Diagnosis before treatment
Dear Professor Winston,

My husband and I have been trying for a baby over 5 years. I suffer from Polycystic ovarian syndrome and my husband’s sperm morphology is low. I am 33 and he is 42. Neither of us has ever had children. To date, we have had 2 fresh and 1 frozen ICSI cycles (last year). All were unsuccessful – no pregnancy achieved. I had endometrial scratching with the second fresh ICSI. Fortunately all this treatment was funded by the NHS Trust so no major costs implications so far. Now we are considering private clinics in UK or Poland (where I am from). I was told that we could benefit from karyotyping/genetics tests and hysteroscopy. Would you be able to advise me on that? Fertility treatment can be very confusing and it is difficult to make right decision. I think that statistics are far more important than individual cases. I quote my consultant: “we are not here to diagnose, we are here to treat.” I am not sure if I agree with that? With Regards, K.

Dear K,

If what you say in your email is correct, I am very perturbed. Did your doctor really say to you “we are not here to diagnose,we are here to treat”? Please confirm this if you can, or otherwise. Where are you being treated and who is your consultant?

Clearly a diagnosis should come before treatment – otherwise you may get the wrong treatment at an emotional cost to you (i.e. failure) and also a cost to the NHS. Why are they suggesting a hysteroscopy now? Have you had an X-ray of the uterus, an hysterosalpingogram? And why the karyotype? If you are sable to give me an answer, I’ll see what I can suggest.

Best wishes
Robert Winston

Dear Professor Winston,

Thank you for your reply.
I will try to answer all your questions.
I am currently finishing a last FET with Hull IVF Unit. It is difficult to judge but I think that despite of my consultant’s statement (which is true) I have received professional care. I have never had any x rays done. My husband and I had series of blood tests and his semen evaluated. Based on results (which have not been fully discussed with us) our consultant decided that IVF is the best option for us. We produced good quality blastocysts in each cycle. We had also visited one of the polish clinics (initial consultation) and was advised on karyotype check and hysteroscopy?
I hope that I clarified all issues. I am looking forward to hearing from you.
With regards ,

Dear K

I really do not think I can help you. But let me explain why: a basis for all medical treatment is first to make a diagnosis. If you have a headache, your GP doesn’t arrange for you to have chemotherapy for a brain tumour until the diagnosis has been made – you may have eyestrain, or a problem with your teeth, a migraine, or meningitis, or just are severely stressed and overtired.

But you have gone through a demanding, expensive treatment (even if you haven’t paid for it it is still expensive to the NHS) and you are empty handed. So now you are asking me what to do – but I cannot help you without a diagnosis. What you seem to be entering into is a disparate group of investigations without any clear method or rationale for them. A comprehensive assessment of your fertility should normally include at least the womb x-ray, a laparoscopy, full hormone tests (the results of which are fully discussed with you and fully explained), regular ultrasound, a post-coital test, ultrasonography and so on. Yet you are asking me about a karyotype, which of all the tests that are worth doing is one of the least likely to give you serious usable information, and a hysteroscopy which is never as valuable and informative as a womb x-ray.

So my advice must be the same as it is for any medical condition at any stage – a lump in the breast, chest discomfort, joint pain, or feeling faint. Find out clearly what is wrong if at all possible and then whenever possible treat the underlying cause. Treating symptoms (in your case infertility) is very likely to leave you no better off and indeed sadly empty-handed.

So sorry not to be of more use.
Robert Winston

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