Medical Contribution by Sunita Kulshrestha, M.D.

Sunita Kulshrestha, M.D., of the Chesterbrook, PA office.

Anticipating your initial fertility appointment can make you feel anxious and nervous, but also eager to obtain answers and begin the path to parenthood. In order to make the most of your consult, plan out what questions you want to ask your physician in advance. No question is too small and your physician will happily answer as many as possible. After your fertility consult and diagnostic testing is complete, your physician will create a personalized treatment protocol that is unique to you. There is no “one-size-fits-all” approach to fertility treatment, but hopefully all of our patients will experience the same successful outcome.

Here are questions that are commonly asked at the first consult:

Q: Why haven’t we been able to conceive?

A: At your initial consult, your physician will begin the process of determining the cause of your infertility. He or she will initially base this information on your medical history and your prior testing, along with additional diagnostic testing, if recommended. While there are many possible causes of infertility, these are the most common:

Advanced maternal age: As a woman ages, many biological changes take place that make it more difficult to conceive. Specifically, aging can have negative effects on egg quality and egg quantity. The risk of miscarriage and birth defects also increases.

Endometriosis: A condition in which endometrial tissue (the tissue that lines the inside of the uterus) grows outside of the uterus, endometriosis may lead to scar tissue formation that blocks fallopian tubes or interferes with ovulation.

FibroidsFibroids are noncancerous growths that develop in or on the uterus that, depending on size and placement, may impact one’s ability to conceive.

Hyperprolactinemia: Excess production of prolactin from the pituitary gland can cause irregular or no ovulation.

Hypothalamic Amenorrhea:  A condition that occurs when the hypothalamus stops producing gonadotropins (the hormones needed for eggs to mature and ovulate), hypothalamic amenorrhea may result in a woman not menstruating for several months.

Male Factor Infertility: Men may have problems related to: sperm production and quality, the anatomy or structure of the reproductive organs, and/or erections and ejaculation.

Ovulatory DisorderWhile there are many types of ovulatory disorders, they are all exhibited by irregular or no ovulation, which may result in infertility. A common cause of ovulatory dysfunction is thyroid disease.

Pelvic Adhesive DiseaseA condition in which scar tissue binds adjacent organs to each other, pelvic adhesive disease may result in infertility if adhesions form inside or around the fallopian tubes and block an egg and sperm from meeting.

Polycystic Ovary Syndrome (PCOS): PCOS is characterized by ovulatory dysfunction and irregular periods. The ovaries may produce excessive amounts of male hormones.

Premature Ovarian Failure: Also known as early menopause, premature ovarian failure is a condition in which menopause occurs before the age of 40.

Recurrent MiscarriageAlso known as recurrent pregnancy loss (RPL), recurrent miscarriage is defined as two or more consecutive, spontaneous pregnancy losses. Frequent causes of miscarriage include: genetic causes, a uterine abnormality, hormonal imbalances, and problems with the immune system.

Tubal DiseaseOften caused by scar tissue or infection, tubal disease is a disorder in which the fallopian tubes are blocked or damaged.

Timing: If a couple does not have intercourse close to ovulation, pregnancy is unlikely to occur.

Unexplained InfertilityAccounting for approximately 10 percent of infertility, a physician will diagnose unexplained infertility if a cause is not determined after a thorough evaluation of both the male and female partner.

Q: What kinds of tests do we need?

In order to create a diagnostic plan that will provide you with the best chance of conceiving, your physician will have both partners undergo various forms of fertility testing (for LGBT or single patients, the need for testing depends on gender). In women, examining the quality and quantity of eggs available (ovarian reserve), determining that the fallopian tubes are open, and evaluating the condition of the uterine cavity (as this is where the embryo will implant) is most important. In men, testing the quality and quantity of the sperm is critical.

Female Fertility Testing

Ovarian function tests: An important part of the diagnostic evaluation is to assess overall ovarian health and egg quality and quantity. A physician determines ovarian function by evaluating several hormone levels on day 3 of the menstrual cycle: FSH (follicle-stimulating hormone), LH (luteinizing hormone), and E2 (estradiol.) In addition, measuring  the anti-Müllerian hormone (AMH) is the most accurate predictor of a woman’s ovarian egg supply. A pelvic ultrasound is useful to determine at the number of antral follicles (egg-containing sacs). Combined together, these evaluations can help determine pregnancy rates.

Evaluation of the uterine cavity and fallopian tubes: Scheduled between the end of menses and the onset of ovulation, a physician may perform one or more tests to look at the pelvic anatomy:

HSG (hysterosalpingogram) — The provider will place a dye through the cervix into the uterus and fallopian tubes. An x-ray will help determine if the uterine cavity is normal and the tubes are open. This is the best test to look at the tubes. At the same time, the provider can look at the shape and contour of the uterus and spot possible polyps or fibroids.
* A patient may schedule an HSG in our Rockville and Towson offices or in any other radiology center or hospital.

Saline sonogram – The provider will insert saline solution into the uterus through the cervix before conducting an ultrasound. This test looks for fibroids, polyps, and scar tissue in the uterus.

