The first time stepping into any Dr’s waiting room can be a daunting task, filled with a plethora of unknowns. When that Dr’s office happens to be a Fertility Specialist the uneasiness is even greater, as this is the office of the Dr. that can change the course of your life.
Your relationship with your Fertility Specialist is a very intimate one – they will see you when you’re emotionally at your lowest, they might even be the bearers of the harshest news, they will hold your hand through painful procedures and they will be by your side, smiling, when you, hopefully, finally become pregnant. For these reasons it’s vital to feel comfortable with your Doctor. Knowing what to expect from your first consult may help ease the tension and also allow you to arrive equipped with your previous test results, history, and with any questions or doubts you may have need answers too.
Usually, most patients have already been through a great deal by the time they see a Specialist. Clinics understand this, which is why you can expect highly competent and compassionate care from them.
During your first appointment, you and your partner will spend between 30 minutes and 1 hour with the fertility specialist. Your first visit is dedicated to an extensive review of your medical history, a comprehensive infertility work up and in-depth explanations and answers to all your questions. Reaching a diagnosis is paramount to subsequent success, and as such this consultation is a very important first step in your treatment. It is necessary to determine whether the infertility is of male or female cause and of what duration. It will be important for your specialist to know such aspects as how long you have been trying to conceive, your cycle regularity, fluctuations in weight, previous abdominal surgeries, or a history of hereditary disease. At this consultation you can expect your specialist to:
- Take a detailed history
- Review any previous tests you may have had
- Do a physical exam
- Examine a broad range of fertility treatment options with you so we can develop a personalised fertility treatment plan that fits you best
- Conduct female blood tests
- Answer any questions or concerns that you may have
- Order additional testing
The evaluation of a couple encompasses the following:
- Evaluation of ovulation and hormonal assessment of egg quality: This is conducted by a blood test which allows for the Specialist to maximise a woman’s ovulation and the quality of eggs involved with fertility treatments.
- Sperm quality and detailed assessment of all sperm parameters: This includes the sperm concentration, motility, forward progression, morphology (shape), and the absence or presence of antisperm antibodies. If this analysis has not been done in the past year you will need to make arrangements to have it done.
- Evaluation of uterine health: This evaluation is made to allow for successful implantation of an embryo and continued growth and delivery of a healthy baby. Pelvic ultrasounds are a routine part of the quality care and, when combined with other diagnostic procedures, provide insight into optimal embryo implantation and pregnancy.
- Blood tests will be necessary to measure hormone levels: FSH, for example, will provide an indication of ovarian function, while the measurement of Anti-Mullerian Hormone (AMH) will provide an evaluation of ovarian reserve. These blood tests may need to be run at a certain time period during your cycle and may necessitate you attending the clinic on another day.
Frequently Asked Questions
Below are some of the questions frequently asked during the initial consultation. While this list is not exhaustive it will help you to prepare for and understand what your first appointment might entail.
What can I do to prepare for the initial consultation?
Please gather any previous relevant records and lab results and have them available for your specialist to review. Write down all the questions you have – you may feel overwhelmed during your appointment for forget what it was you wanted to ask. Also write down your medical history, or family medical history if applicable, for example if you have had treatment for endometriosis or there is a history of endometriosis in your family.
Should my partner also attend the initial consultation?
Yes, if possible. Firstly your partner may need a sperm assessment as well as an evaluation of his medical and reproductive history. Secondly having your partner at the initial consultation will give him the opportunity to ask the specialist any questions that may arise for him. Lastly you will appreciate the support of having your partner with you. A diagnosis of infertility is hard to cope with and we encourage you to actively support one another throughout this process.
Will my medical aid cover the cost of the initial consultation?
Most medical aids in South Africa do not cover the cost of the initial appointment. Many will deduct the costs for out of hospital claims from your medical savings account. For further details on what your medical aid will cover please visit Medical Aid Claim Process
How long will it take to establish a diagnosis and treatment plan?
The answer to this varies from patient to patient. A diagnosis may be relatively easy to make, or may require investigative procedures.
If the problem is related to male factor does my partner need to attend?
Yes, as the treatment for most serious male fertility problems involves the female in the form of IVF or ICSI. It will also be necessary to examine the female partner to ensure that there are no existing female issues that may be uncovered at a later stage once the first attempts at treatment have proven to be unsuccessful.
Tests and Treatments for Women
Fertility Evaluation for Women
A basic fertility evaluation of all couples is recommended. This usually occurs after seeing a specialist. The basic elements of an infertility evaluation target ovarian function, tubal and uterine anatomy, ability of the sperm to reach the fallopian tube and male factor. The efficiency and accuracy of the infertility work up is a key factor in developing the appropriate treatment plan to achieve the couple’s ultimate goal, a healthy baby.
