The phases of the effort to deal with infertility.
Measures and policies that can help to better address infertility.
I have completed 22 years of exclusive work in the field of infertility, and I consider it appropriate to present my conclusions on the subject. I hope that from a scientific point of view the data I have communicated through publications or announcements have contributed to a fuller understanding of the complex nature of the problem. I hope that from a social point of view, the elements that I quote will contribute to addressing the problem in the most pain-free way, by those who are directly related.
The purpose of the effort is clear: the greatest possible benefit with the least expenditure of physical health, mental health, time, and money.
In these 22 years, significant progress has been made in two areas. The one concerns the improvement of IVF and its results and the other concerns the causal approach to infertility and miscarriages. Regarding the first, progress has been made with the continuous improvement of stimulation protocols as well as with the imposition of stricter measures of standardized work and careful handling in embryological laboratories. The competition which arose from the increase of the number of in vitro fertilization centers also played an important role here. Improving the freezing and thawing conditions of embryos, sperm, and eggs, also played an important role.
Admittedly, however, the probability of success of any IVF effort has increased due to the gradually applied causal approach and individualized dealing with the problems of infertility of each couple. This area should not be considered as something simple. In my opinion, it is a complicated and complex section of medicine, where many factors interact and eventually add up to each other, leading to infertility as the final result. The important thing, however, is that despite the heterogeneity of infertility factors, these are now more specified than in previous years. Their everyday treatment contributes to new pregnancies, even with natural conception.
This should be the primary goal of every couple: natural conception. However, at the same time, the maintenance of the pregnancy until the end must be ensured in advance, since miscarriages occur much more often in couples with a history of infertility.
The basic measure, then, that I propose to the couple is to set goals from the beginning and possibly set deadlines.
The first goal should be to determine the responsible causes involved.
That is, the couple must find out exactly why the pregnancy is not coming. Under no circumstances should any treatment or any assisted effort be initiated, unless there is a first conclusion determining all the factors involved individually in the infertility of the particular couple. The only exception is the treatment of the couple’s microbes, which is also a matter of hygiene. And, of course, all this must be done before any thought of trying IVF.
Unfortunately, in most cases this does not apply. By examining a sperm chart and a salpingography, most couples take the path to multiple assisted efforts. Also, unfortunately, if — despite the series of efforts — no pregnancy occurs, these cases are classified as unexplained!
In order to avoid this possibility, it is clearly suggested to insist on the first question: “what are the reasons that we do not conceive?” The cogency of this answer must be well judged by the couple, based on their logic. If they have not understood something, they have to clarify it by asking questions. And for the doctor, I have to say that he knowledgeable in his subject if he knows well how to communicate it on to the non-specialist.
Along with the first question “what are the reasons that we do not conceive?”, the following one must also be asked: “if we do conceive, how do we know that we have done everything to prevent a failed pregnancy?” Considering this, convincing answers must also be given by the doctors. I remind you of course that this is a complex medical field, that extends to the subjects of many clinical laboratories and research specializations. Even for a trained doctor it is not always simple to be able to easily assess every case. What I have concluded is that the doctor requires expertise, experience, and research thinking. Unfortunately, many, in order to appear worthy of expectations, instead of referring to experts, prescribe too long lists of examinations that of course do not focus on questions. What’s even worse, they often misjudge the results. And all this, because of the egoism of the Greek to admit the truth: that he is not sufficiently specialized in the subject, so that he may hold the fate of his fellow man in his hands. And of course, the object of the obstetrician-gynecologist is already huge. He is not required to know the many details required by andrology, immunology, hematology, endocrinology, genetics, and medical laboratory technology — nor can he; but all these are indeed relevant to the subject. In fact, they are often required to a greater extent by classical gynecology and even by assisted reproduction. In particular, the parameters of the sperm are much more important than we considered in the immediate past.
At this point, however, special attention must be paid to the financial issue. Tests must be personalized, few and focused. The term “examination package” does not represent an individualized investigation. It is mostly related to a financial transaction budget. But if a lot of money is spent, then sooner or later it also affects the psychology. The situation then becomes much more serious. Market research must always be done in advance, as well as an effort to prescribe the examinations in the public coffers, at least those provided by the relevant Government Gazette. If a center or laboratory is suggested by doctors, the couple should get a convincing answer about this choice. The higher cost of the exam should be worth the difference and offer higher quality information.
