Deciding to see a Fertility Specialist can be daunting. You might be unsure what to expect, you might be unsure of the charges, you might even be unsure whether you really need to go. I felt foolish when I went the first time, I really thought that I will get pregnant eventually and I thought the Doctor would think I was overreacting. I had just been trying for 9 months, and my Mom however was very worried, she must have had a gut feeling about my fertility as she got me the details of my first Fertility Specialist. She was right to worry, what I didn’t know then was that I was never going to bare my own children. So, really, just go on your gut feel, if you think you’ve got a problem, just go. Close your eyes, drag your partner with and make the appointment.
What is a Fertility Specialist?
A Fertility Specialist is someone who’s qualified as a Medical Doctor and specialises in Obstetrics and Gynecology, with further studies in Reproductive Health.
Why not just see my GP or Gynecologist?
While most GP’s have a fair knowledge of reproduction, they don’t really have the facilities to do regular scans and they have not specialized in Gynecology and Reproductive health. Fertility Specialists know when to to send you for tests, they know that some hormones needs to be tested at different times in your cycles. They know what signs to look out for on the ultra sound scanner, and they know exactly how to diagnose and treat fertility related issues. They really are the best place to go to if you find yourself unable to conceive. Your very first step could be a gynecologist, but just keep in mind that if you’re not pregnant withing 6 months to a year that it’s time to see a specialist.
GP’s cannot diagnose blocked tubes, endometriosis, uterine polyps and many more, they should refer you to a specialist if you’ve been under their care for a while and you have not conceived. If they don’t refer you, ask them to refer you, especially if you’d like to be treated by one of the state hospitals listed here: http://www.getpregnant.co.za/if-you-cant-afford-fertility-treatment-youd-want-to-read-this/
When do I need to see a specialist?
- If you’re younger than 35 years and you’ve been trying for 12 months, or if you’re older than 35 and you’ve been trying for 6 months, it might be time to seek a specialist.
- If, for some or other reason you think or believe that you need helps sooner, make that appointment as soon as you can.
- If you have any known issues or suspected risk factors you should see a Fertility Specialist as soon as you start trying for a family.
Is it compulsory for my partner to go with me?
Most doctors prefer to see the couple as a whole, you would both need to go for investigative testing. If your partner is adamant that he is not the problem and refuses to go for a sperm test, just ask him to accompany you to the consultation. You do need his support anyway. The doctor will most probably be able to explain in a clear way why he needs to be tested and most men are happy to comply with doctors order. It really is just to make sure that all your bases are covered. If he refuses to go to the consultation, you can go without him and and the doctor will start the investigative process without him. But he will eventually have to go in if they can’t find a problem with you or you’re just not falling pregnant. He definitely needs to show up for IUI or IVF unless you’re using donor sperm. But it really is advisable that you go through this as a couple. I also went alone mostly on the first appointment at the first two clinics I attended. Mostly because hubby had pressing work commitments, and also because when I’m unsure I prefer doing things alone. At my third clinic hubby was with me at every consult or test.
What can I expect from my first consultation?
You will be asked a lot of questions, on your history, your cycles your family history etc. Fertility Doctors are quite thorough and they know exactly what needs to be done. I’ve found most fertility doctors to be gentle and kind and patient. Some have a more matter of fact bedside manner, but it most certainly does not detract from their expertise.
If this is your first visit to a fertility clinic, you will most probably be sent for basic a hormone profile and chromosome tests and your partner will be asked for a thorough sperm analysis. You will also be scanned on your first visit.
You might also be asked to come in for a scan on day 2 or 3 of your cycle. Don’t worry about this, I know you’re probably recoiling at the idea that you have to be scanned while you’ve got your period, this is normal, they do this all the time. If it falls on a weekend, they have this covered too! You will be given the opportunity to go to the toilet to remove your tampon if you’re wearing one before the scan. If you’re bleeding heavily just put a sanitary pad between your legs while you wait for the doc to do the scan. Most fertility doctors always has a nurse or female assistant with them while they do the scan. You will get used to the scanning while you have your period as it will most likely happen every time you go in for a treatment cycle.
And in case you wondered, the scan is not the abdominal scan you see in movies, it’s a probe they insert into your vagina, it looks something like a thin vibrator, so if your partner is with you, please brief him on this beforehand so he doesn’t give the doc a left hook
Remember to ask any burning questions that you have, and if necessary take some notes as you will be given a lot of information.
What tests can I expect?
Here is a list of tests you might do, depending of course on your history and symptoms
Basic fertility profile. You will be asked to go in at a specific time in your cycle. The following tests will most likely be tested: AMH, FSH, LH, Prolactin, Estrogen, Progeserone. You will also be tested for autoimmune diseases like Lupus, Antiphospholipd anti bodies, rheumatoid factor, thrombophilia, thyroid and hepatitis.