Following a history and physical examination, the initial tests used to assess the major causes of infertility are:
- Ovarian reserve testing – Common tests include Day 2 or 3 FSH (Follicle Stimulating Hormone), estradiol (estrogen), and antral follicle count
- Hysterosalpinogram (tubal dye test that allows a study of your uterus and fallopian tubes)
- Ultrasound to document the time of ovulation
- Post coital test to see if sperm can penetrate the cervical mucous
- Mid-luteal phase progesterone level
- Prolactin, Thyroid stimulating hormone (TSH), and HIV
In the majority of cases this information is enough to indicate the appropriate initial treatment plan. A laparoscopy is not routinely conducted as it carries the risks of surgery and rarely changes the initial treatment plans. A laparoscopy is usually recommended in specific cases if there is suspected endometriosis or tubal disease.
Ovarian reserve testing
- Anti Mullerian Hormone (AMH) is increasingly used as the most useful marker of ovarian reserve. It reflects the number of eggs remaining and is unaffected by the time in the cycle or other hormone markers. It is used alongside the other tests mentioned below.
- Day 2 or 3 FSH (Follicle Stimulating Hormone) and estradiol (estrogen): One of the best ways to evaluate fertility potential is to measure the concentration of the follicle stimulating hormone (FSH) on the 2nd or 3rd day of the menstrual cycle. With age the number of eggs in the ovaries declines. As egg number or reserve declines the FSH level increases.
The results of the FSH tests provide a rough idea of the number of eggs in your ovaries at a given time. It helps predict how well you might respond to the fertility medications used in superovulation, IVF, and ICSI.
FSH levels may vary from cycle to cycle, it is the highest level of FSH on day 2 or 3 that is associated with the potential outcome of treatment. Other estimates of ovarian or egg reserve such as an antral follicle count can also be used.
- Antral follicle count: An antral (early) follicle count can be used to further clarify a patient’s ovarian reserve. An antral follicle count (AFC) is a vaginal ultrasound examination of the ovaries used to determine the number of antral follicles in each ovary. An antral follicle is a tiny (2-10mm) fluid-filled structure that contains an immature egg. As a woman ages the number of eggs or follicles in each ovary declines.
Much like FSH testing, the AFC gives an estimate of the number of eggs in your ovaries at a given time. An AFC is done prior to IVF or ICSI to help predict how well you might respond to the fertility medications.
There is no specific number of antral follicles that is considered low or high – age and medical and fertility history are considered, along with AFC to estimate ovarian reserve. Typically, an AFC > 10 is reassuring, while an AFC < 5 is worrisome.
A hysterosalpingogram (HSG) is an X-ray test that looks at the inside of your uterus and fallopian tubes. The HSG is the best and least invasive method of evaluating the inside of uterine cavity and patency of the fallopian tubes. HSG can uncover uterine abnormalities such as intracavitary adhesions, fibroids or polyps, and tubal abnormalities. The HSG test can also show:
- Blockages preventing the egg from moving through a fallopian tube to the uterus
- Blockages preventing the sperm from moving into a fallopian tube and fertilising the egg
- Problems on the inside of the uterus preventing a fertilised egg from attaching to the uterine wall
Abnormalities on an HSG may warrant further evaluation with laparoscopy and or hysteroscopy.
During a hysterosalpingogram, a radiologist injects a dye through a thin tube that is inserted through the vagina and into the cervix. The radiologist takes pictures using x-ray (fluoroscopy) as the dye flows through the uterus and into the fallopian tubes. If there is any blockage or problems with your uterus, this will show up on the x-ray.
The proper development of the follicle, which contains the egg, and the timing of its release is critical to the evaluation of infertility. An ultrasound is a safe, painless and non-invasive way of evaluating this factor and timing subsequent tests.
Post coital test
Once the timing of ovulation is determined accurately, the next step is to assess if the sperm can penetrate the cervical mucus. You will be instructed to have intercourse in the early morning followed by an appointment at the clinic, at which time a microscopic examination of the cervical mucus will show if there is adequate penetration of the sperm, and to see whether sperm are present and moving normally. The test is done 1 to 2 days before ovulation when the cervical mucus is thin and stretchy and sperm can easily move through it into the uterus.
Mid-luteal phase progesterone
Some women ovulate but fail to produce adequate quantities of progesterone (luteal phase deficiency) following ovulation. The clinical tests for ovulation (e.g. temperature chart, positive ovulation predictor kit) are not sufficient to diagnose luteal phase deficiency. Thus it is sometimes recommended to obtain a progesterone level approximately 8 days after detection of the LH surge.
A hysteroscopy is a procedure where the doctor passes a hysteroscope—a narrow, telescope-like instrument with a camera on the end—through your vagina and cervix and into the uterus to directly examine the interior of your uterus. This procedure is used to determine if you have any fibroid tumours, polyps, scar tissue, or other obstructions that could be affecting your fertility. During the procedure, the doctor inserts the hysteroscope into your uterus and may inflate the uterus with gas or saline liquid to get a better view of the uterine interior.
