Overcoming the emotional hurdle
Perhaps you and your partner fit the criteria of couples who should see a doctor about fertility difficulties. Yet it's hard to make that first appointment. You keep putting it off.
If this is the case, your hesitation is understandable. It's common for people to find reasons to avoid going to see a doctor. In many cases the individual has a fear of the outcome or diagnosis. You're concerned about how much it might cost. You think the procedures are too involved, too high tech.
You should know that many people are in a similar position. It is normal to feel overwhelmed, uncertain, or stressed. Consider some facts:
- The majority of infertility cases - 85% to 90% - are treated with conventional therapies, such as drug treatment or surgical repair of reproductive organs.
- Fewer than 5% of infertile couples in treatment actually use in-vitro fertilization (IVF), a treatment that might be considered "high tech."
- Your doctor may be able to advise you on whether the fertility testing and/or procedures that you may need are covered by public or private medical insurance. See "Costs of treatment" to learn more. You should be aware that you may need to contact your own private insurance provider for more information on details of your own private insurance plan.
If you want to conceive, it's important to overcome the emotional hurdles and take action. The sooner you see a health care provider, the sooner a problem may be diagnosed and treated.
Deciding what kind of health care provider to see
Some couples first talk to their family doctor. Others meet with a obstetrician/gynecologist (OB/GYN). And some go directly to a fertility specialist , also called a reproductive endocrinologist (RE). Fertility specialists are OB/GYNs who have completed additional training in advanced assisted reproductive therapies (ART).
Getting ready for your visit
Preparing for your visit will help reduce anxieties. For more information see "Suggested questions to ask your doctor" and the Fertility Planner to help guide your way.
Before you make the appointment
Check into your insurance coverage before you see your doctor. Be sure that you're well informed and find out what your provincial and private medical insurance plans will cover. Your policy will outline the coverage available to you.
If this is your first step toward addressing your fertility concerns, take a few minutes to complete the Doctor Discussion Guide and print a copy to take to your doctor. You may also want to review the "Suggested questions to ask your doctor" to ensure you are well prepared.
Get the most out of your appointment
Knowing what to ask your doctor ahead of time will help ensure you get the most out of your visit. It helps a lot if you write everything down in advance. That includes medical histories and questions you want answered. I'm sure we've all left a doctor's office only to remember a question we meant to ask but forgot!
Many people are shy about asking questions, but you shouldn't be. Your doctors want to make sure you understand your diagnosis and treatment options too! And if you don't understand the answers, don't hesitate to ask your doctor to repeat them.
Here are some suggested questions to download and take with you.
Also, take a minute to fill out the Fertility Profile Tool. It's an interactive tool that will give you a better understanding of your own fertility before you see your health care provider.
Suggested questions to ask your OB/GYN or family doctor
When you see your OB/GYN or family doctor for the first time, you'll need to provide him or her with basic information, including:
- your age
- how long you've been trying to conceive
- your medical history, including any history of:
- polycystic ovarian syndrome (PCOS)
- sexually transmitted diseases
- premature menopause
- cancer treatment
- surgery of the reproductive organs
- varicocele (in the male partner)
Based on the information you provide, your doctor should have a sense of whether or not you are at particular risk for having a fertility problem. You can then begin to discuss your potential testing and treatment options. Here are some questions to prepare you for that conversation:
- What specific tests would you recommend to diagnose my infertility?
- Should my partner be tested?
- What are the tests for male fertility?
- Is there a cost for any of the tests involved?
- How long will it take to diagnose our problem?
- Based on the results of those tests, what are my treatment options?
- Will my insurance pay for the testing and/or treatments?
- Will I have to repeat any tests if I go to a fertility specialist or reproductive endocrinologist (RE)?
- Will you be referring me to a fertility specialist?
Suggested questions to ask your reproductive endocrinologist (RE) or fertility clinic
Your first visit to a reproductive endocrinologist or fertility clinic can be an overwhelming experience. On top of dealing with the emotional issues that may arise with infertility, you now find yourself confronting a new and sometimes scary world of treatment options. Bringing this list of questions to your first visit may help you to keep track of your thoughts and increase your comfort level.
- What specific tests would you recommend to diagnose my infertility? How much do they cost?
- How long will it take to diagnose our problem?
- Based on the results of those tests, what are my treatment options?
- What is the national success rate for those treatments in terms of live births?
- Will my insurance pay for the testing and/or treatments? Will your clinic help me determine what my insurance will cover?
- How will I communicate with you during this whole process?
- Does your clinic provide emotional counselling, or can you refer me to a counsellor who deals with fertility problems?
Understanding fertility clinic statistics for success rates
There are a variety of potential measures that can be used to evaluate clinic success rates of assisted reproductive technology (ART), and the range of measures can be overwhelming. For example, the success rate in in-vitro fertilization (IVF) is typically presented in one of the following ways.
