Calming the Nerves with Knowledge
This is it. After a year (six months if you’re over 35) of trying to conceive you’ve got nothing to show for it except fraying good will toward your partner and yourself. You’ve had it with self-help books, the well-intentioned advice offered by fertile pals, or worse, your parents. You figure it’s time to go to the pros and get to the bottom of your reproductive system’s recalcitrance.
Nerve racking? You bet! But in the long run, an evaluation by a fertility specialist, a.k.a., reproductive endocrinologist (RE), could save you precious psychological, emotional and financial strain and move you forward on the path to having a child. And, after all, this is your goal.
“In general, people are anxious about what they’re going to find,” observes Dr. Kaylen Silverberg of the Texas Fertility Center in Austin, TX. “On initial consult, I tell every couple who comes in here that infertility is a team sport, it’s the three of us against the disease.”
Before any reputable specialist makes a treatment recommendation, the RE will put both partners through preliminary exams. For the male half, it means, at the very least, a detailed personal health and reproductive history and a semen analysis (To understand more about the semen analysis, refer to Focus On Fertility fact sheet, “Swimming Toward Conception: The Semen Analysis” by visiting http://www.focusonfertility.org). The RE’s focus, however, will be on the female half of the couple and you can expect the initial workup to be extraordinarily thorough, including that same painstakingly precise history and a careful physical.
The results may simply prove that either partner has a less-than-perfect reproductive system. This is not a judgment of one’s maternal fitness or virility. The question is what are both of you willing to do to find out where that slight or significant imperfection may be. The emphasis here is on both, because remember, 40% of infertility is attributable to a female factor, 40% to a male factor and 20% is either a combination of the two or is simply an unexplainable mystery.
A good RE has the diagnostic skills to help you determine whether overcoming the obstacles to pregnancy require a relatively simple fix, use of sophisticated Assisted Reproductive Technologies or something in between. Be wary if in your initial consult, your RE guarantees results or quickly suggests advanced assisted reproductive procedures.
“Why are all these patients getting to run through IVF?” says Dr. Silverberg. “Think of it like heart disease. When someone comes in with heart disease, the first thing is not bypass or angioplasty. They may just need blood pressure controlled or a beta-blocker. An (infertility) patient may need ovulation induced, or there’s bad sperm and they need intrauterine insemination (IUI).” says Dr. Silverberg. “Only 15% of patients go through in vitro fertilization.”
Dr. Samuel Thatcher, of the Center for Applied Reproductive Science in Johnson City, TN, says, “If you’re not getting all the information, look elsewhere. You should understand the full spectrum of what’s available or not. The discussion shouldn’t move too fast or too slow, and you should never be dismissed.” If you’re over 35, when time is of the essence, your RE may reasonably want to move a little quicker. But, no matter what, be sure you’re comfortable.
What should you expect from your first visit to your RE? First of all, expect that it will take at least an hour. When you make the appointment, see if the fertility center makes preconception counseling available, in the office or by referral, and consider scheduling a consult. While emotional reactions vary, chances are the ups and downs of your psychological roller coaster are about to get steeper. Emotional support during this time can be very helpful.
What’s in the Past May be Present: Personal History
Get ready for revelation. We’re talking up close and very personal here. Your reproductive and general health histories have got to be open books if your doctor is going to derive a diagnosis and treatment plan. Anticipate these kinds of questions:
- How long have you been trying to get pregnant?
- Have you ever been pregnant? If so, what were the outcomes?
- Have you ever terminated a pregnancy?
- When did you first get your period? Are your periods regular? Have you ever stopped having your period?
- What kind of contraception, if any, have you used?
- Do your breasts become tender during PMS or your period, or do you get cramps?
- What is your sexual history? Have you every had any sexually transmitted diseases? If so, what were they?
- What is your family’s reproductive history? Do you have sisters? If so, what are their reproductive histories? Any miscarriages? How old was your mother when she went through menopause?
- Have you had infertility consultations or treatments before? If so, what were the results?
“Bring all records from previous evaluations or treatments,” says Dr. Isaac Kligman, of the Center for Reproductive Medicine and Fertility at the Weill-Cornell Medical Center in New York City.
- Habits: Do either of you smoke, or drink alcohol or caffeine, and how much? Do you exercise regularly? What kind? Do you run marathons or ride your bike 50 miles a day? How many hours of sleep do you get a night?
- Nutrition: What is your diet like? (Be honest!) Do you eat regular, balanced meals? How about fruits and vegetables? Do you take vitamin supplements? If so, what kind? How much do you weigh? Has your weight varied much in the last few years (by 20 pounds, more or less)?
- Work: Is he out in the heat using a power driver or is he an indoor investment banker kind of guy? What does she do for a living? Is there exposure to toxins or heat?
- Home Environment: Do you keep Grandma’s armoire sparkling with heavy doses of cleaning polish? Use any other chemical-based cleaners? Do you spray your lawn with pesticides? Do you lift the week’s garbage to the curb?
- Medications: All of them. Including (but not at all limited to): antidepressants, heartburn relievers, pain relievers, allergy relievers, birth control and those for hypertension or cardiac problems. Have you ever used marijuana or cocaine-or any other recreational substance? Are you allergic to any medications?
- Preexisting medical conditions: High blood pressure. Migraines. Depression or bipolar disorder. And diabetes. “Diabetes is the leading cause of impotence,” says Dr. Silverberg and with paternal age creeping up, it’s an even greater risk.
