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What is a specialist?
What is a specialist? An infertility specialist is an OB/GYN doctor who has had special training in infertility and reproductive endocrinology. Ideally an infertility specialist devotes most of his time to treating infertility. Most gynecologists have had some basic training in infertility during their 4-year residency. They are able to perform the basic infertility evaluation and some forms of treatment. If a gynecologist wants to specialize, they complete 2 to 3 more years of training in a fellowship in reproductive endocrinology and infertility. After completing the fellowship, they are "board eligible". Some reproductive endocrinologist then complete 2 more years of written and oral exams. If they pass the exams, they are then "board certified". This certification is the highest level of achievement in the field of infertility.
Some reproductive endocrinologists have special training and experience with infertility surgery. Most gynecologists can perform laparoscopy and hysteroscopy for diagnosis; however, it requires special skills for the gynecologist to perform corrective procedures during laparoscopy and hysteroscopy.
When should I see a specialist?
Patients are often confused about when the appropriate time is to see a specialist. There are many factors to consider before making the decision to see a specialist. Some factors to consider are age, tubal disease, a very low sperm count, and obtaining a proper diagnosis.
- Age is the most common cause of infertility. Many people get pregnant in the first 3 to 6 months after stopping contraception. If your cycles are regular and you are under 35, seek help from your OB/GYN or reproductive endocrinologist and infertility specialist after 12 months of trying. If you are over the age of 35, begin fertility testing after trying to conceive for 6 months. If you are over 39, testing should begin within 3 months. If your cycles are not regular, seek help immediately.
- Tubal disease If the fallopian tubes are blocked, a specialist should be consulted before proceeding with treatment such as surgery. The surgery for damaged tubes is often not successful and can increase the chance of tubal pregnancy. IVF can be a much more successful treatment and no surgery is necessary. If the fallopian tubes are blocked at the end and filled with fluid, hydrosalpinx, surgery is appropriate prior to IVF. Consultation with the specialist can determine the appropriate procedure. Their expert assessment can help prevent unnecessary second surgeries to perform the appropriate procedure.
- Very low sperm count Patients should seek a specialist as soon as possible if the sperm count is very low or zero. Inseminations, fertility pills, and surgeries are usually ineffective with this diagnosis. These unnecessary medications and procedures can waste your time and money.
Proper identification of the cause of infertility is crucial to the most cost effective, and timely treatment. An infertility specialist can help you avoid unnecessary procedures, such as the advisability of laparoscopy when no symptoms of endometriosis or no history of infections are present and avoid tests of limited usefulness.
Important tests
The following are common examples of important tests that are often missed or done inappropriately.
- Strict sperm morphology
Strict morphology is a very specific method of evaluating the shape of sperm. Most laboratories do not use strict criteria thus potentially missing a sperm problem. Our laboratory is staffed with embryologists trained to analyze sperm with these strict criteria.
- Clomiphene citrate challenge test (Clomid)
The Clomid challenge test is currently the most accurate method of evaluating age and egg quality. This test is appropriate for most women over the age of 37, couples with unexplained infertility, and women who have had multiple miscarriages.
- Ultrasound
A pelvic ultrasound is a very useful test when it is done at the appropriate time in the menstrual cycle. A few days prior to ovulation an ultrasound can evaluate ovulation, follicle growth, endometrial thickness and pattern, polyps, and fibroids. During menses is the best time to evaluate the ovary for cysts and endometriosis.
- Day 3 FSH and Estradiol
(Day 2-3 is acceptable)
Measuring FSH on day 3 of menses is a good way to evaluate age and egg quality, but estradiol also needs to be measured to confirm the accuracy of the test.
- Genetic testing
Genetic testing is not often necessary, but is important in women with premature menopause and multiple miscarriages and men with very low sperm counts. Patients with a family history of a genetic disease can use genetic testing to determine if they are carriers of the disease. We offer Preimplantation Genetic Diagnosis or PGD, which can be performed on embryos. The embryos without the genetic disease can then be transferred to the uterus or frozen for future transfers.
- Insulin
Women who have irregular periods and have been told they have polycystic ovarian disease should have a fasting blood test for insulin and glucose. This information can lead to more effective treatment.
Unnecessary tests
The following tests are rarely needed:
- Post-coital test
- Endometrial biopsy
- Hamster egg penetration (SPA)
- Serum immune testing
- Serum antisperm antibodies
It is important to know that appropriate tests for some may not be necessary for others.
Treatments by a specialist
The advanced training of a reproductive endocrinologist is helpful to provide the most successful treatments for infertility.
Some of these treatments include:
- In vitro fertilization,
- Intracytoplasmic sperm injection,
- Preimplantation genetic diagnosis,
- Ovulation induction,
- Intrauterine insemination.
A specialist is able to evaluate simpler treatments and finely tune them to make them more effective. For example, a specialist can monitor ovulation induction with clomiphene (Clomid) with ultrasound and blood tests. The vaginal ultrasound can be used to assess follicle development and endometrium pattern and thickness. Blood tests assess ovulation by measuring progesterone. Intrauterine inseminations can be done to bypass hostile mucus caused by clomiphene. The specialist can also help decide when to stop a particular treatment and/or proceed with more
What can be done before I see a specialist?
The following tests can be done by your primary care physician or gynecologist prior to consulting the specialist.
These tests help the specialist evaluate your specific situation:
- Day 3 FSH(follicle stimulating hormone) and Estradiol (Day 2-3 is acceptable)
- TSH (thyroid stimulating hormone)
- Prolactin
- Estradiol
- Progesterone: 7 days prior to menses
- Semen analysis
These tests may be useful based on each patient's particular needs:
- Hysterosalpingogram (HSG) or documentation of tubal status
- Hysteroscopy
- Laparoscopy: The surgeon should be able to treat during this procedure, not just diagnosis.
The following treatments may be done, if indicated, for a limited number of cycles:
- IUI (intrauterine insemination)
- Clomiphene citrate (Clomid, Serophene)
At Pacific Fertility Center, we bring a complete team of specialists together to focus on your fertility situation. With extensive backgrounds as reproductive endocrinology and infertility specialists, embryologists, nurses, marriage and family therapists and financial counselors, we can approach your situation from different viewpoints to create a single, integrated solution to your medical, psychological and financial needs.
Please use our Ask the Experts resource if you have further questions. |
