Editor’s note: In “Dear Fertility Doc,” James Grifo, MD answers questions about fertility and reproductive health for Forbes Health. Dr. Grifo is the director of the division of reproductive endocrinology at the NYU School of Medicine and the chief physician of the Prelude Network. Do you have a question? Email him at email@example.com.
Dear Fertility Doctor,
I’m 32 years old, and my husband and I have been actively trying to have a baby for a year. On my last doctor visit, my gynecologist recommended that I go see a specialist for fertility tests.
I thought getting pregnant would be easy, so I am not at all willing to go this route. I am overwhelmed by the information I read and would like to know what I can expect from these tests.
What to expect
Dear What to Expect,
In my years of practice as a reproductive endocrinologist and infertility specialist (REI), patients more often than not expect to experience difficulty conceiving a child. That means it’s just as much my job to educate and make them feel comfortable about the process as it is to help them have a baby. I would like to give you insight into what to expect as you and your partner take the first step in your fertility journey.
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The first step of fertility care
I recommend that anyone considering fertility treatments schedule a pre-conception consultation with their OB-GYN or a fertility specialist to look for immunity status for diseases that are more dangerous during pregnancy, such as measles, chickenpox and rubella. Carrier screening – a genetic test that tells you if you carry genes for certain genetic disorders – allows couples to know their risk before they become pregnant and give birth to a baby with serious, avoidable genetic conditions such as Tay Sachs- disease, cystic fibrosis, fragile X syndrome and many others.
In fact, there are blood tests that can be done on both the egg and sperm sides of the equation that can rule out the chance that a baby will be born with one of the now preventable 502 diseases. In addition, any medical problems that may complicate a pregnancy can be managed preventively.
Fertility test for two
Let’s start by destroying the myth that infertility is a female condition. The truth is that 40% to 50% of infertility cases are related to male factor infertility (MFI). And 20% to 30% of the time, it’s a combination of both female and male infertility factors.
For a pregnancy to occur, sperm, which is the male reproductive cell, must fertilize an egg. The fertilized egg forms an embryo which then implants in the wall of the uterus.
Male factor infertility and testing
The causes of male infertility are broadly classified as obstructive or non-obstructive. In obstructive infertility, there is a block in the reproductive tract that prevents sperm from coming out. In non-obstructive infertility, there may be a problem with sperm production or quality, or with its ability to fertilize an egg. There is also a condition called azoospermia, a total absence of sperm, which is the cause of infertility in 10% to 15% of infertile men and 1% of all men. Azoospermia can be caused by a genetic irregularity, medical treatments including chemotherapy and radiation, anatomical abnormalities, hormone imbalance or blockage in the tubes that carry sperm to the urethra.
To determine the cause of infertility, your partner will need to disclose their medical history and undergo non-invasive tests. Tests to determine MFIs include:
- Semen analysis: A semen analysis will give a clear indication of sperm health, including an overview of semen volume, count, shape and motility.
- Blood tests: Blood tests can identify a person’s levels of reproductive hormones, including testosterone. Hormone imbalances can lead to low sperm counts, erectile dysfunction and lower sex drive.
- Urine tests: Urine tests after ejaculation can determine if a person is experiencing retrograde ejaculation, that is, when the semen enters the bladder rather than being ejaculated.
- Transrectal ultrasound: Doctors use transrectal ultrasounds to detect blockages in the tubes that carry semen from the body or problems with the prostate, such as benign prostatic hyperplasia, in which the prostate is enlarged. During an ultrasound, sound waves produce images that allow doctors to visualize the reproductive organs.
When scheduling your initial consultation, make sure you include your partner so that your specialist can discuss fertility testing for both of you. Having a clear understanding of each person’s reproductive health is important to achieving your pregnancy goals.
Breaking down female infertility testing
Regardless of a woman’s age, every patient should be willing to share a complete medical history with their doctor. There are a series of tests and exams – some non-invasive and others slightly invasive – that can give a clearer picture of a woman’s reproductive health. These include:
- Hormone testing: Blood tests can determine if hormone levels affect the ability to ovulate or maintain a pregnancy. There are also tests to evaluate for thyroid or prolactin disorders, which can affect fertility.
