When to Seek Treatment

Medical Contribution By Dr. Jeanne E. O'Brien

It can be quite a shock to find that getting pregnant doesn't always come easily and in the timeframe when we want. Many people want to quickly find the answers to their questions, while others are comfortable with a wait-and-see approach to conception. Assisted reproductive technology now provides so many pathways to biological parenthood. Some infertile couples see ART as a treasure chest full of options. Some may find the myriad medical possibilities a bit intimidating.

"The first question to be answered," Dr. Jeanne E. O'Brien simplifies, "is when to seek treatment."

Time, The Great Equalizer

There's no cookie cutter approach to quality diagnosis and treatment of infertility. So many variables are at play in the whole process of getting pregnant, and every individual's body presents its own version of fertility on a continuum. It's not an either-or situation. There is one component of the process, though, that often makes a bigger difference than all the rest: time.

"People who are struggling to conceive should be aware of two elements that are time related," Dr. O'Brien explains. "First, a woman's age has been found to have tremendous impact on her fertility. Related to that is the length of time that has passed since someone first started trying to conceive."

Study after study indicates that the average woman's fertility passes through relatively predictable stages as she gets older. Fortunately, with the recent abundance of material about fertility on the Internet and in popular magazines, many women are learning earlier than ever about how crucial reproductive aging is to conception attempts.

You don't need medical training to know that women are most fertile in their 20's, start becoming less fertile in their mid-30's, and by their 40's have less than average chances at getting pregnant. Still, Dr. O'Brien and other specialists continue to see women who've waited so long to finally seek treatment that their chances at success are diminished.

"Age is critically related to the success of any fertility treatment. I think that even the most informed women, though, will put off seeking treatment for several reasons," O'Brien says. "For one thing, there's the 'celebrity factor' -- we see high profile women in their 40's who are happily pregnant, leading to a sense that it's a common experience. The fact is that many of them are using ART and, in some cases, they're using donor eggs." In vitro fertilization (IVF) is the most successful form of fertility treatment for women beyond the age of 38.

Another reason why many women delay seeking specialist care and potentially lessen their chances at pregnancy through even the best ART, is the need for a referral from their OB/Gyn. Reproductive endocrinologist O'Brien, who was previously a practicing gynecologist, says that “Patients are encouraged to try to conceive for up to a year prior to a referral which may not take into account important factors such as age.”

She adds that the recent change in recommendations for women with a history of normal PAP tests to go two years in between tests may be inadvertently leading some women to go without annual exams. The result is that many patients are not being seen annually and referred for specialist care. In some cases, women just will not ask to see an infertility specialist unless their OB/Gyn offers the recommendation.

Watching the Clock, Considering Your Past

"The standard line in medical education is that for a couple in which the woman is younger than 35, has normal cycles and no risk factors for infertility, a year of trying to get pregnant without success is enough to warrant special attention."

But, as O'Brien and other specialists at Shady Grove Fertility recognize, there are most definitely cases in which the one-year standard isn't the best course of action. Generally, when the woman is older than 35, a fertility consultation should be considered after only six months of unprotected intercourse. In cases where a woman is 38 years old or older, O'Brien says that while specialists will go along with the six month period of trying to conceive, they also recommend an initial evaluation be done sooner to make sure there are no infertility-causing conditions besides age.

Also, there are some factors that can have such a definite impact on a woman's fertility, a baseline fertility workup is warranted regardless of age. Such factors include:

• history of irregular menstrual periods or absence of periods
• previous abdominal or gynecological surgery, pelvic inflammatory disease (PID) or other sexually transmitted disease
• known structural abnormalities of the uterus or other reproductive organs
• endocrine (hormonal) disorders such as thyroid disease
• pituitary tumors or hyperprolactinemia

Gauging Your Fertility At Home

The starting point of fertility assessment (FAM) for many people is in the privacy of their own home. A group of activities, sometimes referred to as fertility awareness methods, can help a woman determine if she is ovulating regularly. Instructions on FAM can be found in books and on the Internet. The methods include:

• charting the woman's basal body temperature
• keeping track of cyclical changes in cervical position
• monitoring changes in amount and consistency of cervical mucus

FAM can be helpful in providing a retrospective assessment, that is, a woman can learn whether or not she has already ovulated. So, they're not the best methods for predicting when a woman will be fertile. Ovulation predictor kits (OPK) have become popular and are often recommended by fertility specialists. They work by detecting a surge in the level of luteinizing hormone (LH), an indicator that ovulation will occur within the next day or two.

