In medicine, an accurate diagnosis is very important for the prescribed treatment to be effective for rather obvious reasons. This includes diagnosis and treatment of infertility. Yet, majority of infertility patients
are misdiagnosed and as a result, their treatment is delayed, ineffective, frustrating and unnecessarily costly.
The exact numbers for misdiagnosis of infertility are unavailable and it is not clear how to extrapolate them from the existing data. However, I believe that the problem is rampant and several infertility
conditions are grossly over diagnosed. Probably the most abused wrong diagnosis is male infertility. A popular web site makes fun of parathyroid hormone ( PTH ) testing by noting that it has ridiculously
high rate of errors - 15% and goes on saying that this is unheard of in modern medicine. Well, I wonder what would say say about semen analysis. Two standard deviation on a typical proficiency testing for semen morphology comfortably cover a large area on both sides of normal and abnormal. What it means, for the patient is that his test results
with a high probability will be normal or abnormal depending on where the test has been done and yet, in both cases his test result would have to be considered accurate by diagnostic testing standards. What is the problem with misdiagnosing a perfectly fertile men with infertility? Such misdiagnosis, particularly in case of "moderate infertility", will typically result in IUI cycle (usually more than one), which
would be waste of time, money as well as, importantly, physical and emotional resources, because it is after all is a misdiagnosis and IUI is an inadequate treatment. In practice, a misdiagnosis of male infertility can lead to even more profound problem. For example, in one recent case a man was diagnosed with moderate infertility and no problems were found in a
woman. After several unsuccessful IUI cycles, the couple undergone IVF. A considerable number of eggs was retrieved, fertilization was good, but embryos were highly fragmented. Since the only suspect
was the sperm, it was sent for sperm DNA fragmentation test ($400), which came with high DF index suggesting that e sperm has a high level of damage in DNA. Couple was advised to use sperm donor ($1200) which was reluctantly accepted. In the next cycle, the level of embryo fragmentation was exactly the same. After spending about $30,000 dollars the woman was told she has a poor egg quality and was advised to consider egg donor. Donor eggs with donor sperm (doctor kept her pride) did the trick and woman had a baby after all. In all likelihood there was absolutely nothing wrong with the sperm. We will return to the question whether poor egg quality can be diagnosed quicker and cheaper later in the text. Unexplained infertility diagnosis should not exist. It is unhelpful and pointless. It is in a patient interest, unless a specific causative link was found that explains infertility - poor egg quality diagnosis has to be used instead. Egg quality can only be confirmed after eggs are retrieved during IVF. There is no diagnostic laboratory test that can be used to predict it. AMH, basal FSH, base line ultrasound can only be useful in predicting the number of eggs that can be harvested during IVF, but not egg quality, which is independent variable. Egg quality is comprised of two variables, metabolic and genetic competency. Although, usually we hear about chromosomal competency, it is actually secondary to metabolism. The reason we know more about chromosomal errors is because we have a reliable tool to detect and quantify them. Metabolic problems, on the per hand, at this time, for the most part are purely speculative. What we do know about them is that metabolic problems begin some time during oocytes growth within the follicle. The reason we can say this with certainty is because the majority of chromosomal errors found in embryos are errors of meiosis I, which takes place within e follicle. Several hypothesis were proposed to account for Meiotic chromosomal errors. Some of the strongest idea is probably the one proposed by Keefe who believes that particular arrangement of telomeres in the prophase nucleus are exposes them on the surface of the nucleus and makes them vulnerable to free radicals. However, chromosomal errors cannot be responsible for fragmentation, because we know from everyday experience that perfectly looking embryos with no fragmentation whatsoever can be completely abnormal chromosomally. Why would egg quality vary so considerably between woman? As was pointed out earlier, we can only define egg quality retrospectively, based on embryo development. V Compare to sperm cells, an egg is a much more complex cell. Therefore, if we habitually accept that only minority of the sperm cell is normal, there are no reasons to expect that all eggs would be normal. In fact if an average sperm sample has 20% normal sperm calls, then we have to accept that the percentage of normal eggs cannot be higher than 20%. Furthermore, the percentage of normal sperm cells varies widely between men: some men have virtually Conventional division of infertility Uovulation PCOS He Infertility is usually divided into male female and combined male/female in about equal proportion. This division is highly inaccurate, mainly because of gross overestimation of male infertility. Most common real diagnosis, which does not exist. Nosological jo