|
Next Steps
Learn as much as you can about infertility. Get and read good, reliable
information (not just from popular magazines) from your doctor, library,
or trusted friends or family.
When to See a Specialist for Infertility
In many cases difficulty in becoming pregnant can be resolved by the
gynecologist without an extensive fertility evaluation by an infertility
specialist. Often the problem comes down to timing intercourse with
ovulation, which may be assessed using one of the over-the-counter urine
LH test kits (ovulation predictor tests). Having vaginal intercourse the
day of and the day after the LH surge as indicated by the color change
using one of these kits offers the best chance of conception. If this has
failed then an evaluation of the male consisting of a semen analysis should
be performed. In addition, for the female, an assessment of the uterine
cavity such as a hysterosalpingogram (HSG) and a test to determine if
ovulation occurs should be performed. If an abnormality exists in any of
these tests something can usually be done to overcome the problem and
facilitate conception.
An abnormal semen analysis defined as less than 20 million sperm per
milliliter of semen with less than 45% motility and less than 7% normal
forms should be repeated. If it is consistently low then achieving a
pregnancy without assistance is more difficult. In cases where the number
of motile sperm are consistently low, but at least 11 million motile sperm
are in the ejaculate, intrauterine inseminations (IUIs) can be tried. Many
gynecologists can perform IUIs. In cases where there are less than 11
million motile sperm in the ejaculate, referral to an infertility specialist
should be done so that in vitro fertilization (IVF) with or without
intracytoplasmic sperm injection (ICSI) can be performed.
In cases where an abnormality is discovered on the HSG the problem can be
surgically treated with hysteroscopy, laparoscopy or both depending on the
abnormality discovered. Many gynecologists are adept at operative laparoscopy
and hysteroscopy for restoration of normal pelvic anatomy. However,
consideration should be given to consulting an infertility specialist who
does these corrective operative procedures on a more frequent basis.
A gynecologist using clomiphene can often treat ovulation dysfunction. For
more involved cases where an insulin modifying agent such as Metformin may
be needed or in cases where excess adrenal androgens (male hormones)
requiring steroid treatment is required and in women who don't respond to
Clomiphene citrate, referral to an infertility specialist is important.
Other endocrine problems involving reproduction are also best handled by a
specialist in Reproductive Endocrinology and Infertility. The side effects
of ovulation induction with Clomiphene citrate such as hyperstimulation are
less than 5%. Such complications, however, are generally best managed by a
specialist. In cases where ovulation needs to be induced using injectable
gonadotropins (FSH, hMG), referral to a specialist is critical due to the
complexity of these medications and the higher incidence of adverse effects
such as the ovarian hyperstimulation syndrome (OHSS) and the higher
propensity for multiple pregnancy.
In many cases where the cause for infertility cannot be found, a trial of
IUI with injectable medications is done prior to proceeding to IVF. For
women 38 years of age or older, consideration should be given to proceeding
straight to IVF as time is critical. IVF is best performed under the care
of a Reproductive Endocrinologist.
One way of knowing whether your physician is a specialist in fertility
related problems is to ask whether he or she is a member of the Society for
Reproductive Endocrinology and Infertility, a specialized sub-group of the
American Society of Reproductive Medicine. This society is an organization
of physicians dedicated to providing excellence in reproductive health
through research, education and patient care.
Membership in the Society for Reproductive Endocrinology and Infertility is
strictly limited to physicians who have been certified by the American Board
of Obstetrics and Gynecology (ACOG) as having special knowledge and
proficiency in the specialty of Obstetrics and Gynecology and in the
subspecialty of Reproductive Endocrinology and Infertility. This requires
seven years of formal specialty and subspecialty training after medical
school and certification of special knowledge and proficiency in the
evaluation and treatment of reproductive failure and a wide variety of
endocrine disorders. To date fewer than 800 physicians have achieved this
very special distinction. The American Board of Obstetrics and Gynecology
defines a Reproductive Endocrinologist as "a specialist in obstetrics and
gynecology who is capable of managing complex problems relating to
reproductive endocrinology and infertility, and whose current professional
activity involves the practice of Reproductive Endocrinology in a setting
wherein essential diagnostic and therapeutic resources are available and
being used appropriately." You can also contact RESOLVE (888-623-0744) and
ask about the Physicians on their Physician Referral List who have undergone
extensive screening.
