Parenting: Preconception

Women 35 and older have half the probability of getting pregnant than women 27 or younger, according to a recent study published in the Journal of Human Reproduction. Fertility declines with age and can never be taken for granted.

Nearly five million American couples experience infertility, and many of these people enter the world of infertility treatment. Infertility affects people of all ages and for a multitude of reasons. Some couples try on their own for years, whereas others seek out medical assistance early on.

But where to start? How do you know when to consider talking to a medical professional? Infertility is defined as the inability to conceive after at least one year of unprotected intercourse. Since most couples will conceive during this year, physicians recommend that people unable to do so be assessed for fertility problems.

Let's look at the route taken by a fictional couple, Bethany and Daniel. They are both 30 years old and started trying to get pregnant one year into their marriage. A year later, Bethany is concerned and upset by the sight of her period every month. Daniel doesn't show his emotions as much, but is struggling with his own fears of being "not enough of a man" to get his wife pregnant.

Bethany finally decides to discuss her concerns with a medical professional. She wants a midwife to guide her through pregnancy and childbirth. However, most midwives don't get involved with preconception issues unless they are part of a practice that provides routine women's health examinations or family planning services. In addition, the ability of a midwife to order tests or medications is limited, depending on where she practices. As a result, Bethany decides to talk with her family physician.

The General Practitioner
Talking to a family doctor makes a lot of sense; he or she is trained to be a screener who sends patients on to the right specialist. Dr. Jeff Bernholtz, who practices in Richmond Hill, Ont., sees himself as a "gatekeeper."

"I want to make sure that the patient is sent to the right door to help him or her solve their problem," he says. "... The role of family practice is to make sure that there are no other easily correctable causes of infertility."

According to Dr. Bernholtz, the family medicine approach involves reviewing the patient's history, doing a physical exam and performing baseline investigations. He looks at how long the patient has been trying to get pregnant, as well as medical history, menstrual abnormalities, history of infections (especially STDs), dietary history and mental health.

Family dynamics can also be very important. In some cases, Dr. Bernholtz says, there is "one family member pushing the other into these investigations – unwillingly. Sometimes it's the spouse and sometimes it's a mother-in-law who wants a grandchild, now! This additional stress may be the cause of the infertility and must be considered in any future therapy."

If there are no medical problems found, Dr. Bernholtz will encourage the couple to keep trying for another three to six months. During this time, the male will give a semen sample for analysis of sperm and infection. He will then instruct the couple about the timing of sexual activity.

If conception still doesn't occur, Dr. Bernholtz will initiate a referral to an infertility specialist. Depending on his findings, he might also refer to a gynecologist, a urologist, an endocrinologist and/or a psychiatrist.

In Bethany's case, her family doctor says she is young and there is nothing to worry about, yet. (Doctor's attitudes can vary from this to those that immediately launch thorough investigations.) Bethany decides to visit her OB/GYN, who does preliminary tests, such as monitoring ovulation, post-coital test and basic blood work.

The Obstetrician/Gynecologist
Kim Wade of Laurel, Miss. went to see her OB/GYN after several years of trying on her own. "She did what I call the basics: blood test, sperm count and tubule X-ray," Wade says. "But when she performed the tubule X-ray, she found that my tubes were not blocked. At this point she suggested that I try on my own, because she has found that some women have success once the tubes are 'cleaned.'" Wade ended up trying for another year with no success before returning to her doctor.

The Urologist
Back with our fictional couple, Daniel mentions the fertility issue to his family doctor during his annual physical. He has been having some trouble getting aroused lately (probably due to anxiety), but to be on the safe side, his doctor refers him to a urologist who specializes in male infertility.

Dr. Russel Williams of Houston, Texas is a urologist who completed a fellowship in male infertility and microsurgery. He founded the Male Reproductive Clinic, P.A., a dedicated center for the evaluation and treatment of male infertility. "Fifty percent of couples who present for an evaluation will have a male factor causing decreased fertility," Dr. Williams says. "An abnormal semen analysis, while contributing to infertility, can also be a very important sign of underlying disease ... I diagnose on a frequent basis otherwise silent hormonal abnormalities, genetic abnormalities, prostate infections and erectile dysfunction on the initial visit."

Early identification of a male fertility problem can significantly improve a couple's infertility and save them thousands of dollars that might be spent later on artificial inseminations.

The Reproductive Endocrinologist
If Bethany and Daniel aren't able to conceive under the treatment of an OB/GYN in her case and a urologist in his, then the next step is to see an infertility specialist known as a reproductive endocrinologist (RE).

Patients often spend years working with OB/GYNs and urologists who claim to be infertility experts, but short-term, post-graduate courses in infertility do not qualify them to make this claim. Only physicians who have completed a residency in Obstetrics and Gynecology and then have gone on to advanced training (a fellowship) in the treatment of infertility, recurrent miscarriages and hormonal disorders, qualify as reproductive endocrinologists. These doctors are certified by the American Board of Obstetrics and Gynecology and are trained in advanced procedures such as difficult infertility surgeries, injectable fertility drugs and assisted reproduction techniques such as insemination and in vitro fertilization (IVF).

Wade has been seeing an RE for several years now. Through a procedure called a laparoscopy she found out that she has endometriosis. At this point, she has had inseminations while on the fertility drug Clomid and has had one attempt at IVF. So far she hasn't become pregnant. Her recommendations for women struggling with infertility: "I would first recommend that you start with your family doctor or OB/GYN – as I did – and then move on to a specialist if need be. There are also many Web sites with background information on doctors and clinics. Another good way to find out information is to join a chat group on the Web that deals with infertility ... From experience, I know that infertility is stressful and is an emotional roller coaster ... I have found that talking about it rather than keeping it to myself has helped me out tremendously."

When Bethany and Daniel go to their first appointment with their RE, they will take along some questions to ask to ensure a good patient-doctor fit. They know that they want a doctor who has a high level of expertise in a rapidly-changing field, but they also want someone who is compassionate and will hear their concerns.

The following logistical questions are also important.

1. What are your office hours? (Do they accommodate your work schedule for tests and procedures?)
2. How many times will you try the same treatment before moving on in the game plan?
3. Do you perform all major procedures in your office?
4. What do you charge?
5. What is your success rate?

It is up to each couple to determine the extent of their evaluation and treatment based on their finances, the impact that childlessness is having on their lives and the risks of various medical procedures. Developing a thorough knowledge of infertility treatments and the medical professionals involved is essential to make informed decisions.