We maintain this position because we do not live in a society of angels. Wherever there are financial transactions (not only in the provision of medical services, but in other sectors as well), very often middlemen and percentages (bribes) intervene, whose effects are not only financial, alas! In my opinion, the biggest impact is the decline of the morale of the woman who tries to get pregnant, as she gradually realizes the inadequacy of her doctor. And then comes the insecurity regarding the doctors that will follow…
Having a good psychology, the interested parties (the couples) should be both well-intentioned and suspicious. They must ask questions and always get reasonable answers. They should always feel the return value of the money they spend. Of course, the problems of each couple are different. In some cases, they are more complex, in some other cases they are simpler. But in general, the knowledgeable doctor can inform the couple about the complexity of the problem in such a way that the interested parties understand the justification of the expense.
The second goal is to take therapeutic measures and complete the etiological treatments.
Those interested should understand the relevance of their treatments. That is, they need to know for which infertility factor they are taking each treatment. This way they can ask clarifying questions to the doctors, so that no mistakes are made in the treatments (something that unfortunately happens quite often and is usually not the doctor’s fault).
It has been reported that etiological therapies begin with the treatment of infectious agents (microbial). After that, follows the treatment of the other factors, depending on the way of pregnancy attempt. After the fulfillment of the first goal, i.e., after the end of the diagnostic phase, the couple must orient themselves to the way of attempt. In many cases, where the fallopian tubes are blocked or there is a serious sperm problem, or the couple — for reasons of age or for other reasons — wants the effort “here and now”, there is no question: the IVF effort comes immediately after the completion of the second goal (i.e., taking therapeutic measures). In fact, many of the etiological treatments are temporally adapted to the probable date of ovulation or to the embryo transfer.
But when there are no extreme conditions, that is, when even a doctor can claim that conception can be achieved in pain-free ways, then the couple must set deadlines. That is, “we are listening to you, doctor, and we would very much like to succeed in a natural way, but we cannot wait indefinitely. So, we give a deadline of some months (monthly cycles), after considering our age, our psychological state, our finances, our work, our relationship, the advice of the breast surgeon and the advice of our family doctor; this way, conception might come naturally and so we avoid taking many medicines or making a lot of expenses”.
And in this phase (i.e., of the deadline, regarding natural efforts), the causal therapeutic measures (apart from antibiotics) must be taken correctly in each cycle of effort. Great care is needed for the continuous and at the same time correct receiving of treatment, since apart from the antibiotics that were initially taken for the eradication of germs, all other treatments are temporary measures; that is, they are valid only for a while and must be repeated regularly to remain in force.
During this period, either in the case of natural conception attempts or in the case of assisted ones, most couples achieve pregnancy. The treatments they have received have contributed to the success and in fact will continue to contribute to the proper maintenance of the pregnancy if the instructions and the treatments are applied correctly during the first trimester. If conception does not occur, a meeting with the doctor should follow, about whether a stricter examination should follow, or an attempt should be made in an assisted way, insemination, or IVF.
The penultimate goal. We are pregnant and we need to arrive well at the 12th week.
At this point there is no need for excitement and excessive mobilization. We remind you that unfortunately, failed pregnancies occur mainly in the first trimester and are even more common in couples with difficult fertilization.
It takes patience, optimism, and acceptance of the state of pregnancy in order to control as much as possible (even voluntarily) abrupt movements.
We remind that in the first trimester, there is a congestion of blood in the vessels of the endometrium and with the slightest rupture, detachment can occur, which can be a serious threat.
But in the first trimester, especially worn-out women must not ignore the possibility of a bad outcome. There is one factor (the chromosomal one) that does not warn about the quality of the fetus. Unfortunately, a chromosomal abnormality in a fetus can occur even if the couple still has normal karyotypes. I suggest that women observe their pregnancies as spectators, not only as protagonists. I maintain this view, trying to make the impact of a failed pregnancy on subsequent psychology as light as possible. And for the effort that will follow, the psychology must be as good as possible. An effort cannot be continued when morale has already given up.
I also suggest that the couple do not announce their pregnancy imprudently. Depending on the psyche and the character, the couple may feel bad when they have widely announced a pregnancy that did not end successfully. The right thing to do is to announce the news to their family environment in a controlled way, calculating in advance all the possibilities. At the end of the trimester, the fetal measurements — if they are good — put a first stamp that we are well on our way to the last goal. But, as far as it concerns me, my subject ends here.
