Top 5 infertility tests that physicians and patients should question

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.