Trying to Conceive: When Should You Consult an Infertility Expert?

When should someone consider seeing a reproductive endocrinology and infertility specialist instead of their regular OB/GYN?

Question:

Nearly five million American couples experience infertility. Infertility is defined as the inability to conceive after 12 months of active attempts. Just over one million couples seek medical advice regarding infertility on a yearly basis.

The health care provider evaluating an infertile couple will initiate studies designed to diagnose and treatments intended to correct obvious causes of infertility.

Couples will determine the extent of their evaluation and treatment based on their feelings regarding childlessness, acceptance of the success of various procedures, finances, and the impact treatments will have on their lifestyle.

The clinician must be particularly sensitive to the emotional health and coping skills of the couple. Clinicians caring for infertile couples usually recognize the limits of their capabilities and make appropriate referrals to more specialized care when necessary. The American Society for Reproductive Medicine (ASRM) established guidelines for various levels of infertility care. These are based on worldwide experience and are intended to improve success.

Level I: Couples who have tried less than two years and the female is less than 30 years old

There should be no risk factors for pelvic pathology (sexually transmitted disease, uterine anomaly, known endometriosis, PCOS) or male reproductive abnormalities (symptomatic varicocele, decreased sperm or abnormal sperm, etc.)

Practitioners qualified to care for such patients must be able to consult, educate and advise the partners regarding the general evaluation and treatment of infertility. They must interview and perform a physical examination on the couple and be capable of interpreting the semen analysis and confirming ovulation.

Nurse practitioners, nurse midwives, family practitioners, and urologists who have an interest and specialized training in infertility are capable of providing this level of care. Obstetricians and gynecologists have specialized in infertility training during their residencies and are uniformly qualified to provide basic infertility services.

Level II: Couples you have tried less than three years and the female is less than 35 years old

Clinicians capable of providing level II care should possess certification or documented experience in the workup and treatment of infertility. They should be capable of discussing the risks, benefits, and costs related to the diagnosis and treatment of infertility. They must be capable of performing a hysterosalpingogram (radiologic procedure to ensure a normal uterus and fallopian tubes) and have experience in the management of uncomplicated anovulation, endometriosis, tubal disease and uncomplicated male infertility.

Patients with more complex disorders should be referred to level III practitioners. Couples who fail six months of therapeutic attempts should also be considered for possible referral to a reproductive endocrinologist. Obstetrician/gynecologists and reproductive endocrinologists uniformly meet standards for level II care.

Level III: The woamn is 35 years or older and there are complicated infertility disorders or the couple is under consideration for an assisted reproductive technology (ART).

Level III practitioners have certification and documented experience in assisted reproductive technologies via reproductive endocrinology and infertility training and certification. Their practice should have counseling services available. These practitioners manage complicated anovulation, endometriosis, tubal disease and complicated male infertility. They also provide direct access to male and female microsurgical services and ART procedures.

Recommended levels of care: Patients should discuss their particular situation and establish a time line for the completion of evaluations and treatment regimens with their health care provider. Eventual referral to a reproductive endocrinology and infertility specialist is routinely a part of the overall plan if success is not achieved.

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