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The Infertility Q & A: Testing with a Reproductive EndocrinologistLast Updated: May 20, 2004
Q. How do I know when it's time to seek out an infertility specialist?
A. The definition of infertility is the inability to conceive after a year of unprotected intercourse in women under 35, or after six months in women 35 or over, or the inability to carry a pregnancy to term. Also included are diagnosed problems such as anovulation, tubal blockage, low sperm count, etc. Basically if you fall under any of the following you should seek the specialized help from a reproductive endocrinologist.
- Regular unprotected intercourse with no pregnancy for a year
- Trying 6 months when 35 years of age or older
- Irregular menstrual cycles
- A history of pelvic pain or other problems such as infection or abdominal or reproductive surgery
- DES Exposure
- Two or more miscarriages
- Male problems that may alert you to a problem may include:
- Reproductive surgery
- Low sperm count and./or problems with morphology etc.
- Urinary infections
Q. What exactly is a "fertility specialist"?
A. A fertility specialist is usually an Obstetrician-Gynecologist with advanced education, research and professional skills in Reproductive Endocrinology. The Reproductive endocrinologist has a 2 to 3 year fellowship in the area of infertility with both an oral and written exam that must be passed to become board certified. These highly trained and qualified physicians treat Reproductive Disorders that affect children, women, men, and the mature woman.
If you are not seeing an RE and your OB/GYN does not have the facilities to conduct these routine tests, you should seriously consider switching to a doctor who does. Minimally, a doctor treating fertility patients should have the following:
- Availability of staff and technicians seven days per week. If your doctor or clinic does not offer weekend and holiday hours, you are clearly not in the hands of someone whose priority is helping you get pregnant.
- Transvaginal ultrasound equipment. You should not undergo treatment with Clomid or injectable fertility medications unless this equipment is available for routine monitoring. Though many OBs prescribe Clomid without doing this monitoring, it is in your best interest to have periodic ultrasounds to ensure that the Clomid is indeed stimulating ovulation and that the follicles are releasing the eggs. Under no circumstances should a patient undergo treatment with injectable medications, such as Humegon, Repronex or Follistim, without ultrasound monitoring. If you are using intra-uterine insemination (IUIs), ultrasounds are required for accurately timing insemination with ovulation.
- An on-site, certified lab to do semen testing and prep for IUIs and post coital tests, as well as facilities to do E-2, blood HCG beta and progesterone tests.
See also: How to Chose a Clinic
Q. How do I find an infertility specialist?
Q. How do I find the most recent information on infertility and pregnancy loss?
A. The InterNational Council on Infertility Information Dissemination, Inc. (INCIID --- pronounced "inside") is a nonprofit organization that has been helping couples explore their family-building options with anonimity since 1995. INCIID provides current information regarding diagnosis, treatment and prevention of infertility and pregnancy loss, and offers guidance to those considering adoption or a childfree lifestyle.
INCIID stresses the importance of seeking early care with qualified practitioners and outlines the criteria for moving to a specialist.
Q. Am I alone? How can I find others who feel the same as I do?
A. INCIID has more than 150 forums dedicated to infertility, adoption, parenting after infertility and transitions as well as over two dozen professionals who moderate the medical forums and answer questions daily. When participating, you need only register, posting and lurking are free to everyone 24/7.
The INCIID website receives more than 12 million page views each month representing half a million unique visitors from around the world. Many visitors spend long hours on the site getting to know others with the same unique sets of circumstances. One thing everyone has in common is their sincere desire to build their family. I think our members explain it best. Here are some of their comments:
- Thanks for being such a wonderful resource.
- This board has been so helpful in the past month as I've prepared for an IVF cycle. In fact, I've even met a friend on line because of INCIID.
- INCIID has been invaluable to me as I have gone through infertility. Now that I am pregnant, I rely heavily on the support of the pregnancy after infertility and loss forum. Thank you for keeping this service going!
- Thank you INCIID founders for creating a website that has taught me so much about infertility, achieving pregnancy and now parenting. Without this site, I wouldn't have learned as much as I did and I wouldn't have my little miracle. Thank you again!!
Q. What you can expect during initial visits with an infertility specialist (Reproductive Endocrinologist)
The following is a listing of tests generally included in a woman's routine fertility work-up. Please note that every reproductive endocrinologist (RE) has his or her own standard protocol, and the following is intended to be a basic guideline.
Q. What will happen on my first visit?
A. YOUR FIRST APPOINTMENT:
Try to schedule your first consultation with your RE during the first week of your cycle so that you don't "waste" a cycle. Baseline tests for follicle stimulating hormone (FSH) and luteinizing hormone (LH) must be done on day three of your cycle. If your consultation should take place before that, you'll be instructed to come in for these tests on day three of your cycle. Additional tests will be conducted on the day of Luteinizing Hormone (LH) surge (mid-cycle), and again about seven days after ovulation.
At the first appointment, most REs also do routine screening of both partners---AIDS, hepatitis, etc. Medical histories for both partners will be taken. Try to keep track of the length of your menstrual cycles for several months beforehand. Charting Basal Body Temps (BBTs) for several months will also give your doctor some insights---as will using home Ovulation Predictor Tests (OPTs) and recording the results. A semen analysis will be scheduled. Some doctors will accept your medical records for review prior to your appointment. If not, bring your medical records with you.
