Monday, August 23, 2010

Treatment by halves

" Sonny, send your worst cases to your enemy"-An old Gynaecology Professor to his assistant.

At the Wadia Maternity and Gynaecological Hospital in Mumbai that is exactly what we get. Women who have undergone multiple surgeries that have failed, multiple cycles for infertility treatment and have exhausted their resources but not hope, have lost a number of babies and are taking that one final chance, mothers carrying babies with severe growth restriction or anomalies where the gynaecologist doesn't want to break the bad news, ART practitioners who want their patients to undergo laparoscopy cheaply and save money for IVF and so on.
I speak from hind sight and a review of cases that I have managed and here are some of my observations-
ART practitioners, seem to jump too soon into IUI and then IVF cycles and further ICSI if all fails.
Several patients have a simple problem like lack of knowledge of fertile period, insufficient frequency of coitus, use of lubricants or douches, washing off the ejaculate, pain during intercourse from infection or inadequate relaxation and just advising couples on these basic techniques works for them.

The cervical factor is another neglected area. Most IVF clinics do a transvaginal scan and a simple per speculum or per vaginal check is skipped. Cervical erosions, ulcers, small polyps chronic cervicitis contributing to her infertility are missed. The first time the cervix is looked at is during an IUI by which time its too late to treat and the doctor proceeds with the procedure-which is likely to fail if the infection has tracked into the uterus or results in an abortion should a pregnancy occur. A simple procedure like a cryo or thermo cauterisation cure the erosion and several patients conceive spontaneously after.

Sometimes the cervical canal is tortuous or stenosed or there are large cysts [Nabothian]-obstructing passage of sperms and causing infertility. A generous dilatation, rupturing the cysts, removing the polyps and lysing the adhesions cures the infertility or makes the IUI or Embryo transfer much smoother and bloodless and hence more likely to be successful.

Uterine polyps are treated by most gynaecologists by simply pulling it or curetting it out-increasing chances of recurrence. If done at hysteroscopy taking care to cut the base, the polyp is unlikely to recurr and the patient has better chances of pregnancy -spontaneously or assisted.

Fibroids not only distend the uterine cavity, make the endometrium inflamed and hostile to implantation, they may mechanically obstruct passage of sperm if they are close to the cervix or the fallopian tubes. They also make an IUI / ET a bit more difficult. With modern laparoscopic techniques, it is possible to have few or no adhesions after myomectomy and often patients conceive after the myomectomy.

Poly cystic ovaries or indeed any ovarian cyst needs to be diagnosed and ovarian drilling removes large unruptured follicles that mechanically obstruct newer ones, changes the hormonal environment, and these patients come back pregnant much to their surprise. If they are on treatment, ovarian drilling makes them sensitive to drugs like clomiphene to which they were hitherto resistant, reduces their requirement of gonadotropins and chances of Ovarian Hyperstimulation. However one needs to do just 4-5 punctures, with a minimum current for just a few seconds and copiously irrigate the ovary to avoid thermal damage to other eggs.

Endometriotic cysts are often punctured and left to nature by gynos not sufficiently confident of endoscopy-removing the cyst wall is essential to prevent recurrence of these cysts.

Tiny patches of endometriosis are also left untouched-these release several factors that inhibit ovulation, alter tubal and uterine peristalsis and interfere with conception. Removal of all endometriosis, makes a patient better responsive to ovulation induction and increases her chances of pregnancy.

If there is a problem in sperm count or motility, the male partner is sent to an andrologist who may rule out hernias, hydrocoeles, varicocoeles and undescended testes but rarely bothers to do his sugars, thyroid function tests and take a history of exposure to high temperature or stress, do a semen culture and treat the infection. An exhorbitant nutritional supplement is prescribed that most men stop after a month because of the cost. It is so easy and cost effective to test and take a history to get at the real problem before jumping to do an IUI where the few poorly motile sperms will also be lost and then to ICSI. The chances of successful ART  are also increased by taking care of these other common problems.

Finally, many women have multiple cervical dilatations for various procedures and often have an incompetent os on top of a multiple gestation. Good idea to look out for this prior to infertility treatment and continue to look for it from 3 months onwards with a sonography[ most sonologists never comment on the cervix] and take a stitch if required, preventing a precious pregnancy aborting.

Male gynaecologists avoid proper exam of the patients breasts which is left to nurses. they often miss galactorrhoea and though the prolactin levels are normal, correction of the galactorrhoea does often restore normal cycles and fertility.

Thyroid disorders are missed if the tests are not done at a good laboratory-so looking for signs of thyroid disturbance and sending these patients blood to a good [although expensive] lab may be worth it.

So lets 'Look at the patient not just the disease'. Lets not be in a hurry to start an ART cycle. Lets take care of everything we possibly can-this would help our infertile patients get pregnant at minimum cost and carry their babies to term which is the final aim of both the patient and the doctor.