Our Featured Professional: David Sable, MD
Director, Division of Reproductive Endocrinology
Saint Barnabas Medical Center
Why is there is often no diagnosis?
During training, one of the things that I loved about medicine was the systematic, detective-like way we were taught to go about the process of diagnosis. Every problem had an approach. History, physical exam, laboratory tests, and imaging studies allowed us to narrow down to a differential diagnosis and arrive at an exact cause for whatever the patient's problem was.
Following this pinpoint diagnosis came an equally well-matched cure (after which the doctor went home and had dinner by 5:00 PM). Needless to say this image has been filed in the "naive illusions about medicine" file that resides just behind the folder holding my receipts for malpractice insurance premiums.
Sometimes there are no answers
I now tell my patients that we are much better at achieving results then we are at giving answers. I recommend that they reconcile themselves to the distinct possibility that while we may help them achieve to a pregnancy, we may never be able to tell them why they had trouble in the first place.
I began my career looking for many diagnoses: male factor, anovulation, tubal factor, endometriosis, cervical factor, luteal phase defects, fertilization defects, inadequacy of the uterine lining, timing problems, coital difficulties, ejaculatory defects and (in a very few patients I was sure) a diagnosis of unexplained infertility.
To go along with my grab bag of diagnoses, I had a war chest full of tools to test for them. The basics included the hysterosalpingogram and semen analysis. The laparoscopy was indispensable and the endometrial biopsy a necessary part of every evaluation.
Then there were the post coital test, the hamster egg penetration test, the hemi-zona assay, the hyperosmotic swelling test, the repeat endometrial biopsy, the third repeat endometrial biopsy, the second look laparoscopy, the CA 125 level, the uterine Doppler blood flow study and enough other tests to insure that I would probably never get around to treating anyone before running out of diagnostic possibilities.
Fast forward to 1998: after working in one of the most technologically advanced and sophisticated centers in the world, I am left with the conclusion that virtually all infertility is unexplained and that the best thing I can do for my patients is to work back from the end point. Get them the baby first; worry about what prevented it later.
Of course this is bit of an exaggeration and I do nothing without knowing the couple's tubal status, sperm count and FSH level. These cases notwithstanding, however, my several thousand patients and several tens of thousands of treatment cycles have taught me that certain patterns of treatment, unencumbered by the false paths that certain diagnoses often lead to, get us to pregnancy much more efficiently.