- It can be expressed as a percentage of all treatment cycles started during a given time period that end in pregnancy. This is often referred to as the pregnancy rate per cycle started.
- It can be defined as the percentage of embryo transfers that result in pregnancy. This is often referred to as the pregnancy rate per embryo transfer. Pregnancy rate per cycle started will always be lower than the pregnancy rates per embryo transfer. This is because cycles cancelled before embryo transfer are not counted when calculating the pregnancy rate per embryo transfer.
- Live birth rate is different from the pregnancy rate, in that approximately 15% of pregnancies achieved through ART will end in miscarriage. The live birth rate, then, is really the number of live births per cycle started.
This may seem confusing, so there is an example below to help you better understand. In this example, there are 100 cycles started, 90 cycles reach the embryo transfer stage, 40 result in pregnancies and 6 of those end in miscarriage.
- The pregnancy rate per cycle started then is 40% (40 pregnancies in 100 cycles).
- The pregnancy rate per embryo transfer is 44% (40 pregnancies out of 90 embryo transfers).
- The live birth rate per cycle started is 34% (100 cycles, with 40 pregnancies, 6 miscarriages, and 34 successful births).
According to the Canadian Fertility and Andrology Society, the 2005 and 2006 Canadian data is as follows:
- The average pregnancy rate per cycle started is 32%.
- The overall live birth rate per cycle started is 26%.
There was significant variation in these rates according to age, with women under 35 having the highest average pregnancy rates and overall live birth rates.
The fertility workup
The workup demystified
What happens when you see a health care provider for fertility concerns? Generally, your doctor will conduct an evaluation that begins with a review of your medical and personal histories. You'll likely discuss everything from family medical history to diet and lifestyle to your current sexual practices.
Your doctor will also conduct an exam. Depending on your medical and lifestyle history, he or she will then conduct some tests, beginning with the simplest and least invasive ones. At a later point, you may need to undergo more advanced evaluation.
What happens during the female exam
The female exam consists of a general physical exam, a breast exam, and a comprehensive pelvic exam. During the pelvic exam, your doctor will determine the size, shape, and position of your reproductive organs. Many doctors will also complete a routine Pap test to detect any infections and rule out cervical cancer. Blood work will also be done to check for sexually transmitted infections like human immunodeficiency virus (HIV), gonorrhea, and syphilis. Individual hormone levels will also be tested. Your doctor may also recommend an ultrasound to look at the ovaries.
What happens during the male exam
The male exam includes a general physical along with an examination of the testes, penis, and scrotum. Your doctor will look for varicoceles in the scrotal sac, which are found in about 40% of men who are undergoing evaluation for infertility. Your doctor may also take a culture from the opening of the penis in order to rule out infection.
What your health care provider is looking for
Basically, your doctor is attempting to answer four key questions:
- Is there a sperm problem?
A man will be asked to provide a semen sample to determine the quality, volume, concentration, and motility of his sperm. The health care provider may also conduct blood tests to check FSH (follicle stimulating hormone), LH (luteinizing hormone), and testosterone levels (see the Glossary for information on these hormones).
- Is there an ovulation problem?
Even when a woman is having her periods, she may not be ovulating. Your doctor will attempt to determine if your ovulation is irregular or if you're ovulating at all. A number of tests can help determine your ovulatory status.
Some doctors may gather information about the menstrual cycle using a basal body temperature (BBT). You take your temperature each morning and plots its daily changes. After a few months of charting, your doctor can often determine if ovulation is happening and if problems are occurring within the cycle.
Blood work may also be performed to determine if hormonal imbalances exist.
- Are the egg and sperm able to unite?
A number of factors can make it difficult for the sperm and egg to come together.
Sometimes the mucus around a woman's cervix prevents sperm from reaching the fallopian tube. In rare cases, if your doctor suspects a problem, he or she may order a cervical mucus or postcoital test to determine if the quality and consistency of the mucus is allowing this to happen.
Often, sperm and egg can't unite due to structural problems in the reproductive organs. Your doctor might perform tests to look for blockages within the uterus, fallopian tubes, or pelvis. One of these tests is an X-ray procedure called a hysterosalpingogram (HSG) that allows the healthcare provider to assess the contour of the inside of the uterus and determine whether or not the fallopian tubes are open. Your doctor may also conduct tests that look for polyps or fibroids. Surgical procedures may help overcome these conditions.
Your doctor may also order a laparoscopy to detect tubal disorders, scar tissue, or endometriosis (the presence of uterine tissue outside the uterus). This surgery, however, is usually performed late in the workup, if at all.
- Can the embryo implant and be sustained in the uterus?
Even if the sperm and egg are able to unite, the embryo may have difficulty implanting and sustaining itself in the uterus. Your doctor may also obtain a tissue sample, often referred to as an endometrial biopsy, from the uterine lining to see if it is developing properly or a conduct an ultrasound to see how thick the uterine lining is.