Pap Smear: Some clinics will do a pap smear, other clinics will refer you back to your gynecologist for a pap smear.
Day 21 Progesterone test. You will be asked to go in on day 21 of your cycle to test your progesterone, this will give an indication on whether or not you ovulate
Chromosone tests: Some clinics prefer to send their couples for chromosome tests
HSG Xray: This will be preformed if they suspect blocked tubes or other uterine abnormalities. If you are sent for an HSG X ray, please pack a sanitary pad as you will be bleeding, some ladies find this extremely painful, while other ladies sail through this. If you want to you can take 2 anti inflammatory pain pills an hour before the procedure. You will be asked to lie on a table, they will insert a speculum into your vagina, then a tiny catheter will be inserted through your cervix, a dye will then be pushed through the catheter into your uterine cavity. The whole procedure will be filmed so they can examine the fluid movement through your tubes and they will also be able to pick up if you have an abnormally shaped uterus, polyps and scar tissue. I’ve found that as the dye hit my tubes and uterus that it felt like a really bad menstrual cramp. In any case it’s over as fast as it started. You will be given an antibiotic just to make sure that no infections will develop. The procedure does not cause damage to your tubes or uterus in any way.
Laparoscopy: This will be performed if they suspect endometriosis or adenonyosis among other things.
HLA studies: This is an extremely expensive test, ours cost R12 000.00 in 2008. They do this if you have recurrent miscarriages, it tests to see if you and your partner might have similar genetic markers that could be causing the miscarriages.
Post Coital test: If they suspect you might have a hostile cervical environment you will be asked to do this test. You and your partner will be instructed to have intercourse on the morning of the test then go through to the clinic within one or two hours. You would not be able to shower afterwards, so make sure you shower before. A swab will be taken and the sample examined under a microscope. If there are a lot of dead or slow sperm (granted your partner has gone for a sperm test and they know more or less what to expect) it might show that you have a hostile cervical environment for sperm.
Sperm test: Your partner will be asked to do a sperm test. They will test the count, motility and morphology of the sperm. They might even test for DNA damage, and other factors like antibodies, infection etc. Some clinics have facilities for the sperm sample, safe private rooms with some reading material if needed. Some don’t, so ask first, if they don’t have facilities and you live close enough, he can do the sample at home, remember to pick up the empty sample bottle before the test date. You must make an appointment for the test as they have to allocate a specific time and date to do the sperm test as sperm starts dying very quickly after the deposit. You would need to deliver the sample within and hour of the deposit and it needs to be kept at body temperature, so maybe tucked into your bra while you drive over there.
It is very common for men to freeze up and not be able to perform during this time, the pressure is immense! If they have facilities at the clinic the reading material might be helpful, if he’s doing it at home or some place private near the clinic, you might be able to sweet talk him. If it’s not happening at all, cancel the appointment and make it another time and try again.
What type of fertility treatments can I expect?
This is by no means a complete list of all the tests and procedures, I’m sure there will be changes in protocols and drugs etc. as time goes on. This is just to give you an overview of what to more or less expect when you see a Fertility Specialist. Of course this all depends on your diagnoses, but here are treatment options you would most often find:
Medicated cycle: You will be scanned on day 2 or 3 of your cycle to check for cysts before you are given an ovulation inducing drug, you will most likely receive Clomid, Fertomid or Femara, unless you’re a poor responder, in which case they will give you injectable drugs to administer at home. You can either do it yourself, or ask your partner to help you. Once you get over the initial reaction of horror at injecting yourself it will become easier. Luckily for me both hubby and I had been on diets where we needed daily injections so we were quite comfortable with this. It feels more or less like a little pin prick, Nothing to worry about. Hopefully you get pregnant before you get to this point!
You will then be scanned at various times closer to ovulation as they need to see how your follicles are developing. If you’ve produced too many follicles your cycle will be cancelled and you will be requested to abstain from intercourse as a pregnancy at this point will be life threatening.
If you’ve produced no follicles your cycle will also be cancelled and you will have to start again with your next cycle and they will tweak your ovulation inducing drugs.
When they see that your follicle will ripen soon you will either be given an injection like Ovidril to control the release of the egg and you will be given instructions on when to have intercourse. Or they will skip the injection and just give you instructions on time and frequency of intercourse. You may or may not need to do the injection yourself, it all depends on your follicle size, but don’t worry, their instructions will be clear. You will then be instructed on when to go in for your pregnancy test. Just as a side note, Ovidril or a similar drug is the hCG hormone, so don’t do any pregnancy tests for at least 10-13 days after the injection as you will receive a false positive on a pregnancy test. Rather wait to do the blood test at the lab.