Technological advances are allowing the majority of couples having difficulty
achieving pregnancy the joys of parenthood. Medical or surgical therapy or
a combination of both may be needed to achieve successful conception. While
many couples may achieve pregnancy through their gynecologist or primary
care provider, couples with more complex problems and women attempting
pregnancy who are over the age of 35, may more readily benefit under the
care of a specialist in Reproductive Endocrinology and Infertility.
Selecting an Infertility Physician
An important question many couples struggling with infertility ask is,
"When is it essential to seek the medical advice of an infertility specialist?
When is the care of an Ob/Gyn no longer appropriate?"
Many couples have a hard time acknowledging that there may be an infertility
problem to begin with. After each menstrual period they hope that "maybe
it will work this cycle." When these hopes are dashed month after month, the
woman usually consults her regular Ob/Gyn. Depending upon the attitude of
the doctor, she may begin some preliminary tests such as monitoring ovulation,
post-coital test, basic blood work, etc. At the other extreme, she may have
a doctor who has the attitude that there is nothing to worry about. He or she
may give the message that since the woman is "young and healthy," she is
unnecessarily worried. She may be told that she should "relax." In either
case, the doctor's care may be less than ideal. In fact, the expertise of
an infertility specialist can make the difference between years of infertility
and that much desired outcome -- successful pregnancy.
Many Ob/Gyn's and urologists will say that they are well trained to treat the
infertile patient. A listing in the telephone yellow pages, certificates on
the office wall announcing membership in the American Society for Reproductive
Medicine and/or completion of a short post-graduate course in infertility, do
not qualify one to become an infertility specialist. It is often up to you,
the patient/consumer, to determine by means of self-education that you are
not getting the kind of medical care you need.
What is an infertility specialist?
All doctors with "M.D." after their names have completed four years of
medical school. The medical student then goes on to do an internship, either
in a specified field or does a so-called "rotating internship" which exposes
him/her to many areas of medicine. If a doctor decides to specialize in a
specific field such as Ob/Gyn, he/she must complete a residency program in
this area. In general, infertility training in medical school, internship
and residency is limited to a few weeks at best. Little emphasis is placed
on the intricate endocrinology and physiology that could contribute to female
and male infertility.
Rarely is time devoted to understanding ways to help couples deal with the
emotional component of infertility.
To become Board Certified in Obstetrics and Gynecology the doctor must
graduate from college and medical school and complete a four year residency
training in Ob/Gyn. In Addition, he/she must pass a written examination in
Ob/Gyn, complete a two-year practice experience and then pass an oral
examination in Ob/Gyn.
If the doctor decides to become Board Certified in Reproductive Endocrinology
he or she must successfully complete requirements for board certification
in OB/GYN and in addition attend a two-three year fellowship in reproductive
endocrinology, pass a written examination on the topic, finish a two-year
practice experience in reproductive endocrinology and then pass a three hour
oral examination in reproductive endocrinology. Some doctors have completed
all but the oral examination and are still in their practice experience in
reproductive endocrinology. These doctors are Board Eligible in Reproductive
Endocrinology.
There are about 500 Board Certified Reproductive Endocrinologists in the USA
. Another 800 plus doctors are board eligible. It should also be noted that
some doctors can also "learn by doing" and are considered to have expertise
in infertility.
Urologists with a sub-specialty called Andrology, are the most highly qualified
physicians to deal with all aspects of male factor infertility. These doctors
have completed a two year fellowship and passed an examination to become a
Board Certified Andrologist.
Who should see a specialist?
At RESOLVE we feel a couple should see an infertility specialist if they fall
under any of the following categories:
Women who are 35 years old or older;
Patients who need microsurgery or treatment for endometriosis or tubal
damage;
Patients who have a history of three or more miscarriages;
Patients who have irregular menstrual cycle with evidence of irregular
ovulation and have not responded to clomiphene citrate or serophene;
Patients with poor semen analysis showing low count or motility or poor
morphology;
Women with a previous history of pelvic infection;
Couples who are so-called "normal infertiles," i.e., couples whose basic
tests came back normal but who, after two years, have not yet succeeded in
conceiving.
Couples who are considering the assisted reproductive technologies (IVF,
GIFT).
How to select a infertility specialist
How can you find out who is a specialist and who is Board Certified in
Reproductive Endocrinology? Several avenues are available to you. You can
ask your doctor about his/her training. You can also look in the Directory
of Medical Specialists, published by Who's Who, available at most public
libraries; it lists all Ob/Gyn's and their training. Two resources to learn
about a physician's credentials are the American Board of Medical Specialties
(847-491-9091), web site: www.ama-assn.org and www.medseek.com. Also contact
RESOLVE. We have surveyed many doctors across the nation and have over 700
physicians who are on the RESOLVE Physician Referral List. A list of specialists
in a geographic area is available to RESOLVE members. By calling or writing
the RESOLVE national office, a member can also obtain specific data on the
physicians regarding their medical training and special expertise and
interests.
