More is not always better with fertility treatment

The fertility clinic waiting room is a space where many people will find themselves at some point in their lives. In spite of cheery music, shared success stories, infertility awareness weeks, and positive media campaigns, this can be a challenging and sensitive time.

About one in six Canadians experience fertility problems — these range from difficulties getting pregnant to difficulties staying pregnant and experiencing pregnancy loss.

As fertility specialists, we know that most of our patients have a very specific goal: having a baby and growing their families. They are very motivated and focused and make sacrifices of their time, resources, relationships, and well-being to achieve it.

Fertility treatments can be intensive and disruptive to the lives and routines of our patients. Our protocols often involve invasive testing and examinations that need to be done on nearly a daily basis for periods of time. These can include frequent internal (transvaginal) ultrasound alongside daily injection medications and blood work. These tests and treatments are timed to our patients’ menstrual cycles, which can sometimes be difficult to predict or plan ahead of time.

But not all tests, medications, and treatments offer clinical value. And more is not always better when it comes to fertility treatment.

To help ensure fertility patients aren’t offered options that are not clinically beneficial, the Canadian Fertility and Andrology Society (CFAS), which represents over 800 reproductive specialists, scientists and allied health professionals working in the field of Assisted Reproduction in Canada, has joined with the Choosing Wisely Canada campaign, to urge both clinicians and patients to talk about what interventions they need and what will not benefit them.

We have developed a list of recommendations showing that sometimes in reproductive medicine, more interventions may be unnecessary, wasteful, and sometimes harmful. While our patients are looking for hope and good outcomes, we shouldn’t try to meet these expectations with unnecessary medications, procedures, and tests. This wastes precious health care resources, our patients’ time, and, most importantly, can cause harm.

Patients undergoing fertility care spend a lot of time in our waiting rooms, but fertility doctors need to do better as a profession to ensure that it is time well spent.

One of the recommendations on our list has to do with the overuse of medications; specifically, patients should avoid high doses of gonadotropins during ovarian stimulation for in-vitro fertilization (IVF).

Gonadotropins are injectable hormones patients are taught to self-inject during IVF cycles in order to grow multiple follicles, each of which contains an egg. The goal is to have multiple mature eggs, which can be assisted by these medications. However, too much of this medication can have very harmful side effects, such as ovarian hyperstimulation syndrome, causing bloating, pain, fluid in the abdomen and lungs, and other harmful side effects.

Another recommendation on our list is about unnecessary testing, such as avoiding routine genetic testing on embryos prior to IVF. While this testing can be beneficial for certain patients, it should not be recommended for all, especially since the testing carries a risk of misdiagnosis and is expensive, which can add undue stress to an already stressful experience.

Reducing unnecessary testing and treatments in reproductive medicine is a powerful way to demonstrate respect for those undergoing the procedures: their time, bodies, and well-being.

Instead of asking patients to come to clinic for a redundant test or treatment that won’t help achieve a pregnancy, fertility specialists could give patients a day off. Sometimes a conversation with our patients about their hopes, fears, expectations, and challenges is the best medicine and can make this challenging time less stressful.

As fertility specialists, we encourage both patients and colleagues to start a conversation about what they need and what they don’t. To start that conversation, Choosing Wisely Canada has four critical questions to kick off a conversation:

1. Do I really need this test, treatment, or procedure?
2. What are the downsides?
3. Are there simpler, safer options?
4. What happens if I do nothing?

Claire Jones is a gynecologic reproductive endocrinology and infertility specialist and co-chair, Choosing Wisely working group for the Canadian Fertility and Andrology Society. Eileen McMahon is a nurse practitioner and president, Canadian Fertility and Andrology Society.

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