When Should I See a Fertility Specialist?


When Should I See a Fertility Specialist?

After 6-8 months of trying to conceive without pregnancy, many couples begin to wonder whether they should seek professional help. While the answer to this question depends mostly on the woman’s age- a definite YES if the female partner is 34 or older- there are other factors that should prompt a couple to seek help sooner.

You can take a proactive path in identifying the causes of infertility by paying attention to your menstrual cycle and medical history.

So let’s go through the interview:

1. How long have you been trying to conceive?

If the answer is 3 years or longer, and especially if your menses are regular, the cause of your infertility is probably serious.

Severe male factor, tubal damage, pelvic adhesion and advanced endometriosis are often involved in chronic infertility, and these conditions require the most aggressive treatment such as IVF.

As can be seen in the graph above, most couples (93%) will achieve pregnancy after 2 years of trying. There is only a minimal increase in pregnancy rate (to 95%) when trying on your own for another year.

Bottom Line: After 2 years of infertility, you should seek professional help.

2. What is the duration of your menstrual cycle?

The length of the cycle is measured from the first day of normal flow (not just spotting) to the first day of the next menses. The normal cycle length is 28-30 days.

A history of long cycles (32 days or longer) can mean that your follicle is developing too slowly. Stress (physical or mental) can impair the release of FSH (follicle stimulating hormone) from the pituitary gland. FSH stimulates the development of the egg and low FSH can result in a slow growing follicle that cannot produce sufficient progesterone to mature the uterine lining for implantation.

A history of short cycles, on the other hand, is worrisome because it can suggest a low ovarian reserve. When the pituitary perceives that the ovaries are running low in egg reserve, it secretes a high amount of FSH to compensate, which in turn hastens the growth of the follicle leading to earlier maturation and ovulation.

Women with low egg reserve usually ovulate early, on day 10-11 instead of day 13-14. Hot flashes can occur when the ovaries are unable to produce enough estrogen and are often seen during the early phase of menopause. Women who smoke tend to have low egg reserve from premature aging of their ovaries.

Bottom line: If your cycles are longer than 32 days or shorter than 28 days you should seek help.

3. Do you have milky breast discharge or excessive hair on the face and abdomen that requires weekly removal?

Milky discharge can be a sign of excessive secretion of prolactin, which is a pituitary hormone that promotes milk production for lactation. However, a high level of prolactin can suppress the release of FSH and delays follicle growth.

Conditions that lead to excessive production of prolactin include a pituitary tumor, hypothyroidism and polycystic ovary syndrome (PCOS).

Polycystic ovary syndrome (PCOS) is a common condition that is associated with elevated production of testosterone that can inhibit follicle growth. Excessive hair on the face and abdomen that require removal at least once a week can be a sign of excessive male hormone production, which can inhibit follicle growth.

4. Have you been diagnosed with hypothyroidism or polycystic ovary syndrome?

Patients with thyroid conditions or PCOS can have delayed follicle growth or suboptimal ovulation and would benefit from taking ovulation induction medications to ovulate better.

Bottom Line: If you have been diagnosed with hypothyroidism or PCOS, you probably will need help to ovulate better.

5. Have you ever had abdominal surgery?

Myomectomies (surgery to remove fibroids) nearly always result in pelvic adhesions that can impair the ability of the tubes to find or pick up the egg after it is released from the ovulating follicle. Tubal surgery for ectopic pregnancy or for tubal adhesions implies existing tubal damage and co-existing pelvic adhesions. Bowel surgery for appendicitis or other conditions can result in significant pelvic adhesions.

Bottom line: If you had myomectomy or tubal surgery, you should see a fertility specialist after 1-2 years of trying to conceive.

6. Have you ever been treated for any STD (Chlamydia, Gonorrhea, HIV, HPV, herpes, syphilis)?

Gonorrhea and chlamydia are well known to cause infertility by damaging the tubes and causing pelvic adhesions. Chlamydia is an STD that can cause infertility without symptoms; thus, its treatment is often delayed due to late detection.

HPV can cause abnormal changes in the cervical cells that may necessitate surgical treatment of the cervix such as LEEP or cryosurgery, which in turn can lead to cervical stenosis (constriction of the cervical opening), impairing the movement of sperm into the uterus.

Bottom line: If you have a history of four STDs and 2 years of infertility, you likely will need help.

7. Do you have painful intercourse or severe pain with menstruation?

Deep pain with intercourse is very suggestive of endometriosis, a condition in which implants of the endometrium grow in the pelvic cavity. Endometriosis can cause pelvic adhesions and impair the fertilization process. While most women experience cramps during menstruation, severe menstrual pain can suggest endometriosis or uterine fibroids.

Unfortunately, the only reliable way to confirm endometriosis is through laparoscopy. You can consult your OBGYN or see a fertility specialist to discuss treatment options.

8. Have you had 2 or more miscarriages?

Most miscarriages that occur during the first 12 weeks are caused by suboptimal ovulation and abnormal embryos. Occasionally, thrombophilia (tendency to form clots) or abnormality in the chromosome of the parent(s) such as translocations can be the cause of recurrent early miscarriages.

Miscarriages that occur after the 12th week can be caused by structural abnormalities such as a fibroid, uterine septum and other malformations of the uterus.

Bottom line: If you have had 2 or more miscarriages, especially if one  loss occurred after the first trimester, you might want to see a fertility specialist sooner than later.

9. Does the male partner have the following?

  • Male surgery- vasectomy reversal, varicocele repair or testicular surgery can suggest sperm problems (low count and low motility). Surgery can also lead to formation of sperm antibodies that can impair fertilization.
  • Previous infection of the male organs (prostatitis, epididymitis) can impair sperm motility and survival and cause formation of sperm antibodies that can bind to the tail to slow down the sperm or to the head to prevent fertilization.
  • Heavy smoking can result in damage of sperm DNA that can lead to formation of an abnormal embryo.
  • Low semen volume or watery semen can suggest retrograde ejaculation in which semen flows back into the bladder as a result of a weak sphincter at the bladder neck.
  • Testosterone supplement, a popular treatment nowadays for low male libido, can lead to complete suppression of sperm production in a short time. Many men who took just 2-3 months testosterone have been shown to have no sperm in their semen.
  • Hair loss medications such as Propecia can decrease the semen volume and sperm concentration. Medications that affect calcium ion action (calcium channel blockers for hypertension) can impair the fertilization potential of the sperm.

Bottom line: A semen analysis can quickly detect severe male factor to allow timely consultation with a fertility specialist.

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