Some additional questions you may want to ask include:
Information about fee structure and payment plans, and insurance coverage.
Does the doctor or his nurse have a call-in time so that you can ask
questions about your case?
Is the lab and ultrasound office open on weekends and holidays?
Can procedures be done on weekends if needed? (example: inseminations.)
If it is a group practice, ask if you will be seeing only one doctor or
several doctors in the practice?
Ask which hospitals the doctor has admitting privileges to.
If relevant, ask if the doctor refers to a particular urologist for
evaluation of the male.
Does the doctor do assisted reproductive technologies (IVF, GIFT, etc.)? If
so, is it done there or at a different location?
Is the doctor a member of the American Society for Reproductive Medicine?
It is always helpful to get the name of the office manager, secretaries and
nurses. Then you can ask for them by name when you call. If you are going
to switch from an Ob/Gyn to a specialist, make sure all the test results you
have had are sent to the specialist. Call to see that they have arrived
before your scheduled appointment. If you have suspected tubal or uterine
problems and a hysterosalpingogram has been done, ask the x-ray department
or radiologist's office for the x-ray films themselves. You can take them
to the appointment with the specialist and he/she can review them with you.
A typed written summary or report of x-ray or lab findings is not as helpful.
Some infertility specialists do repeat lab tests but the whole work-up will
not be repeated if you change your medical care. If you are thinking of
making a transition from an Ob/Gyn to a specialist, you may want to do this
before the diagnostic laparoscopy is scheduled.
Most infertility specialists prefer to see the couple together at the first
appointment. This is an opportunity for the couple and the doctor to
review what has been done and what tests still need to be done. It is a time
to ask questions and establish the beginning of a good doctor-patient
relationship. Whether it is the man or woman, or both, who is experiencing
the infertility problem, treatment of infertility is a couple problem!
Both individuals will have to cope with the stress, frustration, and sadness
of having their reproductive capacity delayed or impaired. It is essential
that the doctor recognize these emotional issues and include both partners
in the discussion of how to pursue treatment for the infertility problem.
If there is a male factor problem, referral may be made to a urologist who
specializes in infertility, or to an andrologist (a sub-specialty in urology).
In either case, it is essential that there be good communication among all
doctors involved in your infertility care. Don't assume that the doctors
themselves will facilitate this. Request that reports be sent to the other
participating doctors and that they communicate frequently.
Getting the most out of your care
To get the most out of your relationship with your doctor and their practice,
it is a good idea to keep an on-going list of questions that you want to ask
about your care. When you go for an appointment, ask your questions at the
end of the appointment so that your appointment is not just focused on
answering your questions. Find out what your doctor's plan is for you, then
ask your questions. Some couples find it works best if they go together to
the appointment; one partner can ask the questions and the other can jot down
the answers. By doing this, it relieves the stress of one person having to
remember everything. Also, many people find that they sometimes "blank out,"
if their doctor says something they don't expect, such as suggesting a new
drug treatment or reporting an abnormal lab result. From this point on in
the appointment, some patients find it hard to focus and keep their mind and
questions organized. Having both partners at the appointment can help with
this.
Getting a second opinion or changing doctors
As with any medical situation, the consumer has to evaluate the type of care
he or she is receiving. Reading about infertility and educating oneself are
important tools for patients to use in evaluating their care. Some other
indications that it may be time to change your medical care are:
The doctor does not seem to have a treatment plan or wants to continue the
same treatment that has been used for three to four cycles without success.
Communication between you and the doctor is poor. You feel reluctant to ask
questions and feel like your concerns are quickly dismissed.
The doctor seems confused about your case. You have to remind him/her that
various test, etc., "have already been done."
The obstetrical part of a practice seems to affect the amount of quality
time the doctor can spend with his/her infertility patients.
Gonadotropin hormonal treatments are not being carefully monitored with
blood tests and ultrasound.
Infertility results in feelings of frustration and helplessness. One
tangible and important step that can reduce some of these feelings is
finding and selecting the best medical care. By finding a specialist and
taking an active role in your own medical care, you can regain some sense
of control and feel the satisfaction of actively participating in the
decisions which will affect the course of your infertility treatment.
|