- Luteal phase deficiency testing: Luteal phase deficiency testing, performed with a blood test, uterine ultrasound, endometrial biopsy or a combination of these, determines whether the uterine lining can sustain a pregnancy. The luteal phase occurs after ovulation when the uterus begins to grow a lining in preparation for a fertilized egg. If that lining does not grow properly, the uterus cannot sustain a pregnancy. This can lead to infertility or recurrent miscarriage. If deficiencies are detected, hormone therapy can help stabilize the uterine lining and prepare it for implantation of the fertilized egg.
- Ovarian reserve fertility test: Ovarian reserve fertility testing can help determine how many eggs you have in the ovaries and their likelihood of having a pregnancy. This test consists of two parts: a blood test and a pelvic ultrasound. The blood test evaluates hormone levels that correspond to the amount of eggs still in the ovarian follicles, and the ultrasound helps your doctor see how many follicles remain in reserve.
- Ovulation examination: Normal ovulation occurs about two weeks before your next expected menstruation. Understanding whether you ovulate regularly is essential to understanding your fertility. Your doctor may use hormone-sensing blood tests, ovarian ultrasound examinations, or a home ovulation test kit to determine your ovulation patterns.
- Tubal transparency examined: Because fertilization occurs in the fallopian tubes, a blockage or scarring in the tubes can make it difficult for sperm to reach the egg. Tubal transparency examination uses one of two tests to visualize the fallopian tubes and uterus. Hysterosalpingography (HSG) combines an X-ray with radiographic dye to create an image that allows your doctor to diagnose any blockages. Salt sonogram works in a similar way, using saline solution and ultrasound imaging.
- Examining uterine abnormalities: Using ultrasound tests, we examine your reproductive system to look for uterine abnormalities that could potentially cause infertility, such as fibroids, polyps, adhesions, and congenital abnormalities that affect the shape of the uterus. An endometrial biopsy can be used to examine the uterine lining for problems that prevent implantation or lead to recurrent miscarriage.
Understanding costs is important
There can be many surprises in fertility care, and cost is no exception. To help prepare for the financial part of diagnostics, I highly recommend talking to your insurance provider to find out what is and is not covered regarding fertility testing.
After your doctor has determined which tests you should both undergo, see the clinic’s financial advisor if any of those tests are not covered by your insurance. Too often, financial accessibility is a deterrent to seeking fertility care, but preparing yourself can help you understand what those costs are and the financial options available to you.
When to undergo a fertility evaluation
For those with a female reproductive system who have medical conditions that can affect fertility, such as endometriosis or polycystic ovary syndrome, they should consult a reproductive specialist as soon as they decide to try to conceive.
For others, the question of when it’s time to seek fertility care depends largely on age, as it is the main factor in determining reproductive health, as egg quality and quantity decreases as women age. Women who are 35 or younger should seek a fertility evaluation if they are not pregnant after one year of unprotected sex. A woman between 36 and 39 years old should try for three to six months before considering testing. Women 40 or older should seek treatment as soon as they decide to become pregnant, as the chances of achieving a natural pregnancy are about only 5% for this age group each month.
It is also important to note that you do not have to wait as long as these guidelines suggest to see a fertility specialist if you are anxious or worried about your fertility. Make that initial appointment and discuss your concerns sooner rather than later with a specialist.
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Knowledge is power in reproductive health care
While the idea of relying on modern medicine to build your family may sound overwhelming, it means understanding your reproductive health, taking control of your fertility. Through these tests, your doctor can determine the cause of your or your partner’s infertility and implement a treatment plan for both of you.
Just remember that when you feel overwhelmed, knowledge is power, and empowering yourself through this process is an important part of your experience and outcome.
“Dear Fertility Doc” is for informational purposes only and should not replace professional medical advice, diagnosis or treatment. Always seek the advice of your doctor or other qualified healthcare provider with any questions about a medical condition. By submitting your letter, you agree to have Forbes Health use it in part or in full, and we may amend the letter for length and clarity.