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The Unofficial Guide to Overcoming Infertility
- 3 -
Dealing with Doctors
GET THE SCOOP ON...
- When to consult a doctor
- Finding a good fertility specialist
- Taking control of your treatment
- When to switch doctors
To overcome a fertility problem, you and your partner will need to undergo testing,and most likely one or both of you will undergo some form of treatment--be it hormonal,surgical, or both. But first, you need know what the problem is--or at least be ableto rule out certain conditions. The best way to do this is to consult a fertilityspecialist.
Finding the right doctor for you
Many women naturally gravitate to their regular OB/GYNs when they think they havea fertility problem. This may seem like the logical choice to you. After all, yourOB/GYN knows you and has probably been handling your contraceptive needs and gynecologicalproblems for many years. While this may be okay as a preliminary step, seeing yourregular OB/GYN is ultimately not the best choice unless he or she is a qualifiedfertility specialist. Most OB/GYNs, do not have the advanced training in infertilitynecessary to effectively diagnos e and treat many of the more serious infertilityproblems.
Infertility is a couple's problem that requires specialized knowledge of boththe male and female reproductive systems. This is especially true since at leasthalf the time, male factor infertility is a primary or secondary cause of a couple'sinability to conceive. Some doctors say they are fertility specialists regardlessof their postgraduate or specialized training. Remember, just because doctors advertisethemselves as fertility specialists doesn't mean they are.
What is a fertility specialist?
A fertility specialist should be a licensed medical doctor who has extensive postgraduatetraining in reproductive medicine, and usually reproductive endocrinology and reproductivesurgery, as well. Usually OB/GYNs and urologists are the ones who ultimately becomefertility specialists. Depending on your particular problem and needed treatment,you and your partner may see one or more of these fertility specialists.
If you're already seeing a fertility specialist and your partner is not, ask for a referral for your partner. You'll be certain that way you'll both be on the same track and your doctors can consult with each other about your case.
Physicians who are board certified in the surgical specialties of obstetrics (themanagement of pregnancy and childbirth) and gynecology (the diagnosis and treatmentof the female reproductive system). They may or may not have extensive training ininfertility. Many OB/GYNs devote a large portion of their time to obstetrics.
Doctors who have usually been trained as OB/GYNs but have chosen to specializein gynecology.
Reproductive Endocrinologists (REs)
These are OB/GYNs who have completed a fellowship in reproductive endocrinology.This involves three years of intensive training in infertility, focussing on therole of hormones in reproduction. To become board certified, they must then passspecial examinations conducted by the American Board of Obstetrics and Gynecology.
REs who have additional advanced training in microsurgery, and are usually trainedin the assisted reproductive technologies such as in vitro fertilization (IVF). Theyare sometimes referred to as reproductive surgeons. Reproductive surgeons can beurologists as well as OB/GYNs.
Physicians who specialize in the diagnosis and treatment of the urinary tractin men and women, as well as the male reproductive organs. Urologists are also qualifiedsurgeons. They may or may not have had advanced training in the diagnosis and treatmentof male infertility.
Physicians, usually urologists, who specialize in the male reproductive systemand male hormones. Many andrologists also specialize in infertility.
What to look for in a doctor
Finding a good doctor is not always easy. Nor should you expect it to be. Yoursuccess in overcoming infertility depends heavily upon the doctor you choose. Soyou should be prepared to devote some time and care in choosing your specialist.Some people balk at the idea of questioning prospective physicians--they may feelintimidated or they just may not want to go through the effort. If that describesyou or your partner, ask yourselves this question. Would you buy a new house withoutresearching and carefully inspecting it? Or a car, for that matter? Your medicalcare should be even more important. You'll be investing a lot of money and time inyour doctor. Your chances of fulfilling your hopes and dreams for a family depend,to a large extent, on this doctor. That's why it's important to choose this personvery carefully.
Be wary of doctors who guarantee that they will help you get pregnant. No doctor can or should guarantee this.
There are basically three important things you need to look for in a fertilityspecialist: credentials, convenience, and compatibility.
You should always ask about the doctor's post- graduate training. Some doctorssay they're fertility specialists but lack the necessary training.
Fertility specialists should be either board certified or boardeligible. A physician who is a board certified reproductive endocrinologistfirst has to have completed a residency in obstetrics and gynecology. She or he thenhas to take a three-year fellowship in reproductive endocrinology, and pass bothwritten and oral exams. Those who have done all the above except taking or passingtheir oral exams are considered board eligible reproductive endocrinologists.Once they pass their oral exams, they become board certified.
