Attempting pregnancy can be incredibly frustrating. Months of cycle tracking and hopeful expectation, followed by a moment of crushing disappointment, only to begin the cycle again with each period. Unsuccessful attempted pregnancies can have a significant impact on each partner’s mental and physical health.
To all people hoping to become parents with each cycle: we see you, and we’re in this together. There is hope ahead.
Following decades of medical research, clinical process improvement, and patient experience successes (and failures), fertility treatment has become a very effective method in helping people achieve their goal of having a baby. These days, fertility providers are full of optimism and know that in most cases, success is possible. This blog will take you through what you need to know about getting started with fertility treatment.
When should you see a fertility doctor?
The answer is usually sooner rather than later. The classic definition of infertility is the inability to conceive after one year of trying if you are under the age of 35, or six months of trying if you are over the age of 35. These guidelines do not apply to everyone. People who know there may be a problem should seek help right away. Examples include women who know that they have fibroids, endometriosis, have had previous major pelvic surgery, or have periods that occur more than 5-6 weeks apart. Men with a known history of low sperm count or a history of surgery of the testicle or groin area should be evaluated as soon as possible. There is no reason to delay in these cases. If the tests come back normal, fantastic, you can always keep trying. But if test results are abnormal, you will be able to seek help from a Reproductive Endocrinologist without delay. Reproductive Endocrinologists are physicians who have completed a residency in Obstetrics and Gynecology and an additional 3-year fellowship reproductive endocrinology and infertility. Once you have selected your doctor, you will work with them to determine the best course of care.
What to expect when seeing a Reproductive Endocrinologist:
At NYU Langone Fertility Center, patients have a consultation with their physician before any testing is done. This is an opportunity for patients to make sure they are a good fit with their doctor. Patients should expect to be treated with compassion and feel listened to, as physicians understand how infertility can affect all aspects of patients’ lives. A good fertility doctor will work with you to determine the best treatment plan and will advocate for your specific needs.
While fertility testing may seem overwhelming, the good news is the initial testing is very straightforward. Following your new patient consultation, your doctor will schedule your first in-person appointment comprised of bloodwork and a transvaginal ultrasound. If the results look good, very little additional testing is needed. If any abnormalities are found, patients may be scheduled for additional tests and consultations before starting treatment.
The trans-vaginal ultrasound: This is a simple and quick exam that causes minimal discomfort. You may have even had this performed before! We use transvaginal ultrasound as it provides a clearer picture than scans performed over the belly. Here, your doctor examines the uterus to make sure it is a normal shape and is free of polyps and fibroids. Next, the ovaries are examined for any abnormal cysts. While your doctor may see a follicular cyst, which grows during the ovulation process, or a corpus luteum cyst, which occurs after ovulation, these are normal and often expected. While there are many types of abnormal cysts, the most common we look out for are dermoid and endometriomas cysts, which can negatively impact fertility.
Ovarian reserve: This refers to the number of eggs a woman has remaining in her ovaries. Women are born with about two million eggs and do not develop more throughout their lifetime. As women age, the quantity and quality of their eggs decline. We don’t fully know how or why this happens, but eventually this loss leads to menopause (and the end of fertility) at the average age of 51. Not all women lose eggs at the same rate. There are some young women with very few, while some older women have more than average. Understanding each patient’s ovarian reserve is critical in their treatment, and we determine ovarian reserve in two ways. First, during the transvaginal ultrasound we count the number of follicles present in each ovary. Follicles are fluid filled sacs each containing an egg. During the natural menstrual cycle each month, one follicle matures and releases an egg, while the others typically stay the same size and the eggs . While eggs are not visible via ultrasound, follicles are visible, and the more follicles you have, the larger your ovarian reserve. It is important to understand that ovarian reserve is just one factor in your overall fertility and has very little to do with your ability to get pregnant on your own, as it does not take into account factors like egg quality or the regularity of ovulation. However, for IVF patients, ovarian reserve is important as the higher the ovarian reserve, the more eggs we can retrieve. Because many eggs do not result in a healthy embryo, the higher the egg yield, the higher the chances of a healthy pregnancy per IVF cycle.
AMH: We also assess ovarian reserve via blood tests to check AMH levels. AMH is a hormone produced by ovarian cells that surround the follicles. The more follicles present, the more surrounding cells, and thus the higher the AMH. Typically, a high AMH level and a good number of follicles go hand in hand.
The hysterosalpingogram (HSG): This is an x-ray test to confirm the fallopian tubes, connected to the uterus and open to the ovaries, are open. Eggs leave the ovary via the fallopian tubes, where they are fertilized before implanting in the uterus. Tubal blockage can lead to infertility and treatment may involve surgery or IVF.
The Semen Analysis: Here, we assess sperm to make sure certain parameters – volume, motility, and morphology – are in the normal range. For volume, we look for quantities over 1.5cc with at least 15 million sperm present per cc. Looking under a microscope, we examine the sperm to assess motility – how well it is moving – which should be at least 40%. Finally, we look at the morphology, or shape, of the sperm cells to make sure they are at least 4% normal, though lower percentages may still be fine. Low sperm counts and motility can at times be improved under the guidance of a Reproductive Urologist. If they can not be improved, pregnancy is still achievable using IVF.