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Taking a history in the evaluation of women with tubal factor infertility
FERTILITY AND STERILITY威 VOL. 81, NO. 1, JANUARY 2004 Copyright ©2004 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A.
Taking a history in the evaluation of women with tubal factor infertility David Hubacher, Ph.D.,a David Grimes, M.D.,a Roger Lara-Ricalde, M.D.,b and Julio de la Jara, M.D.b Family Health International, Research Triangle Park, North Carolina; and the Instituto Nacional de Perinatologia, Mexico City, Mexico
Little proof exists that taking a history aids in the evaluation of women with tubal factor infertility. (Fertil Steril威 2004;81:18. ©2004 by American Society for Reproductive Medicine.)
Received June 9, 2003; revised and accepted June 9, 2003. Supported by the United States Agency for International Development (USAID) and the National Institute for Child Health and Human Development through a contract with Family Health International (USAID contract no. CCPA-00-95-00022-02). The views expressed in this article are those of the authors only and do not necessarily reflect those of the authors’ affiliate institutions or of the agencies that provided research funding. Reprint requests: David Hubacher, Ph.D., Family Health International, P.O. Box 13950, Research Triangle Park, NC 27709 (FAX: 919-544-7261; Email: [email protected]). a Family Health International. b Instituto Nacional de Perinatologia. 0015-0282/04/$30.00 doi:10.1016/j.fertnstert.2003. 06.013
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Our critics make an impassioned plea for the status quo. However, they provide no objective evidence of the typical validity or reproducibility of women’s recall of upper genital tract infection. Given that many damaging cases of salpingitis are asymptomatic (“silent”), information gained by history alone is doomed to being incomplete. Such was the situation in the study cited by McComb (1) in which over a quarter of patients had no identifiable etiologic cause for their tubal factor infertility. Research has documented that patients have difficulty recalling even memorable health events such as hospital admissions and fractures (2– 4); to expect valid and reliable information about often asymptomatic infections is unrealistic. Moreover, given the low threshold for medical intervention for possible pelvic inflammatory disease and the resulting false-positive cases, many women will simply believe they had the condition; this further limits the usefulness of this history. As noted a quarter century ago by the Editor of The New England Journal of Medicine (5), physicians have an ethical obligation to make sure that what they do is worth the money, pain, and inconvenience that it costs, yet re-
grettably, most practices have never been validated from that point of view. Unless we question traditional practices, we will not make progress. For example, the postcoital test was a routine part of the infertility evaluation for 140 years; evidence has now shown that it drives up the cost and complexity of care without improving outcomes (6). We hope that the controversy we raised will prompt others to replicate our study; only with additional evidence can our conclusions be confirmed or refuted. References 1. Taylor RC, Berkowitz J, McComb PF. Role of laparoscopic salpingostomy in the treatment of hydrosalpinx. Fertil Steril 2001;75:594 –600. 2. Norrish A, North D, Kirkman P, Jackson R. Validity of self-reported hospital admission in a prospective study. Am J Epidemiol 1994;140:938 –42. 3. Champion VL, Menon U, McQuillen DH, Scott C. Validity of self-reported mammography in low-income African-American women. Am J Prev Med 1998;14: 111–7. 4. Honkanen K, Honkanen R, Heikkinen L, Kroger H, Saarikoski S. Validity of self-reports of fractures in perimenopausal women. Am J Epidemiol 1999;150: 511–6. 5. Relman AS. On controversy in medicine. Pharos Alpha Omega Alpha Honor Med Soc 1978;41:18 –22. 6. Oei SG, Helmerhorst FM, Bloemenkamp KW, Hollants FA, Meerpoel DE, Keirse MJ. Effectiveness of the postcoital test: randomised controlled trial. BMJ 1998; 317:502–5.
Taking a history in the evaluation of women with tubal factor infertility David Hubacher, Ph.D.,a David Grimes, M.D.,a Roger Lara-Ricalde, M.D.,b and Julio de la Jara, M.D.b Family Health International, Research Triangle Park, North Carolina; and the Instituto Nacional de Perinatologia, Mexico City, Mexico
Little proof exists that taking a history aids in the evaluation of women with tubal factor infertility. (Fertil Steril威 2004;81:18. ©2004 by American Society for Reproductive Medicine.)
Received June 9, 2003; revised and accepted June 9, 2003. Supported by the United States Agency for International Development (USAID) and the National Institute for Child Health and Human Development through a contract with Family Health International (USAID contract no. CCPA-00-95-00022-02). The views expressed in this article are those of the authors only and do not necessarily reflect those of the authors’ affiliate institutions or of the agencies that provided research funding. Reprint requests: David Hubacher, Ph.D., Family Health International, P.O. Box 13950, Research Triangle Park, NC 27709 (FAX: 919-544-7261; Email: [email protected]). a Family Health International. b Instituto Nacional de Perinatologia. 0015-0282/04/$30.00 doi:10.1016/j.fertnstert.2003. 06.013
18
Our critics make an impassioned plea for the status quo. However, they provide no objective evidence of the typical validity or reproducibility of women’s recall of upper genital tract infection. Given that many damaging cases of salpingitis are asymptomatic (“silent”), information gained by history alone is doomed to being incomplete. Such was the situation in the study cited by McComb (1) in which over a quarter of patients had no identifiable etiologic cause for their tubal factor infertility. Research has documented that patients have difficulty recalling even memorable health events such as hospital admissions and fractures (2– 4); to expect valid and reliable information about often asymptomatic infections is unrealistic. Moreover, given the low threshold for medical intervention for possible pelvic inflammatory disease and the resulting false-positive cases, many women will simply believe they had the condition; this further limits the usefulness of this history. As noted a quarter century ago by the Editor of The New England Journal of Medicine (5), physicians have an ethical obligation to make sure that what they do is worth the money, pain, and inconvenience that it costs, yet re-
grettably, most practices have never been validated from that point of view. Unless we question traditional practices, we will not make progress. For example, the postcoital test was a routine part of the infertility evaluation for 140 years; evidence has now shown that it drives up the cost and complexity of care without improving outcomes (6). We hope that the controversy we raised will prompt others to replicate our study; only with additional evidence can our conclusions be confirmed or refuted. References 1. Taylor RC, Berkowitz J, McComb PF. Role of laparoscopic salpingostomy in the treatment of hydrosalpinx. Fertil Steril 2001;75:594 –600. 2. Norrish A, North D, Kirkman P, Jackson R. Validity of self-reported hospital admission in a prospective study. Am J Epidemiol 1994;140:938 –42. 3. Champion VL, Menon U, McQuillen DH, Scott C. Validity of self-reported mammography in low-income African-American women. Am J Prev Med 1998;14: 111–7. 4. Honkanen K, Honkanen R, Heikkinen L, Kroger H, Saarikoski S. Validity of self-reports of fractures in perimenopausal women. Am J Epidemiol 1999;150: 511–6. 5. Relman AS. On controversy in medicine. Pharos Alpha Omega Alpha Honor Med Soc 1978;41:18 –22. 6. Oei SG, Helmerhorst FM, Bloemenkamp KW, Hollants FA, Meerpoel DE, Keirse MJ. Effectiveness of the postcoital test: randomised controlled trial. BMJ 1998; 317:502–5.