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Home / How Much Is It to See a Fertility Specialist

How Much Is It to See a Fertility Specialist

Credit... Claire Merchlinsky

Seeking assistance for fertility issues doesn't have to mean signing up for in-vitro fertilization. Here's advice on when to find a specialist — and what questions to ask.

Credit... Claire Merchlinsky

This guide was originally published on June 3, 2019 in NYT Parenting.

Thanks to headlines about Tina Fey, Janet Jackson and other celebrities having babies in their 40s and beyond, the average woman might believe she'll be fertile in midlife. But even healthy couples in their 20s have only about a one in five chance of conceiving in any given month. Change the scenario just a little — by adding an older partner, irregular periods or a history of smoking — and the odds dip even further.

"Most people don't realize how inefficient we are at reproducing even when we're young — and many don't realize how quickly fertility declines for women in their 30s," said Dr. Elizabeth Ginsburg, M.D., medical director of assisted reproductive technologies at Brigham and Women's Hospital in Boston.

At least one in seven couples in the United States has trouble conceiving, according to the American Society for Reproductive Medicine. And many don't seek help, assuming that seeing a fertility specialist means they will have to commit to the intense and costly experience of in-vitro fertilization. But an early consultation can mean less invasive treatments or easier routes to creating the family you want.

For this guide, I read through the science and spoke with several clinicians who treat and study male and female infertility to help you decide whether, when and how to seek out a fertility specialist.

In the United States, approximately 9 percent of men and 11 percent of women of child-bearing age have experienced infertility, according to the National Institutes of Health. Several factors contribute to a risk of infertility. In both men and women, these include:

  • Being overweight or underweight

  • Strenuous physical labor or excessive exercise

  • Body-building supplements that contain androgen hormones such as testosterone

  • Substance use: heavy smoking, tobacco use, heavy drinking or the use of cocaine or heroin

  • Radiation therapy and chemotherapy

  • Thyroid disease, diabetes or other endocrine disorders

  • Certain genetic conditions, such as cystic fibrosis or Klinefelter's syndrome

In men, high blood pressure can change the shape of sperm, and the regular use of hot tubs or saunas can reduce sperm survival because of high temperatures. As of now, clinicians don't see a cause-and-effect link between cellphone radiation and a man's fertility, according to Dr. Michael Eisenberg, M.D., director of male reproductive medicine and surgery at Stanford University.

Women's risk is increased by:

  • Increasing age — the greatest risk factor for a woman

  • Polycystic ovarian syndrome, endometriosis and other reproductive conditions that cause irregular periods or a failure to ovulate

  • Uterine fibroids

  • Pelvic infections that cause fallopian tube blockages

  • A family history of early menopause

Sperm cells are produced continually over the course of a man's life. But a woman is born with all the eggs she will ever have — every egg cell grows old with her. Just as bodies accumulate lingering aches that might affect your ability to run a marathon late in life, aging egg cells may build up chromosomal defects that decrease their ability to form a healthy baby.

"Most people don't realize that the egg is a single cell, and you're asking this single cell to go through with you in life and somehow produce a baby 30 or 40 years later," said reproductive endocrinologist Dr. Marie Menke, M.D., of the University of Pittsburgh.

Healthy couples typically need to try to conceive — meaning unprotected intercourse during a woman's most fertile time — for several months before they succeed. That's because even for a couple in their 20s or early 30s, the chances of conception are only 20 percent to 25 percent each month.

Women in their 30s may find the process takes a little longer, since their eggs may not be as healthy. Experts advise couples to seek help if they are in their mid-30s and have been trying for six months.

Both men and women can use over-the-counter tests to improve their chances of conception or to decide whether to consult a doctor.

At-home sperm tests such as SpermCheck Fertility, Trak and YO can tell men if their fertility is a cause for concern. Although the tests aren't as good as clinical exams, they can help couples gauge whether to see a doctor. If a home test shows no sperm, for example, they needn't wait for a year to seek out a urologist or reproductive endocrinologist. "It helps reduce stress that something's wrong," Dr. Eisenberg said. Look for kits that are F.D.A.-approved, he added.

