Finding a Fertility Specialist

The diagnosis and treatment of infertility is a complex and emotional process, which is just one reason why it is so important if you are having trouble getting pregnant that you seek treatment from a doctor who specializes in infertility and has the appropriate training and experience in order to help you conceive.

How do I know if I am infertile?

Infertility is defined as the inability to conceive after one year of unprotected intercourse or, when the woman is 35 or older, after six months of unprotected intercourse. Couples who do not conceive in this period of time, as well as women who have had three or more miscarriages, should seek medical assistance. Risk factors for infertility in women include irregular or absent periods, extremely low body fat, endometriosis or tubal damage, or the presence of certain chronic diseases. For men, low sperm count, exposure of the testes to high temperatures and a history of genital infection can all lead to infertility.

About 40 percent of all cases of infertility can be attributed to the woman, 30 percent attributed to the man and 20 percent of cases are caused by a medical problem in both the man and woman. The remaining 10 percent of couples have unexplained infertility, but many of them can still be treated successfully. In order to get the most cost effective and timely treatment, identification of the cause of infertility is crucial. An infertility specialist can diagnose the problem, help you avoid unnecessary procedures and map out with you a plan for treatment.

When should I see a fertility specialist?

Sometimes couples aren't sure when the appropriate time is to see a specialist. There are many factors that might influence your decision, some of which are listed below.

• Age - The most common cause of infertility is age. As mentioned above, if you are under the age of 35, have regular menstrual periods and have not conceived after twelve months of trying, you should seek a medical evaluation. If you are over the age of 35, you should seek help after trying to conceive for six months. Further, if you are over the age of 39, you should see a specialist after trying unsuccessfully to get pregnant for three months. The older you are, the more likely you are to be affected by infertility.
• Tubal disease - If your OB/GYN has determined that your fallopian tubes are blocked, you should consult a fertility specialist before proceeding with treatment like in vitro fertilization or surgery. Immediate consultation with a specialist can determine the appropriate procedure to treat the problem before any more damage is done.
• Very low sperm count - You should seek a fertility specialist as soon as possible if a doctor has determined that your male partner's sperm count is very low or zero. Because inseminations, fertility pills and surgeries are usually ineffective with this diagnosis, it is important for you to consult a specialist in order to avoid wasting time and money on unnecessary medications and procedures.

What makes a doctor a fertility specialist?

A fertility specialist is an obstetrician-gynecologist who has had special training in infertility and reproductive endocrinology. Most gynecologists have had some basic training in infertility and are able to perform evaluations and some forms of treatment. For example, the majority of gynecologists are able to perform laparoscopy and hysteroscopy for diagnosis; however, it requires special skills to perform corrective procedures. Gynecologists can diagnose and treat general disorders of the female reproductive system and care for a woman during pregnancy, childbirth and during the postpartum period, but they are not trained in the more advanced reproductive technologies, so it is important to understand the different roles of each.

In order for gynecologists to become reproductive endocrinologists (REs) devoted specifically to treating infertility, they must complete a two to three-year fellowship in infertility treatment, followed by two more years of clinical experience. They must also pass a series of oral and written exams. Once they have done so, they become "board certified" by the American Board of Medical Specialties, the highest level of achievement in the field of infertility. There are about 780 Board Certified RE's in the US. Another 100 are "board eligible," meaning they are in the process of completing their clinical experience and have not yet taken the oral exam.

How do I choose a fertility specialist?

Once you've made the decision to consult a specialist, you might want to consider talking to your regular physician or OB/GYN first, as she may be able to refer you to a reproductive endocrinologist that she knows and trusts. A referral from another physician is one of the quickest and best ways to find a doctor.

Another way to look for a specialist is on your own, starting your search from scratch. This may seem like a daunting task, but there are several resources available for you to utilize. RESOLVE, Inc., the National Infertility Association, publishes a helpful tip sheet on selecting an infertility specialist. The American Society of Reproductive Medicine can provide you with a list of physicians who have expressed an interest in fertility treatment. In addition, the Endometriosis Association can help you find an experienced specialist if you are struggling with endometriosis-related infertility. While membership in the organization doesn't certify a doctor's fertility treatment competency, it is a good place to start.

You might also wonder whether you should consult with a private physician or go to a large fertility clinic. A private physician can treat most fertility problems; the additional skills and expertise provided by large clinics are only needed in about 10 percent of cases. Some couples who have gone to large clinics have complained that they felt isolated and anonymous, not receiving much of the physician's personal time. If you'd like more personal attention, a private practice may be a better choice for you. One of the positive aspects of large clinics is that they provide services that many smaller organizations do not, such as on-site X-ray and testing laboratories and counseling and support groups. But the decision is up to you. Before you decide to go with a clinic, be sure to ask for the CDC report on their success rates. You can use these statistics as a starting point for your research. Below are some additional questions you might want to ask about a particular clinic's success rates.

• How many babies have been born as a result of your procedures?
• How many of them were born to women ages 30-39? 40 and over?
• How many treatment cycles have been initiated here in the past two years?
• How many deliveries were multiple births?

In addition to questions regarding success rates, the questions below can be used to assist you in the interview process with a particular clinic about cost, convenience and services.