If the doctor finds anything abnormal, he or she may remove a small sample for further examination. You don’t need to have an incision with a hysteroscopy, and most women recover within an hour or two.
A laparoscopy is a surgical procedure that involves looking directly into your abdomen and pelvis using a small camera that is placed through an incision in your umbilicus. This allows the Specialist to evaluate and potentially treat gynaecological problems such as scar tissue (adhesions), endometriosis, and ovarian cysts that may affect fertility.
For this operation you will require a general anaesthetic (you will be asleep), but in most cases you will go home the same day.
Most women experience bloating, abdominal discomfort and/or back and shoulder tip pain for 24-48 hours after surgery. This is normal and is related to the gas used to distend your abdomen during the surgery. This pain should not be severe and should gradually improve over 24-48 hours.
Tests and Treatments for Men
Traditionally infertility has been thought of as a female problem; however, this is far from the truth. A male problem can be identified in nearly half of all couples who have difficulty achieving conception. The term ‘infertility’ is used when the ability to fall pregnant is diminished or absent. It does not mean that you are unable to have children but that you may require treatment or assistance to achieve a pregnancy. For men the infertility problem may involve the sperm, the testes, the ducts that lead out from the testes, or it may be a functional problem in relation to sexual activity.
One of the most important tasks is to establish the cause of a man’s infertility. While it is often difficult to diagnose the cause, it is important in the indication of the best method of treatment. The most common causes of infertility for men are:
- Damage to sperm production – affects two thirds of infertile men
- Obstruction to the ducts leading our from the testes
- Functional problems
- Hormonal problems
- Genetic problems
Sperm Production Problems
One of the most common causes of infertility in men is damage to the production of sperm resulting in a low sperm count (oligospermia). This can also be associate with reduced sperm movement and abnormally shaped sperm. A severe case of this results in azoospermia which means the total absence of sperm in the ejaculate. Common causes of damage to sperm production are testicular injury, undescended testes, a twisted testes, cancer treatments, varicocele and genetic problems.
Obstruction occurs when the fine tubes in the epididymis become blocked preventing the sperm from reaching the penis. Obstruction can be caused by infection, congenital disorders, vasectomy and other surgery.
Function problems can cause or be due to the following:
- Impotence – the ability to maintain an erection sufficient for sexual intercourse
- Failure to ejaculate or retrograde ejaculation (ejaculating backwards into the bladder)
- Side effects of prostate surgery
- Multiple sclerosis
- Anti-sperm antibodies – where the man’s immune system makes antibodies that hinder the activity of the sperm
Low testosterone levels in men can result in the inability to produce sperm. Endocrine disorders can cause a drop in the sperm count. These disorders include thyroid disease, diseases of the pituatiary gland, hereditary haemochromatosis, sickle cell anemia and thalassaemia.
Male Infertility Tests
Presuming that the problem is male infertility the Specialist may check for:
- A good quantity and quality of male sperm. There will be a decrease in fertility if the sperm are not being produced in adequate numbers, obstructed and cannot reach the penis, not swimming very well, being attacked by antibodies from either the male himself or his female partner.
- The right balance of hormones to allow sperm development and support.
A semen analysis measures the amount of semen a man produces and determines the number and quality of sperm in the semen sample. A semen analysis is usually one of the first tests done to help determine whether a man has infertility problems. Problems with the semen or sperm affects more than one-third of infertile couples.
Tests that may be done during a semen analysis include:
- This is a measure of how much semen is present in one ejaculation.
- Liquefaction time. Semen is a thick gel at the time of ejaculation and normally becomes liquid within 20 minutes after ejaculation. Liquefaction time is a measure of the time it takes for the semen to liquefy.
- Sperm count. This is a count of the number of sperm present per milliliter of semen in one ejaculation.
- Sperm morphology. This is a measure of the percentage of sperm that have a normal shape.
- Sperm motility. This is a measure of the percentage of sperm that can move forward normally. The number of sperm that show normal forward movement in a certain amount of semen can also be measured (motile density).
- This is a measure of the acidity (low pH) or alkalinity (high pH) of the semen.
- White blood cell count. White blood cells are not normally present in semen.
- Fructose level. This is a measure of the amount of a sugar called fructose in the semen. The fructose provides energy for the sperm.
A normal semen analysis will met the following criteria:
- Volume of semen: More than 2ml
- Sperm concentration: More than 20 million sperm per ml
- Sperm motility (the ability to swim): More than 50% of the sperm are moving forward or 25% are moving forward very quickly
- Sperm morphology (shape): More than 15% have a normal shape
- White blood cells: Less than 1 million cells per ml
- Sperm antibodies: Less than 50% coated sperm
An ultrasound examination of the testes and prostate can be a useful diagnostic test. An ultrasound probe is placed on the testicles to provide a picture of the testes and epididymis. It is alo useful for diagnosing testicular cancer and varicocele.