- Ethnic background: “We ask about their ethnic group, because certain groups carry certain diseases,” says Dr. Kligman.
“We try to figure out from the history where the likely area of abnormality might be,” notes. Dr. Thatcher
The Physical Self
Then comes the hands-on, head-to-toe exam that focuses on all the parts women have always regarded as most private. It’s daunting but this physical may yield valuable insights into your conception struggle, so recognize that it’s in your interest that your doctor be as deliberate as possible.
The first visit should take place, ideally, on the third day of your cycle, so that blood can be drawn for a complete blood count and baseline hormone tests (if not you will be asked to come back then for it).
In essence your RE will be checking:
- Thyroid: Your doctor will palpate your throat to make sure the thyroid isn’t enlarged. An overactive or underactive thyroid can interfere with ovulation. It plays a critical role in hormone stimulation and regulation.
- Breasts: Checking for tumors or discharge. If there is discharge nursing, it’s an indicator of excess prolactin, a hormone (yes, regulated by the thyroid) essential in milk production. But, if you’re not nursing, that elevated prolactin level becomes fertility-compromising.
- Chest: Ensuring heart and lungs are normal. Young women are more likely to have mitral valve prolapse, according to Dr. Silverberg, which can often be detected with a careful listen.
- Abdomen/Pelvis/Uterus: Any signs of tenderness may indicate infection such as pelvic inflammatory disease, uterine fibroids or ovarian cysts, which are all potential threats to fertility. Your RE needs to ensure that the organs are not enlarged and they’re mobile and that there’s no scar tissue from endometriosis or infection. Many RE’s routinely perform a pelvic ultrasound to rule out structural abnormalities, uterine masses, ovarian cysts, severe endometriosis or polyps. Bear in mind many of these things are surgically correctible.
- Excessive hair growth on face, breasts and lower abdomen can all point to disorders of ovulation especially if you are overweight and your cycles are irregular or more than 35 days apart.
Then there are baseline blood tests.
- Ovarian Function: The first order of business is analyzing hormone levels to assess how well the ovaries are working. Follicle-Stimulating Hormone is an indicator of ovarian reserve (the quality of ova) and functional capacity,” says Dr. Kligman, of the Center for Reproductive Medicine and Fertility. “It gives an idea of how the ovaries are working.”. FSH levels rise when ovaries aren’t producing sufficient estrogen (a very high level can signal the onset of menopause). Leutinizing hormone (LH) causes the follicle to rupture and release the ovum. The ratio of LH to FSH is key. If it is high, along with physical characteristics such as excess body hair and weight gain, may indicate Polycystic Ovarian Syndrome (PCOS). In that case, there will likely be follow-up blood work and an ovarian ultrasound to confirm this preliminary diagnosis.
And there will be screening for:
- Thyroid Stimulating Hormone for a well-functioning metabolism, as well as a good supply of the essential reproductive hormones that the thyroid controls.
- Progesterone (which prepares the uterine lining for the embryo).
- Immunity to rubella (German Measles) and varicella (Chicken Pox), two diseases which can have a catastrophic effect on a developing fetus if the mother is infected in early pregnancy.
- Prolactin levels if there is breast discharge or irregular menstrual cycles.
A Few More Things
- A hysterosalpingogram (HSG) x-ray is one of the most important routine tests because it gives a clear structural picture of your anatomy to ensure the uterine cavity is a normal shape and that the Fallopian tubes are clear and open. It’ll also uncover scarring or tumors. Another option for determining how the uterus is doing is a laparoscopy: your doctor will use a fiber optic telescope to check the uterus, as well as the ovaries, endometrium and pelvis.
If the HSG shows anything questionable about the uterus, your RE may recommend a hysteroscopy. A tiny telescope would be inserted into the uterus, through the cervix, so your RE can literally look at your uterus, including taking “photos,” to get the clearest, closest pictures possible of any abnormalities or growths.
A hint of an abnormal endometrium will lead to an endometrial biopsy. It can be done at the same time as a hysteroscopy, right before your period. Your RE will take a small amount of tissue from the endometrium to test for luteal phase defect (in which a hormone imbalance causes thinning of the uterine lining) or hyperplasia (when the uterine lining is too thick, which may be a precursor to precancerous cells).
The Next Phase
Sometimes the answer to your pregnancy dilemma may be as simple as lifestyle changes: a bit less wine to chill out before bed or give up marathons for now. Sometimes it’s a more complex puzzle that requires further investigation. But after the initial physical and baseline blood tests, your RE should be able to determine if follow-up tests are necessary and which ones would serve you best.
For most people, even acknowledging there might be a problem is overwhelming and scary. Although your RE and this raft of exams, tests and procedures are designed to narrow the wide spectrum of possibility to one of probability-the most likely cause of your difficulties conceiving-it may still seem like it’s all about figuring out what’s “wrong” with you. In fact, this is the best way for your RE to figure out the right treatment option to help you have the child you’ve been dreaming of.
It is important to remember that anxiety is normal. Having support, a place to discuss your concerns, and gather information can take some of the sting out of that first visit to the RE. So contact the American Fertility Association, toll-free at 1-888-917-3777 or log on to http://www.theafa.org or visit http://www.focusonfertility.org. We’ve been through it. We know exactly how you feel. We can help.