• What procedures are offered by the clinic?
• How many Board Certified reproductive endocrinologists are on staff?
• Is there a laboratory on-site?
• Does the clinic offer counseling?
• Is the clinic affiliated with a hospital?
• Is the clinic open on weekends? Does it offer extended hours?
• How much does treatment cost, including drugs and lab work?
• What insurance plans are accepted?
• How are payments structured?
• Do you prepare a treatment plan for your patients?

How should I prepare for my first visit?

You may want to consult with more than one fertility specialist before choosing a physician you think is right for you. Not only do you want to check their credentials, but you also want to make sure you feel comfortable asking questions and conversing with them. The initial meeting is the perfect opportunity to talk with the doctor and assess how well you will be able to work together. Below is a list of questions you may want to ask. Consider bringing a notebook and a pen along to jot down notes.

About the doctor's practice

• Where did you receive your medical training? When? Are you a Board Certified reproductive endocrinologist?
• How long have you been treating infertile patients?
• Will you send me to any other physicians or laboratories for treatments or tests?
• Who can I call if I have a problem after office hours? Are you affiliated with a hospital?
• Will you treat my partner? If not, who will?
• Do you use Pergonal/Metrodin/Humegon/Lupron to induce ovulation? If so, do you monitor egg development with ultrasound and blood estrogen to avoid multiple births?
• Are you on the RESOLVE, Inc., recommended list of physicians?
• Are you a member of the American Society for Reproductive Medicine (ASRM)?
• Are you a member of the Advanced Reproductive Care network?
• What insurance plans do you accept?
• Do you offer any financing options or payment plans?

About tests, medication, surgery and treatments

• What kinds of procedures do you perform? What will the results tell you?
• Do you offer the assisted reproductive technologies (ART)?
• Does this practice have a donor sperm/donor egg program?
• How much will treatment cost? Does that include lab work, procedures and medications?
• Will it hurt? Are there any side effects?
• How will I feel afterward? Will it interfere with our sex life?
• Do you perform the tests/treatments in your office or in a hospital?
• Can I drive myself home afterward?
• Will I be incapacitated? For how long?
• Will my partner or I have to miss work or delay our vacation?
• How many times will treatment be repeated?
• Do you perform sterilization reversals? What is your success rate?
• Do you perform microsurgery? What is your success rate for vasectomy
reversal? For fallopian tube repair?

Is there anything I should watch out for?

Once you've chosen a specialist, you should continue to monitor his or her performance. You should be informed and aware of what's going on at all times. Below are a few things that may signal to you that you have chosen the wrong physician. If you notice any of them, you may want to take a step back and reconsider your choice.

• Lack of a treatment plan - Your fertility should not be a game of hit-or-miss. After your first visit with your doctor, he or she should be able to outline the a plan for you to follow together. Once the plan is implemented and test results come back, which may take up to six weeks, your doctor should be able to present you with a more detailed plan of action for your treatment. If any changes are made to the initial plan, ask questions and find out why.
• Poor communication - In the beginning, it is completely understandable to feel somewhat awkward discussing a topic as intimate as your fertility with a stranger. After a few visits, however, you should be comfortable enough to discuss it with your doctor with a greater sense of ease. If you have questions, don't be embarrassed to ask them. It is your doctor's job to make sure you totally understand what's going on, but you have to take the initiative and speak up. If you are worried about forgetting to ask a certain question, try to write it down before your appointment. If your doctor seems impatient or irritated about explaining terms and treatment, will not return your calls, or is too often unavailable when you need help, find another.
• Unorthodox treatment or methods - If your doctor does something you believe to be out of the ordinary or incorrect, such as fail to perform a semen analysis or prescribe fertility drugs before doing a complete evaluation, you have a right to voice your concerns. You may have misunderstood something you read or heard, or your case may have special circumstances. If you still feel uncomfortable after sharing your concerns with your doctor, you may wish to request a second opinion. If you do not have complete faith in your RE's decisions, you should look for a new one.

* Your treatment is taking too long - The amount of time required to diagnose and treat each fertility problem is different for each patient, which is why the amount of time it should take for you to get pregnant is hard to pinpoint. Still, there is a general timeline you may refer to. Your doctor should be able to give you a diagnosis within four to six weeks - two months at the most - and your treatment should begin shortly thereafter. It is easy to become impatient when trying to conceive, but remember, even after treatment, you are no more fertile than the average woman of your age and you only have a 20 percent chance of getting pregnant each month. Doctors often use a more aggressive approach with older couples who do not have many fertile years left. If you feel your fertile years are slipping away and your doctor isn't responsive to your concerns, find another.

How can I give myself the best chance at success?

There are two things you and your partner can do to ensure that your experience with a fertility specialist is a positive one. The first is having regular discussions with your partner about your RE and the treatment process he or she has outlined for you. Make sure you are both comfortable with your physician, understand your options and that you are getting the information you need to make informed decisions.

The second is to seek out the plethora of support and information that is available to you. Fertility treatment is an emotional process. Organizations like RESOLVE, Inc. and the American Society for Reproductive Medicine can help you understand your options and become connected with other couples who are experiencing infertility.

Experienced reproductive endocrinologists can diagnose and successfully treat most couples with fertility problems; but remember, fertility treatment isn't magic. You are responsible for selecting the doctor who is best qualified to help you, and for the quality of care you receive.