What's the Plan?

Patients can usually be divided into active and passive subtypes. Active patients read books (like this one), cruise the internet, pepper their RE with questions and engage in extensive discussions of the options available to them. Passive patients look across the desk at us and say “Doctor, you decide what is best.” Although at the end of the day, the active patients can certainly leave you feeling exhausted, I really enjoy these interactions and the challenge of making a treatment plan with them. I worry about the passive patients. Do they really understand what they are doing? Can they justify the treatments that they are pursuing in terms of finances and the emotional/physical/psychological costs of infertility care? If they abdicate all responsibility for the decision making process then I am left on the hot seat.

So when making a plan where do we start? First of all, we consult the “Magic 8 Ball” of fertility care and whatever treatment appears in that little window is what we do…not really. This question is the “Question of the Day” from the book that has yet to generate any interest in Hollywood…although rumor has it that Matt Lauer wants to play me if the movie ever gets made.

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

In general, reproductive endocrinologists recommend a particular course of treatment only after obtaining the results from the full spectrum of fertility tests. These tests usually include a pelvic ultrasound, an assessment of tubal patency (hysterosalpingogram or laparoscopy), a semen analysis, and a variety of 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). 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 will offer counseling about the alternative treatments available to them. Not all couples are prepared to undergo extensive treatments for their infertility, so their physician will likely tailor the options appropriately when proposing a course of action to a particular couple. 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.