Dr. O'Brien warns that ovulation prediction methods don't work for some women, including those with the relatively common cause of infertility called PCOS (polycystic ovarian syndrome). "Women with PCO can have elevated levels of LH throughout their cycle, so OPKs can give them false positive readings."

Basic Fertility Work-Ups

A number of tests can be performed for those who've tried the home methods and found they're ovulating but haven't been able to get pregnant, or those who are concerned that they are not ovulating. In some cases, depending on a patient's insurance plan, some of the baseline testing to gauge fertility levels can or must be performed by the patient's primary care physician or OB/Gyn. These evaluations include:

• Follicle stimulating hormone (FSH) & estradiol, a blood draw on Cycle Day 3, which can assess a woman's ovarian reserve;
• Hysterosalpingogram (HSG), sometimes referred to as "the uterine dye test", which can determine if there are structural and blockage problems present in either the uterus or fallopian tubes;

It Could Be Him

Another important point to keep in mind is that 1 in 5 couples who seek fertility treatment will have significant male factor issues. Male factor makes up nearly half of all infertility cases.

The only way to surely gauge a man's level of fertility is through semen analysis (SA) - the primary way to identify whether or not a man is producing enough good quality sperm cells to be fertile. Because SA is comparatively less invasive, less painful, and less expensive than many of the female diagnostic tests, the male partner should undergo semen analysis at the start of the diagnostic process. Otherwise, it's quite possible to spend a lot of precious time and money on testing the woman when the couple may have undiagnosed male factor issues.

Opening the Door to Treatment

One particular high-tech fertility treatment, IVF, tends to get more attention in the media than other lower tech means of aiding conception, like artificial insemination through intrauterine insemination (IUI). For this reason, many who find themselves wondering about their fertility may feel hesitant to pursue the answers for fear of being whisked into choosing IVF to conceive.

While many OB/Gyns can certainly offer initial fertility evaluation and treatment such as the use of clomiphene citrate (an inexpensive, oral medication). Patients who choose to undergo therapy at a specialist practice such as Shady Grove Fertility will find that they are closely monitored to optimize conception chances. Ultrasound and blood monitoring can help determine the best timing for an IUI cycle.

"The truth is that the vast majority of people seeking treatment at Shady Grove undergo a sequence of gradually more complex treatment, depending on their circumstances," Dr. O'Brien clarifies. "IVF will never be our very first recommendation for patients unless there's a clear-cut indication, such as severe male factor or a woman in her 40's who's already been trying unsuccessfully for many months without treatment. Even then, there are patients who simply aren't ready to consider IVF. There are several less intensive alternatives."

O'Brien continues, "There's a limited truth to the thought that IVF can take care of any kind of infertility. Diminished ovarian reserve, whether due to primary ovarian failure or age, cannot be cured by IVF unless donor egg is used. IVF is highly successful, though, in cases of women with normal ovarian reserve, tubal disease, PCOS, and male factor infertility.

Affording Fertility Treatments

Financial considerations also keep many from walking through the door to their first fertility consultation. While it's true that many insured people do not have coverage for fertility treatment, it's also the case that many mistakenly think they don't have coverage, when they actually do. Financial counseling staff at Shady Grove Fertility can help even people who are just considering treatment to clarify their benefits and get the facts.

Dr. O'Brien illustrates the importance of thinking ahead when it comes to the insurance question. "We see patients who've just changed to a new insurance policy and, without fully understanding their coverage, have just switched to a plan that doesn't cover infertility when their previous one would have." Her recommendation: "You can't go wrong by being proactive with your fertility care, whether it's regarding your insurance and financial issues or getting a handle on the fertility status of both you and your partner."

Nearly half of the people who seek treatment at Shady Grove Fertility are self-referred. O'Brien sees this as a positive sign that people are educating themselves and feeling empowered enough to find and request the evaluations they need to make good treatment choices.

"I was talking with a new patient not long ago," the physician relates, "who said she felt guilty about scheduling a fertility consultation, because her gynecologist had been telling her to just keep trying." Even without further testing, a medical history interview with the woman revealed significant risk factors for infertility, including an increasingly irregular menstrual period and a history that included previous abdominal surgery.

"I made sure that the patient, who feels a sense of loyalty to her gynecologist, understands that the risk factors make an evaluation a very reasonable decision.”

The primary message that Dr. O'Brien and her colleagues wish to convey to people trying to get pregnant: seeking early consultation for fertility assessment is being proactive about your family's healthcare. Initial infertility evaluations are relatively simple and may, in fact, uncover a diagnosis that requires more specialized care in order for successful pregnancy to occur. Finding out about potential problems early puts time on your side.

If you would like more information, or would like to schedule an appointment, please speak with our patient liaisons by calling 888-761-1967.

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