Question 18. How will my reproductive endocrinologist determine a plan of therapy?

Here in Washington we are surrounded by planners. People are available to plan your party. People are available to plan your finances. People are available to plan for your kid applying to college (or secondary school or even kindergarten). People are available to plan your attempt to lose weight and get in shape (personally I am doing the Special K diet...gotta look good for my college reunion at the end of May). So it is not surprising that patients look to their RE to plan their fertility evaluation and treatment. I am not a "me doctor - you patient" type of guy, but there is a point where I step up and say here are my recommendations. These may be negotiable but I really try to give my perspective. And yet, it doesn't matter how wonderful the plan seems to me.....if it is unacceptable to the patient then it is back to the drawing board.

Cookie cutter medicine is dangerous. One size does not fit all. I really hope that the physicians of tomorrow will still try to individualize care rather than relying upon only guidelines. My mother was diagnosed with breast cancer back in 1993. She had a very poor prognosis at that time with a <5% five year survival rate. One oncologist told my Dad that if it was his wife that he would "take her to Florida and make her ready for the end." Well, my Dad refused to take that advice and she underwent surgery, chemo and radiation therapy. Now 17 years later she has, knock on wood, never had a recurrence of her cancer. Fertility treatment can be nearly as stressful but the spontaneous cure rate is much better than with cancer. One of the best aspects of offering Natural Cycle IVF has been to allow patients with a poor prognosis to still try their hand at IVF. For some of these patients it is enough to have tried and then they can either give up or pursue donor egg IVF or adoption. For the ones that have a baby after being told that they were a hopeless case, Natural Cycle IVF seems nothing short of a miracle.

So here is today's Question of the Day.


18. How will my reproductive endocrinologist determine a plan of therapy?


In general, reproductive endocrinologists recommend a particular course of treatment only after performing a complete fertility evaluation which usually include a pelvic ultrasound, an assessment of tubal patency (hysterosalpingogram or laparoscopy), a semen analysis, and a variety of hormonal blood tests.

The therapeutic plan for any couple is unique to them. If testing has demonstrated a clear problem, such as blocked fallopian tubes or a markedly abnormal sperm count, then in vitro fertilization (IVF) may be recommended as the only reasonable alternative. However, most couples are not sterile but merely subfertile, so they may be offered a range of therapeutic options—from expectant management, to the use of insemination with or without fertility drugs, to IVF with or without intracytoplasmic sperm injection (ICSI). Furthermore, IVF can be performed using the patient’s own eggs, donor eggs, or donor sperm.

A couple’s particular therapeutic plan will be developed with their specific needs in mind. For those patients in whom IVF is not an option, whether because of religious, financial, or philosophical reasons, the physician should provide counseling about alternative treatments available to them. Not all couples are prepared to undergo extensive fertility treatments, so physicians need to consider a couple’s particular situation when proposing a course of action. Given that infertile couples can sometimes achieve spontaneous pregnancies, the desire of a couple to proceed with therapy needs to be weighed against the likelihood of success for that therapy and the cost involved. These costs may include financial, physical, and emotional considerations. We strongly urge our patients to consider ll options when dealing with infertility including alternative pathways to parenting ranging from adoption to the use of donor sperm, donor egg, donor embryo and gestational surrogacy.

Carol comments:
I feel that finding an RE who will work with you and listen to you is one of the most important factors in achieving a positive outcome. Each individual who is faced with infertility deals with the varying costs (financial, physical, and emotional) differently. For some, the financial aspect limits the number or attempts they can make. For others, the physical and emotional aspects take such a toll that they are only willing to go through a set number of attempts. Based on my discussions with other women who have faced fertility challenges, I believe that each person has a unique threshold for these costs. If you are dealing with a doctor who strictly adheres to a “one size fits all” policy and won’t take your personal situation into consideration, it will only add more stress to an already stressful situation.