Q. What happens on my second visit?
A. YOUR SECOND APPOINTMENT:
This appointment should be scheduled on the day of LH surge---BEFORE ovulation. In most cases, you will be directed to use home ovulation test kits and call for an appointment on the day you detect a surge. Included in this exam will be:
Cervical Mucus Tests---These include a postcoital test (PCT) to see that the sperm can penetrate and survive in the cervical mucus and a bacterial screening. It is important to note that the appropriate time to do PCTs is just before ovulation, around the time of luteinizing hormone (LH) surge, when mucus is the most "fertile." PCTs at other times may give false results.
Ultrasound Exams)---On the day of LH surge, Ultrasound Exams are used to assess the thickness of the endometrium (lining of the uterus), monitor follicle development and assess the condition of the uterus and ovaries. If the lining is thin, it indicates a hormonal problem. Fibroid tumors and ovarian cysts can often be detected via ultrasound, as well as abnormalities of the shape of the uterus. In some cases, endometriosis can also be detected. Many doctors order a second ultrasound two or three days after the first. This second ultrasound confirms that the follicle actually did release the egg, and can rule out luteinized unruptured follicle (LUF) syndrome---a situation in which eggs ripen but do not release from the follicle.
Hormone Tests---If the blood test at your first appointment indicated a high LH to FSH ratio, an indication of polycystic ovarian disease (PCOD), your doctor will order an "Androgen Panel" to check levels of free testosterone and dihydroeprandrostone (DHEAS). Prolactin and Progesterone should be tested seven days post LH surge. Tests which can be done at any time (and therefore done at the second appointment) include: Prolactin, Thyroid Stimulating Hormone (TSH), Free T3, Free Thyroxine (T4), Total Testosterone, Free Testosterone, DHEAS and Androstenedione. The normal hormone levels for each of these during specific parts of your cycle are as follows:
Luteinizing Hormone (LH)
- Follicular Phase (day two or three): <7mIU/ml
- Day of LH Surge: >15mIU/ml
Follicle Stimulating Hormone (FSH)
- Follicular Phase: <13mIU/ml
- Day of LH Surge: >15 mIU/ml
- Day of LH Surge: >100 pg/ml
- Mid Luteal Phase (seven days after O): >60 pg/ml
- Day of LH Surge: <1.5 ng/ml
- Mid Luteal Phase >15 ng/ml
Free T3: 1.4 to 4.4 pg/ml
Free Thyroxine (T4): 0.8 to 2.0 ng/dl
Total Testosterone: 6.0 to 89 ng/dl
Free Testosterone: 0.7 to 3.6 pg/ml
DHEAS: 35 to 430 ug/dl
Androstenedione: 0.7 to 3.1 ng/ml
KEY: <= less than; >= greater than; mIU=milli International Units; ml=milliliter; pg=picograms; ng=nanograms; uIU=micro International Units; dl=deciliter; ug=micrograms
NOTE: These levels are those used at the Chapel Hill Fertility Center laboratory, and have been excerpted from The Couple's Guide to Fertility by Berger, Goldstein and Fuerst, published by Doubleday.
Q. Will there be any additional Testing
After the initial workup, many doctors continue with some of the following tests.
This test is used to examine a woman's uterus and fallopian tubes. It is essentially an x-ray procedure in which a radio-opaque dye is injected through the cervix into the uterus and fallopian tubes. This "dye" appears white on the x-ray, and allows the radiologist and your doctor to see if there are any abnormalities, such as an unusually shaped uterus, tumors, scar tissue or blockages in the fallopian tubes. If you are trying to get pregnant in the same cycle as an HSG, make sure to schedule the test PRIOR to ovulation so that there is no danger of "flushing out" a released egg or developing embryo. Although most women report only minor cramping and short-term discomfort during this procedure, some women, especially those who DO have blockages, report intense pain. Speak to your doctor about taking a pain medication about 30 minutes prior to the actual procedure.
If a uterine abnormality is suspected after the HSG, your doctor may opt for this procedure, performed with a thin telescope mounted with a fiber optic light, called a hysteroscope. The hysteroscope is inserted through the cervix into the uterus and enables the doctor to see any uterine abnormalities or growths. "Photos" are taken for future reference. This procedure usually is performed in the early half of a woman's cycle so that the build-up of the endometrium does not obscure the doctor's view. However, if the doctor is planning to do an endometrial biopsy at the same time, it is done near the end of the cycle.
A narrow fiber optic telescope is inserted through a woman's abdomen to look at the uterus, fallopian tubes, and ovaries and to discern endometriosis or pelvic adhesions, and is the best diagnostic tool for evaluating the ovaries. This test us usually done two or three days before menstruation is expected, and only after an HCG beta blood test ensures the woman is not pregnant.
This procedure involves a scraping a small amountof tissue from the endometrium shortly before menstruation is due---between 11 and 13 days from LH surge. It should ONLY be performed after an HCG blood test shows the woman is not pregnant. This test is used to determine if a woman has a luteal phase defect --- a hormonal imbalance which prevents a woman from sustaining a pregnancy because not enough progesterone is produced.
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