Conceiving can be a difficult journey for many couples or individuals. It has been estimated that 1 in 6 couples will have difficulty conceiving. So, when is the right time to speak to a specialist about it? If you’re in search of those answers, this is a good place to start. We spoke with Dr. Al Yuzpe, MD, FRCSC, Canada’s most senior Reproductive Endocrinologist and co-founder and co-director of Olive Fertility Centre, to highlight what to expect when you begin a fertility journey.
At what point is someone experiencing “infertility?”
Infertility is typically defined as “failure to conceive following 12 months of regular unprotected intercourse.” However, this definition only refers to a heterosexual couple. However, this definition should be modified depending on a number of factors including the age of the couple, the length of time they have been trying to conceive and their medical histories including surgeries (past and present).
A thorough fertility investigation will help determine whether there is a definable cause for a couple’s failure to conceive. In some cases, there is no definable cause. Those who receive this diagnosis are often referred to as suffering from “sub-fertility” or having “unexplained infertility.”
If you’re in a same-sex relationship, infertility is likely due to missing the egg or the sperm factor in the equation. This is a situational issue that can also be treated using Assisted Reproductive Technology (ART).
What is the difference between a Reproductive Endocrinologist (REI) and an Ob/Gyn?
Reproductive Medicine and Infertility is a subspecialty of Ob/Gyn. After completing a residency program in Ob/Gyn (4-5 years), one must complete an additional REI subspecialty program in Reproductive Medicine to qualify as an REI specialist (2 years in Canada, and 3 years in the USA). Other countries have different requirements. So, while seeing an Ob/Gyn can be beneficial, REI’s have more in-depth knowledge on infertility factors, and with that, more answers.
When should a couple/person make an appointment with an REI?
Maternal and paternal age are important factors in fertility, in the risk of miscarriage, congenital anomalies, and other obstetrical issues.
If there is a suspicion of an underlying cause of infertility for the female partner, an REI appointment should be made even before pregnancy is attempted to ascertain whether there is or could be a relationship with the ability to conceive.
These underlying causes vary but can include an irregular or no period at all, a chronic medical condition, a previous pelvic infection or salpiningitis (PID), the use of certain medications, or difficulty/pain with intercourse.
Even with an absence of symptoms listed above, the female’s age and duration of trying to conceive without a healthy pregnancy should be taken into consideration:
- If the female is less than thirty-five years of age, she should seek help after twelve months of trying with regular intercourse.
- If the female is between thirty-five and thirty-eight, she should seek help after six to nine months of trying.
- If the female is older than forty, she should at least have a consultation at the start of trying or no later than after three months of trying.
It is never too early to seek advice or help regarding fertility — the harm lies in seeking help too late. If there is any concern for infertility, preconception counseling is advised from either a family physician or Ob/Gyn. If there is still concern, most consulting physicians can order a basic fertility investigation.
The preceding guidelines should be of help for someone looking to better understand their fertility and what a journey may consist of.
A Typical Fertility Consultation
Most clinics follow a specific routine prior to the first fertility consultation. However, some clinics vary in their routines. You may be asked to have certain tests done in advance of that appointment. They may also ask both you and your partner to complete a medical history so that the physician you will be seeing will have a basic knowledge of your situation. It is very important to complete these forms since they will often affect the direction of discussion and the treatment plan and make the first visit much more productive and will allow for a more complete discussion of your particular circumstances. Be certain to answer all questions as completely and honestly as possible.
Before your appointment, make a list of your questions and concerns and be sure that all of them are answered or dealt with at that appointment. Ask about how your provider communicates – some prefer phone while others prefer email, some set aside certain times of the day for patient communication, others have a less structured approach, etc. Factors such as these can affect your experience.
The first visit is very important because, among other things, you will have the opportunity to form a rapport with your new physician. You should go into it openly and as comfortable as possible since this will enable you to discuss things freely and without reservation. If you have any concerns, make sure that your physician is aware of them. By the time you leave your first appointment, you should be aware of any tests that require completion. In some cases, a tentative investigation and treatment plan will be established at that visit.
Remember, you are choosing the clinic that will be looking after you. You may want to know about the success rates associated with various treatments that they offer. A clinic that quotes the highest pregnancy rates may not necessarily be the right clinic for you. You may have had a clinic suggested to you from friends, Google reviews, etc., but keep in mind, each person’s fertility journey is unique. You are the one that needs to be comfortable with your choice.
Common Diagnoses as Causes of Infertility
There are several causes associated with infertility – some of which are female-factor related, some that are male-factor related and some that are a combination of the two. For that reason, a fertility investigation must include investigation of both the male and the female.
While not absolute, there have also been links to lifestyle factors that can impact fertility, some of which include smoking, obesity, low body fat, STIs, and others.