IUI: Or Intrauterine Insemination. You will follow the same route as the medicated cycle, but your ovulation will definitely be induced by Ovidril so they know exactly when to do the insemination. Your partner will be requested to give a sperm sample one hour more or less before the scheduled insemination, the sperm will be washed, and counted and prepared for insemination.
In case you were wondering whether you can do the insemination yourself at home, you can’t. Unwashed sperm that enter the uterus is extremely dangerous. The seminal fluid contains prostaglandins that will cause extreme cramps, you could even lose your uterus. This is life threatening. You would have noticed that you always have some sperm leakage when you have intercourse at home, that is the seminal fluid that your cervical mucous ejects from your body as it cannot allow it to enter the uterus. Sperm washing removes all the seminal fluid and other impurities before you can be inseminated.
You will then be told when to come in for a pregnancy test.
IUD: Intrauterine Donor Insemination: If you have major male factor fertility issues you could consider using donor sperm. Donor sperm should always be discussed with your partner, always consider his feelings first. Many men aren’t comfortable with using someone elses sperm, but many couples have gone on to have happy families after considering donor sperm.
The procedure for IUD will be much the same as IUI except you will receive a thawed out straw of donor sperm instead of your partner having to give the sample.
IVF: Invitro Fertilization: This is what I call getting out the big guns. You will have to undergo IVF if you have blocked tubes, major male factor infertility, unexplained infertility, if you’re not ovulating or you’ve had recurrent pregnancy losses. Your scanning regime will be much the same as the previous two procedure, but you will receive a lot more drugs and the protocols will be very different. I’m not very familiar with IVF as I’ve never had it myself but your clinic will guide you through every step. There are differences in IVF protocols, you get long protocol and short protocol, but your doctor will know exactly which one is best for you. You may or may not be given birth control pills before hand. They use birth control pills to prior to a stimulation protocol which may help the ovaries respond better and it gives them better flexibility in planning your cycles.
A typical IVF Cycle may look like this
1. Initial Contraceptive: To help the ovaries respond better with stimulation and give better flexibility of your cycle.
2. GnRH Analog (Lupron) Administration: This is to prevent premature release of the eggs from the ovaries prior to egg retrieval. These are injections which you have to administer yourself.
3. Baseline Ultrasound: You will have an ultra sound at the start of your period to check your ovaries and to check for cysts. You will also have your estradiol levels tested. If your estrogen is to too high or you have a cyst you may be asked to continue with the Lupron until your levels have stabilised or to allow your cyst to resolve itself.
4. Ovarian Stimulation: This is started after your period starts if your estrogen levels were favourable and you don’t have any cysts. The dosage and type of drug used will depend on your ovarian reserve, how you’ve typically responded to to stimulation in the past etc. Typically the injections are given between daily between 8 and 12 days. The typical quantity of eggs they are looking for is between 8 and 15 eggs on egg retrieval day. It is the quality of eggs they are looking for not the quantity. If you’ve produces less eggs, they may still continue with the cycle depending on how they develop through out your cycle. If you’ve produced more eggs you might suffer from ovarian hyperstimulation syndrome, This can be life threatening and if you have any symptoms that are worrisome and painful you have to contact your clinic immediately. To see the symptoms for Ovarian Hyperstimulation Syndrome click here.
5. Monitoring of Follicles and Estradiol levels: You will be monitored with ultrasound and blood tests throughout your IVF cycle to make sure you respond correctly and the correct doses of drugs are given to you.
6. Final maturation and hCG administration: Drugs like Ovidril which contains hCG will be given to you to stimulate the final maturation of your eggs.
7. Egg retrieval: Egg retrieval is typically done under sedation as it is quite painful. They will use ultrasound to guide them, a thin needle is inserted into your vagina to just behind your uterus where your ovaries are located. They then retrieve the eggs. At the same time or just before, your partner will be asked to produce sperm, which will be washed and prepared as they do for IUI.
8. Insemination of eggs: The sperm and eggs will be placed together to fertilise the egg, in some cases the embryologist will find a healthy sperm and inject it directly in to the egg to fertilise it.
9. Embryo transfer: Your clinic will decide whether to transfer the fertilised eggs after 3 or 5 days. It all depends on how your babies grow and develop, but your clinic will guide you through every step. The embryos will be transferred by inserting a speculum into your vagina, the embryos will be loaded into a small catheter and with the help of an ultrasound scan they will deposit it into your uterus. You will probably be asked to remain lying down for an hour after the procedure and you might even be asked to remain at rest for at least 24 hours after the transfer.
10. Progesterone supplementation: You will take progesterone injections from the evening of your embryo transfer until your pregnancy tests. If you are pregnant you will most probably continue with the injections for another 10 weeks or so.