in selecting multiple follicles since by that time a dominant follicle will already been selected.
When clomiphene citrate is started on day- 5, it is just in time to stimulate the recruitment of multiple follicles.
If a woman starts Clomid earlier than day 5, it is possible to stimulate multiple ‘dominant follicles’, which may result (theoretically) in a higher incidence of multiple gestation pregnancies. While some physicians may choose to begin Clomid on days 2, 3, or 4, there is not a significant increase in pregnancy rates.
However, from a nursing perspective, it is much more convenient to start clomiphene citrate on day-5. It gives time for the patient to come in for a baseline ultrasound (to confirm there are no cysts) and bloods (at InVia Fertility Specialists we like the estradiol level to be less than 100 pg/mL).
Of course in patients who do not ovulate, clomiphene citrate can be started on ANY day since these patients do not have menses. It is a good idea (in these patients) to do a pregnancy test prior to starting clomiphene citrate.
The American Society for Reproductive Medicine has as part of its practice guidelines that a couple wishing to engage in an egg donor recipient cycle must visit with a mental health professional. Given the road you have already travelled with all the hurdles you have jumped to get this far, why would you be required to see a mental health professional?
The decision to engage in an egg donor recipient cycle is a very psychologically complicated one. For most couples, using an egg donor to conceive is not your first choice. You may have undergone a great deal of testing and possibly several failed IVF attempts before your doctor recommends the use of a donor egg. Embracing the choice of a donor egg means the loss of the use of your own egg. This loss must be acknowledged and grieved by the couple. The counselor will ask you to recount your journey to conceive and help you to reflect upon it. He or she will help you understand where you are in the grieving process and if you are ready to move forward with the egg donor cycle.
Another challenging issue to discuss is with whom will you share your decision to use a donor egg. While you may want to initially keep this decision between the two of you until you are successfully and safely pregnant, ultimately, it is difficult to “keep a secret” forever. The counselor will help you to consider the different scenarios you will possibly encounter in your future, e.g. do we tell the pediatrician, the child’s guardian, siblings, grandparents, etc?
Even more critical and emotionally fraught is the decision of whether or not to disclose the use of the donor egg to the child. There are pros and cons and you will have to contend with your own family and cultural dynamics. And even in the case where you have decided you will tell the child, the question of when to tell, what to tell, and how to tell can be confusing and overwhelming. The mental health professional can help you sort out the issues you may need to consider. The counselor will offer guidance and educational material to help you in your future conversations about how to handle this very important issue.
Another area that will be addressed is the donor selection process. How have you decided to approach this highly unusual task? What are your feelings about using the donor, are you in agreement about your strategy for selection? The mental health professional will elaborate on how the psychological evaluation of the donor is conducted and speak to issues of what kind of person volunteers to be a donor and how the compensation they receive factors into their decision to be a donor.
The counselor, who possesses a professional license, will also obtain a mental health history from each of you and determine if there are any untreated mental health issues or significant life stressors that should be addressed before moving forward. This is done with the attitude that taking care of any difficulties will maximize the probability of successfully conceiving.
The spouses are interviewed separately. This format is employed so that each spouse can speak candidly in a confidential setting and attest that they are pursuing the egg donation option of their own free will. They are also free to raise any issue or ask the counselor any question they desire. The counselor will also be able to observe congruence between the spouses in what and how they report their thoughts and experience. You ‘ll then be brought together with the counselor after your individual interviews and any issues that surfaced are discussed with one last chance for questions. After signing consent forms, a brief letter indicating you have fulfilled this requirement is sent to your physician at In Via Fertility.
While the idea of going to a counselor’s office may be foreign and perhaps concerning to you, the entire experience is constructed to be informative, educational, and emotionally supportive. There is no “pass/fail” pronouncement made and the sole intent is to partner with you to do everything possible to achieve your goal of having a baby.
Mary V. Speno PhD is a licensed clinical psychologist and has been conducting recipient couple meetings for In Via Fertility since 2006. She can be reached through Lake Cook Behavioral Health Resources at 847-577-1155 x 239.
Methotrexate is a cancer drug (chemotherapy) that is used to treat tubal pregnancy. A single dose of the medication will treat a tubal pregnancy in up to 90% of properly selected patients. Thus a single injection is useful for treating a condition that previously required surgery. Sometimes, a second weekly injection is required (and rarely a third). Chemotherapeutic agents are known to have adverse effect on ovarian follicles (eggs) and fertility. This is definitely the case when they are given in high and repeated doses. It is therefore reasonable to ask, “Does methotrexate therapy for tubal pregnancy affect subsequent ovarian reserve and number of eggs retrieved during in vitro fertilization (IVF)?
This very issue was discussed in a recent publication (Fertility and Sterility 2013; In Press) by a group of researchers from a large fertility clinic with offices in Maryland and Washington DC. Hill et al. analyzed data from 153 patients that were treated with methotrexate and 36 patients treated with surgery for tubal pregnancy (or pregnancy of unknown location, PUL) from 2004 to 2010. Pregnancy of unknown location (PUL) included patients with multiple plateaued quantitative values of human chorionic gonadotropin (hCG) (values not increasing over 50% in 48 hours) or with hCG values >2,000 and no ultrasonographic evidence of intrauterine pregnancy. They analyzed basal antral follicle count (AFC), basal serum follicle-stimulating hormone (FSH) levels and number of eggs retrieved from IVF. This is what they found:
They compared result from patients treated with methotrexate (n = 153) and those treated with surgery (n = 36)
- Neither group demonstrated differences in ovarian reserve or oocyte yield in a comparison of the before and after treatment values.
- The change in ovarian reserve and oocyte yield after treatment were similar between the two groups.
- The number of doses of methotrexate was not correlated with changes in ovarian reserve, indicating no dose-dependent effect.
- Time between treatment and repeat ART was not correlated with outcomes.
- Live birth in subsequent cycles was similar in the two groups.
The authors therefore conclude that there was no difference between the use of methotrexate or surgery to treat tubal pregnancy or PUL in IVF patients. This was a large study (23,000 fresh IVF cycles were performed during the study period) that confirmed that there is no negative effect of methotrexate on ovarian reserve in IVF patients.
We want to extend a big THANK YOU at this very special time of year! We are especially thankful to all of you for giving us the opportunity to help you acheive your dream of becoming a family. To our current and former patients, thank you for updating us at this time of year with your beautiful holiday pictures and kind words. It is so fun for us to remember our patients and see their children growing up. We are all grateful to be a part of the InVia team and a part of your lives.
Happy and healthy holidays to you and your family!