When to See a Specialist for Infertility
In many cases difficulty in becoming pregnant can be resolved by the gynecologist without an extensive fertility evaluation by an infertility specialist. Often the problem comes down to timing intercourse with ovulation, which may be assessed using one of the over-the-counter urine LH test kits (ovulation predictor tests). Having vaginal intercourse the day of and the day after the LH surge as indicated by the color change using one of these kits offers the best chance of conception. If this has failed then an evaluation of the male consisting of a semen analysis should be performed. In addition, for the female, an assessment of the uterine cavity such as a hysterosalpingogram (HSG) and a test to determine if ovulation occurs should be performed. If an abnormality exists in any of these tests something can usually be done to overcome the problem and facilitate conception.
An abnormal semen analysis defined as less than 20 million sperm per milliliter of semen with less than 45% motility and less than 7% normal forms should be repeated. If it is consistently low then achieving a pregnancy without assistance is more difficult. In cases where the number of motile sperm are consistently low, but at least 11 million motile sperm are in the ejaculate, intrauterine inseminations (IUIs) can be tried. Many gynecologists can perform IUIs. In cases where there are less than 11 million motile sperm in the ejaculate, referral to an infertility specialist should be done so that in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) can be performed.
In cases where an abnormality is discovered on the HSG the problem can be surgically treated with hysteroscopy, laparoscopy or both depending on the abnormality discovered. Many gynecologists are adept at operative laparoscopy and hysteroscopy for restoration of normal pelvic anatomy. However, consideration should be given to consulting an infertility specialist who does these corrective operative procedures on a more frequent basis.
A gynecologist using clomiphene can often treat ovulation dysfunction. For more involved cases where an insulin modifying agent such as Metformin may be needed or in cases where excess adrenal androgens (male hormones) requiring steroid treatment is required and in women who don't respond to Clomiphene citrate, referral to an infertility specialist is important.
Other endocrine problems involving reproduction are also best handled by a specialist in Reproductive Endocrinology and Infertility. The side effects of ovulation induction with Clomiphene citrate such as hyperstimulation are less than 5%. Such complications, however, are generally best managed by a specialist. In cases where ovulation needs to be induced using injectable gonadotropins (FSH, hMG), referral to a specialist is critical due to the complexity of these medications and the higher incidence of adverse effects such as the ovarian hyperstimulation syndrome (OHSS) and the higher propensity for multiple pregnancy.
In many cases where the cause for infertility cannot be found, a trial of IUI with injectable medications is done prior to proceeding to IVF. For women 38 years of age or older, consideration should be given to proceeding straight to IVF as time is critical. IVF is best performed under the care of a Reproductive Endocrinologist.
One way of knowing whether your physician is a specialist in fertility related problems is to ask whether he or she is a member of the Society for Reproductive Endocrinology and Infertility, a specialized sub-group of the American Society of Reproductive Medicine. This society is an organization of physicians dedicated to providing excellence in reproductive health through research, education and patient care.
Membership in the Society for Reproductive Endocrinology and Infertility is strictly limited to physicians who have been certified by the American Board of Obstetrics and Gynecology (ACOG) as having special knowledge and proficiency in the specialty of Obstetrics and Gynecology and in the subspecialty of Reproductive Endocrinology and Infertility. This requires seven years of formal specialty and subspecialty training after medical school and certification of special knowledge and proficiency in the evaluation and treatment of reproductive failure and a wide variety of endocrine disorders. To date fewer than 800 physicians have achieved this very special distinction. The American Board of Obstetrics and Gynecology defines a Reproductive Endocrinologist as "a specialist in obstetrics and gynecology who is capable of managing complex problems relating to reproductive endocrinology and infertility, and whose current professional activity involves the practice of Reproductive Endocrinology in a setting wherein essential diagnostic and therapeutic resources are available and being used appropriately." Please visit our online Directory of Services for a listing of RESOLVE Professional Members.
Technological advances are allowing the majority of couples having difficulty achieving pregnancy the joys of parenthood. Medical or surgical therapy or a combination of both may be needed to achieve successful conception. While many couples may achieve pregnancy through their gynecologist or primary care provider, couples with more complex problems and women attempting pregnancy who are over the age of 35, may more readily benefit under the care of a specialist in Reproductive Endocrinology and Infertility. |
