As one of my final Newsletter columns, I would like to touch upon my favorite subject in obstetrics and gynecology, that is infertility care. Over the years, I have seen a number of cases where infertility patients have gotten lost in the system. Don't let that happen to your patients.

It's appropriate to begin an infertility valuation whenever a patient expresses anxiety with her lack of conception. This is especially true when the patient is over 35 years of age. Don't send her off to do three months of basal temperature charts to "prove that she is serious". Use her time wisely, for indeed her biological clock is truly running and her anxiety level is building monthly. I am not suggesting that we run immediately to the Operating Room to carry out a diagnostic laparoscopy; however, a thorough and no-invasive work up an easily be accomplished within six weeks for most couples. Obvious problems will be detected and can then be treated appropriately and timely. Don't put her off.

Our various therapies each have expected pregnancy probabilities. Know what these are in order to move on to more advanced treatments in an expeditious fashion. This will avoid patients continuing a course of management well beyond the hope of success. Too many times, for example, I have seen patients on clomiphene citrate for 10 to 12 months, when good data suggests that most pregnancies will occur in the first four cycles. This is exposing patients to needless therapy, expending their energies and perhaps causing enough frustration that they prematurely quit their treatments. It might be helpful to put things in perspective for your patients by sharing with them the expected natural fecundity rate for her particular age presuming all things are normal. Rave a finite, agreed upon end point with all therapies.

Move on in an orderly fashion from simple treatments to progressively more advanced and complex therapies. One mistake that can be made is to hold back on the "final" option of in vitro fertilization much too long. Age clearly is a big determinant to IVF outcome. Additionally, patients with recurrent, significant endometriosis are losing ovarian function and reserve follicles as they go through repeat operative procedures for recurrent endometriomas. Before you know it, when IVF is finally suggested out of desperation, the ovaries respond very poorly, resulting in a much-lowered likelihood of pregnancy. I suspect that such a patient would have done much better if IVF had been considered earlier, while her ovaries still functioned well. Don't save WF as a "last resort".

Be careful with empiric therapy. Often times, if you look well enough, a specific problem can be found, and addressing it will frequently result in pregnancy. There is very little, if any, good evidence based data for many of the random treatments that are utilized. Some may even lessen the chance for pregnancy, such as using clomiphene citrate in a patient who is already spontaneously ovulating quite fine on her own. This would be due to the negative endometrial and cervical effects that can develop after a few months of use. Know what you are treating. Stay on top of your patient's treatments. Be involved. Keep looking for the little things that could prevent success. Review appointments every two months are very helpful here.

Finally, set up guidelines at the start of your therapy. What are the realistic expectations for this specific couple, given their history and age? Don't give them false hope of success. How far is this couple willing to go in their efforts to conceive? This needs to be known to prospectively plan a sequential course of action. Remember that outside consultation is available. Don't forget to say when enough is enough and it's time for your couple to move on with life. Just do your best to maximize their efforts along the way.