By: Daniel Stein, MD, RMA of NY
It is estimated that approximately one of every eight couples (12%-13%) suffers from infertility, a disease defined as the failure to conceive after twelve months in women 35 or younger, or after six months in women older then 35. Couples who fail to conceive month after month often wonder when to seek help, and from whom. The stress and distress suffered by women and their partners can be devastating. Fortunately, for most couples, help exists and successful conception can be attained.
Who should I go to for help?
For women 35 and under who have been trying to conceive for up to one year, have regular menstrual cycles (every 21 to 35 days), no history of sexually-transmitted diseases, pelvic pain or pelvic surgery, and whose partners are in good health, the obstetrician gynecologist (OBGYN) doctor can be an excellent first resource to begin to evaluate the causes of infertility. Some well-trained OBGYN doctors are comfortable with treating mild ovulation disorders with oral ovulation induction medications like Clomiphene Citrate or Letrozole. In many cases, infertility is due to causes unrelated to ovulation and a more extensive evaluation of the couple is warranted. OBGYN doctors are experts in managing pregnancies, office gynecology and some pelvic surgery. As OBGYNs, however, receive only a few weeks of training in reproductive endocrinology and fertility, they typically refer couples with infertility to Reproductive Endocrinologists.
What is a fertility specialist and when should I see one?
While any physician can state that she or he is fertility specialist, true specialists in fertility and reproductive medicine are called Reproductive Endocrinologists, physicians who are not only fully-trained and board-certified in Obstetrics and Gynecology, but who have also completed two to three years of additional fellowship training in the diagnosis of complex reproductive disorders and their treatment, including assisted reproductive technologies like in vitro fertilization, egg and embryo freezing, egg donation, and reproductive surgery. Reproductive Endocrinologists work closely with reproductive Urologists in cases in which the male partner has significant sperm deficiencies or abnormalities in sexual function. While it is beneficial for all couples with infertility to see a reproductive endocrinologist, the following are conditions in which a woman or couple should see a Reproductive Endocrinologist as soon as possible:
- If the couple has tried to conceive for six or more months and the woman is 35 or older
The ability to conceive diminishes significantly as a woman approaches her mid-thirties. As women age, the number of eggs in the ovaries decreases and an increasing proportion of those eggs are genetically abnormal. As such, advanced reproductive age is characterized by decreased rates of infertility and increased rates of miscarriage and birth anomalies.
- A couple with a history of two or more miscarriages
Multiple miscarriages occur for a variety of reasons including chromosomal abnormalities in embryos, uterine masses or malformations, and immunologic or hormonal abnormalities. A Reproductive Endocrinologist is trained to diagnose the cause(s) of recurrent pregnancy loss and offer appropriate treatment options.
- A woman with a mother or sister with menopause at age 45 or younger
The average age of menopause is 51 and ranges from ages 45 to 55. The age of menopause depends on the number of eggs a woman is born with. As menopause denotes the time that a woman is depleted of functional eggs, women born with a low number of eggs run out of eggs sooner than those born with a higher number and therefore experience menopause earlier. Women with a mother or sister with early menopause are at risk of experiencing early menopause themselves.
- A woman with a history of pelvic surgery or pelvic diseases
Many adolescent and reproductive-aged women undergo surgery in the pelvis or abdomen which can lead to the development of pelvic scar tissue (causing blockages in the fallopian tubes) or ovarian damage. Sexually-transmitted infections like Gonorrhea and Chlamydia can be destructive to fallopian tubes as can pelvic operations including appendectomies, removal of ovarian cysts or masses, or removal of uterine masses. Ovarian surgery can lead to destruction of eggs within ovaries.
- A woman with ovulation dysfunction who has failed to conceive with three cycles of Clomiphene Citrate or Letrozole
- A man with an inability to achieve an erection or ejaculation
- A man with a low sperm count (< 10 Million per ml) or with poor sperm motility (<40%) or morphology (<4 %)
A problem in the male partner is involved in approximately 40% of couples suffering from infertility. Diminished sexual function as well as suboptimal or poor sperm concentration, motility and/or morphology are commonly encountered. Before the OBGYN initiates the use of ovulation induction agents or inseminations, a semen analysis should be performed in an andrology laboratory. When a problem is detected, the man is referred to a Urologist, preferably one who specializes in infertility.
- A woman with significant autoimmune disease (e.g. hypothyroidism, lupus, rheumatoid arthritis)
- A woman or a man who is planning to start chemotherapy for cancer or autoimmune disease
- A woman over 30 who is planning to delay childbearing
If a woman and/or her partner have difficulty conceiving and meet one or more of the above criteria, it is advisable that they make an appointment with a reproductive endocrinologist. Finding the right specialist can be challenging but biographies of reproductive endocrinologists are usually available online. Board-certified Reproductive Endocrinologists have passed a vigorous series of examinations over several years to achieve and maintain such certification. The Society for Assisted Reproductive Technology (SART) website (www.sart.org) lists local centers by zip code and allows prospective patients to view important information and statistics about each center.
Daniel E. Stein, M.D.