Ovulation predictor kits for women measure the hormonal spike associated with the release of an egg and can help couples time intercourse to a "fertile" window. For most women with a typical 28-day cycle, that window is six to seven days mid-cycle. Many studies have found the kits are highly accurate. They're not essential, though. "Most couples will get pregnant without having to track the exact days," Dr. Ginsburg said. "But they can help couples who are exhausted or have erratic work schedules."

Ovulation kits can yield false positives for women who suffer from polycystic ovarian syndrome or other issues. And they don't account for the age or quality of an egg.

The information that home tests provide can reassure couples, but they don't replace a doctor's advice — especially for older women.

A woman's age is considered the most critical determinant of fertility, because of the risk of chromosomal abnormalities in eggs. Albeit to a lesser extent, a man's age matters too. "Fertility is a team sport," Dr. Eisenberg said. "Men used to think their runway was unlimited in terms of paternity, but studies now show that sperm counts decline with age, and it takes longer to conceive."

Before embarking on treatments, a clinician will typically perform several tests on both partners, beginning with bloodwork and physical exams to check blood pressure, cholesterol, thyroid hormones and other factors that may influence an individual's fertility. Men undergo a semen analysis and exams to rule out blockages in the ducts that transport sperm and fluids. Women undergo tests to check the levels of reproductive hormones at various points in the menstrual cycle, the number of egg-making follicles in their ovaries, exams to rule out scar tissue left from prior pregnancies or endometriosis and exams to check for obstructions in the fallopian tubes.

Many of these exams can be conducted by a urologist (for men); an ob-gyn (for women); or a reproductive endocrinologist, who can evaluate a couple. Based on the results, couples can decide whether they want to begin treatment — and what kind of treatment they want. Health insurance typically covers infertility evaluation, but coverage for treatment varies by plan and by state.

"Most couples don't necessarily want to take that step to come into our facilities, just because they believe that almost routinely, the answer to their problems is going to be in vitro fertilization," said Dr. Harry J. Lieman, M.D., director of the Division of Reproductive Endocrinology and Infertility at Montefiore Health System in New York. "Not every person needs I.V.F."

Treatments vary based on a person's specific medical issues. A minor surgical procedure can treat blocked ducts that prevent the release of sperm or fallopian tube obstructions. Similarly, medications can boost low sperm counts or induce eggs to mature. Other options such as artificial insemination can also help certain couples.

But age matters too, Dr. Lieman said. "If you find out at the age of 38 that your tubes are damaged, we could fix them, but I.V.F. is going to give you a much better chance," he said. "After 35, I.V.F. definitely needs to be a routine part of the conversation."

Discuss your options with a reproductive endocrinologist, who can help you decide whether — and for how long — to try less-invasive routes before considering I.V.F.

Find a doctor you feel comfortable speaking to, since you will be discussing intimate personal details. Some patients feel more at ease in large, academic hospitals while others prefer a calmer, less intimidating environment.

An office that's conveniently located is also a big factor. "It sounds simplistic, but fertility testing and treatment is like a part-time job on top of people's already busy lives," Dr. Ginsburg said. Since patients might need to visit the office for tests multiple times a month, "if it's an hour to get to an appointment, that really does add significantly to the stress."

Check the Centers for Disease Control and Prevention's annually updated database for a clinic's success rates. But don't rely entirely on the data — some clinics refuse to treat overweight patients or those with lower chances of success. Ask about the clinic's experience with patients who have your particular diagnosis.

Fertility exams and treatments exact a heavy emotional toll — not unlike that of a cancer diagnosis or the death of a loved one, according to researchers. Finding support through talking with a partner, a therapist or a support group can help patients cope.

"Paying attention to the emotional aspect is really important," said Dr. Lynn Marie Westphal, M.D., a professor of reproductive endocrinology at Stanford University. "Most patients, I think, find the emotional part is much more difficult than the physical."

Despite all efforts, fertility treatments don't always result in a baby. It's important to plan for that possibility as well, Dr. Menke said. Establish self-care routines and practices that are meaningful to you, whether it's meditation or a long vacation.

Jyoti Madhusoodanan, Ph.D., is a science journalist.

How Much Is It to See a Fertility Specialist

Source: https://www.nytimes.com/article/fertility-specialist.html