The Most Common Female Causes
- Ovulation disorders — PCOS and other hormonal issues can cause ovulation failure, thus making conceiving naturally far less possible if at all without treatment
- Tubal diseases — pelvic inflammatory disease or other issues with female organs can cause infertility
- Endometriosis — may cause pelvic adhesions or endometriomas (a type of ovarian cyst)
- Certain chronic diseases — endocrine disorders may play a role in conceiving and pregnancy
- Uterine causes — congenital abnormalities, and uterine fibroids
- Medications and other drugs
- Advanced female age — this varies from one woman to another
The Most Common Male Causes
- Sperm abnormalities — abnormalities in quantity, quality, or function of sperm
- Erectile dysfunction (ED), reduced libido, dysfunction in ejaculation
- Previous vasectomy
- Associated medical illnesses – diabetes or other hormonal disorders
- Genetic diseases — e.g. Cystic fibrosis
- Medications or drugs
- Advanced paternal age – often associated with reduced sperm quality and an increase in ED
- Lifestyle issues – smoking, recreational drugs, and excess alcohol consumption may impact sperm quality as well as other hormones
Common Treatments
Before reviewing treatment options remember that you and your partner, if you have one, are going through a unique experience. Just because you know someone who tried a treatment plan that worked well for them, it doesn’t necessarily mean it is the treatment option for you. Don’t be discouraged by that! If you are confident with the clinic you have chosen, then you should follow your physician’s advice and recommendations.
Your physician may suggest changes as simple as:
- “You should continue to try on your own for a specified length of time”
- “Adjust your frequency of intercourse”
- A lifestyle adjustment – smoking cessation, weight loss/gain, etc.
Other treatments for the female may include:
- Lifestyle adjustments – smoking cessation, weight loss including diet and exercise, adjustment of intercourse timing & frequency, complementary therapies including acupuncture, yoga, mind-body techniques, supplements (this is a controversial area)
- Surgical intervention — for any underlying pathology which is amenable to surgery
- Intrauterine insemination (IUI) — with or without associated medication for the female
- Ovulation induction — for absent or infrequent ovulation or other menstrual disorders
- Correcting or controlling any associated medical disorders
- Assisted Reproductive Technology — IVF +/- any of its many variants (egg donor)
- Weight stabilization — management of excessive weight or low body weight
Male treatments may include:
- Specific supplements related to sperm production (antioxidants, zinc , magnesium, selenium, CoQ10, likopenes, etc.)
- Lifestyle adjustment — smoking cessation, weight loss, adjustment of intercourse timing & frequency
- Correction of underlying medical issues — improved control of diabetes, treatment of ED, etc.
- Correction of sperm factors — varicocele repair
- Intrauterine insemination (IUI)
- Sperm retrieval procedures such as:
- Electroejaculation in the spinal cord injured male
- PESA** — percutaneous sperm aspiration
- MESA**or TESE** — microscopic surgical extraction of sperm directly from the testis or epididymis
- Assisted reproductive technology – IVF, ICSI
** Sperm retrieved by PESA, MESA, TESE is combined with intra-cytoplasmic sperm injection or ICSI
The Cost of Fertility Investigation and Treatment in Canada
Fertility investigation of both the female and male is primarily covered by provincial health insurance. However, not every test qualifies for this coverage. In addition, coverage varies from province to province. Be certain that you are well informed about what tests are not covered by the provincial health care plan and exactly what the cost is for a specific test. You should also be aware of any additional coverage that you have for a specific test or treatment by way of any extended health benefits, like Progyny, offered by your employer.
Fertility Testing
The basic fertility evaluation for a female can include:
- An assessment of uterine integrity and tubal patency
- HSG, SHG, and a hysteroscopy
- Ovarian Reserve Testing
- AMH, AFC
- Evidence of Ovulation
- Menstrual history, BBT, progesterone testing, LH testing
- Hormone profile and genetic screening
- Ultrasounds, MRIs, hysteroscopy or laparoscopy
The basic fertility evaluation for a male patient usually includes:
- Semen analysis
- Volume of the ejaculate
- Sperm count, motility, and morphology (shapes)
- Specialized tests including:
- DNA fragmentation
- Leukoscreen
- Anti-sperm antibodies
- Scrotal ultrasound
- Hormonal and genetic testing
- Testicular biopsy
Some clinics will add additional tests to those mentioned above. When there is more than one test noted to assess a specific fertility function, they all likely provide the same information. Your physician will choose the test that she/he considers the best for you. A complete general physical examination is also a part of any fertility investigation.
A fertility evaluation and the foray into potential treatment may seem overwhelming, but by asking questions, leaning on your support systems, and establishing a trusted relationship with your physician can help you take the first step towards your future family! For more information on how to start your fertility journey through Progyny in Canada, please contact your Progyny PCA!