Hysteroscopy — The provider will insert a narrow telescope through the woman’s cervix (under anesthesia) to evaluate and correct any uterine cavity abnormality.

Male Fertility Testing

Semen analysis: A semen analysis looks for possible male causes of infertility. A semen analysis evaluates the sperm concentration (count), motility (movement), and morphology (shape) of the sperm. The results help determine which is the best treatment option for the female (intrauterine insemination (IUI) or in vitro fertilization (IVF)). Unlike eggs, males continually replenish sperm. Therefore, semen quality can vary every three months. Additionally, many lifestyle factors (e.g. alcohol and heat extremes) can temporarily affect sperm quality.

For Both Partners

Infectious disease and genetic testing: Both male and female partners will undergo screening for a variety of infectious diseases. We also recommend routine genetic screening of both partners to ensure that the baby will not be at risk for an acquired genetic disease.

Q: What treatment do you recommend trying first?
A: At Shady Grove Fertility, our physicians believe in a stepped approach to care. While treatment will of course differ depending on individual diagnosis, conservative treatment options will be the first approach when possible. Patients do not directly pursue IVF or donor egg treatment unless there are certain conditions that make that necessary from the outset, or if low-tech treatment options have proven ineffective. The majority of our patients will begin with treatment options such as IUI.

Q: What side effects are most common with fertility medications?

A: Fertility or ovulation induction medications stimulate your ovaries to develop and release eggs, which may result in ovarian enlargement and an increased blood estrogen level. Many symptoms associated with these medications are similar to premenstrual symptoms, such as breast tenderness, pelvic discomfort, or bloating. Your physician and nurse will discuss all potential side effects with you before prescribing any medication.

Q: What is the likelihood of conceiving multiple babies (twins or more) with the treatment you’re recommending?

A:  While the public perception of fertility treatment is that multiples are standard, this is not the case. For IVF, improved laboratory technologies have greatly aided embryo development and the physician’s ability to determine which embryos are the most likely to succeed, lessening the need to transfer multiple embryos. This has led to Shady Grove Fertility becoming a strong advocate for elective single embryo transfer (eSET). For patients who have a good prognosis (based on the age of the female partner, clinical outlook, and the developmental stage of the embryo), transferring only one embryo will provide them with the same chance for a successful pregnancy as transferring more than one embryo, yet minimize the risk of a multiple pregnancy.
For our IUI patients who are undergoing ovulation induction with their IUI, your physician will use bloodwork and ultrasound to monitor and control the risk of a multiple pregnancy. For those patients who take Clomid, a medication that induces ovulation, there is a 10% chance of a multiple pregnancy.
Q: Are there any long-term complications associated with fertility treatments?
Assisted reproductive technologies have been in widespread use for over 35 years. Hundreds of thousands of patients successfully pursue fertility treatments. To date, there is no convincing evidence that such treatment adversely affects a woman’s health in the future. Additionally, there are no known negative effects on future reproduction, sexuality, or age at menopause.
Q: What are your pregnancy success rates?
A: Each year, Shady Grove Fertility provides comprehensive information and success rates published by the Society for Assisted Reproductive Technologies (SART) and the Centers for Disease Control and Prevention (CDC). You can find success rates for all of our treatment programs on our website (updated yearly). In 2013 (2014 data will be available mid-2015); women under 35 had a 48 percent ongoing pregnancy rate per embryo transfer. Based on a woman’s age, a physician uses the following to provide a unique expected success rate before each treatment cycle:

  • AMH
  • FSH
  • antral follicle count
  • body mass index
  • uterine condition
  • quality of the sperm being used

Q: Can I do all of the necessary testing and procedures in your offices?

A: Our goal is to make the treatment process as convenient as possible for our patients. We have 18 full-service and four satellite offices in Washington, D.C., Maryland, Virginia, and Pennsylvania. A patient can have bloodwork, ultrasounds, and monitoring performed at all of our locations. For all procedures, we have ambulatory surgery centers and embryology laboratories at our Rockville, MD, Towson, MD, and Chesterbrook, PA, locations.

Q: Is there someone I can call for questions at any time?

A: Throughout your fertility journey, you will have a designated nurse. Your nurse is your primary point of contact throughout your treatment with Shady Grove Fertility. Most patients will meet their nurse immediately following their initial consult with their physician. The physicians perform the procedures and are also readily available to answer any questions and provide guidance.

Additionally, we have a weekend and holiday nurse line so that someone will always be available to answer your questions, as well as an emergency answering service for after-hours urgent questions and emergencies:

Weekend/Holiday Nurse Line: 301-340-1188, Option 5
Emergency Answering Service: 301-446-2645; 800-239-5613

Your first fertility consult will provide you with the tools and information that you will need to move forward on your journey, as well as the team that will help you through this process and be with you every step of the way. In order to get the most out of this experience, don’t forget to bring your records and other important clinical documents (see the appointment checklist). We look forward to meeting you soon!

If you have questions regarding infertility treatment or would like to schedule a new patient appointment, please call our New Patient Center at 877-971-7755 or click to schedule an appointment.