While there are about 28,000 OB/GYNs in the United States, only about 500 areboard certified, and another 800 board eligible, in reproductive endocrinology. Mostof thes e subspecialists practice in large cities or medical centers.
There are several ways of checking a doctor's credentials:
- Contact RESOLVE, a not-for-profit national support, education, and advocacy organization for infertile men and women. Local chapters of RESOLVE keep an up-to-date list of fertility specialists that includes information about their qualifications.
- Call your county medical society. Local county medical societies have directories of physicians that give information such as medical school attended, year of graduation, and board certification or eligibility in a specialty or subspecialty. You can usually find these directories in your local public library.
- Ask the doctor. You can ask the doctor directly about his or her qualifications, or check the diplomas on the wall. You can always double-check by calling the medical school or hospital where the doctor says he or she was trained.
- Check with the appropriate medical board, such as the American Board of Obstetrics and Gynecology or the American Board of Urology.
Ask what percentage of the doctor's practice is devoted to infertility, and what percentage is obstetrics and gynecology. Fertility specialists should devote most, if not all, of their time to infertility patients. And look around the waiting room. If you see mostly pregnant patients, chances are the doctor is primarily practicing obstetrics and may not have the necessary time to devote to infertility.
Infertility treatment is a major inconvenience in most people s' lives. Therefore,it is helpful to find a doctor who is conveniently located, has convenient hoursand offers other amenities. Here's a list of convenience factors you might want toconsider:
- Location. Not everyone has enough qualified doctors to choose from to be picky about location. But if you live in an area with many fertility specialists, location is something to consider, especially if you are working. Infertility testing and treatment can be very time consuming. For example, you may have to go in for blood tests, sonograms, or inseminations several days in a row. Getting away from work in the middle of the day for doctors' appointments can be tricky business. So the location of your doctor's practice can be very important. On the other hand, you don't want to sacrifice quality of care for a convenient location.
- Office hours. Flexible office hours can be extremely useful. If you aren't always able to get away from work for doctors' appointments, a doctor with early morning hours or evening hours might be best for you. Weekend coverage and weekend hours can sometimes be important. Be sure to discuss scheduling issues with the doctor ahead of time.
- Phone hours. Ask about phone hours. Some doctors have special hours set aside for patients to call about test results or other important medical matters. You should feel free to call your doctor whether or not there are special phone hours, but be brief, both out of consideration for your doctor and the other patients who may need to reach him or her. Many doctors don't charge for short calls. However, if your phone ca lls become too time-consuming, your doctor will most likely charge you an amount pre-determined by your insurance policy. Sometimes phone calls are handled by your doctor's nurse or other assistants. This can be fine, especially if they're familiar with your case.
- Type of practice--group or solo. Seeing a doctor in a group practice solves some problems, such as weekend coverage. These groups also tend to have more flexible hours than solo practices, as well. However, while you're always guaranteed to have a physician available at all times, you probably won't always get to see the doctor of your choice. A solo practice provides consistency of approach, continuity of care, and regular contact with the same physician. But he sometimes cannot addresss the issue of weekend hours.
- Help with insurance. Since infertility treatment can be incredibly expensive, a physician's willingness to help you with medical insurance issues can be crucial. In fact, some fertility specialists hire people just to help their patients--and themselves--with insurance matters. Your doctor should be willing to provide the insurer with the necessary information about your case, and his or her staff should be willing to help you fill out the appropriate forms. But keep in mind that your health insurance policy is a contract between you and your insurer. Whether or not you get reimbursed is ultimately up to your insurance company, not your doctor.
- On-site lab and other equipment. Ideally, your doctor will have the necessary equipment in or near his or her office so that you don't have to run all around town for various tests. Most reproductive endocrinologists will have the necessary equipment to do routine and sometimes advanced tests and procedures. Some doctors may not have room for all the necessary equipment, but they should be able to refer you to convenient nearby facilities.
Get all the information you can about a doctor before your first appointment. After checking his or her credentials, call the office manager or nurse and ask about office hours, coverage, fees, and insurance plans. If you don't like what you hear, don't make or keep any appointment with that doctor.
Compatibility with one's doctor, while very important, can be very difficult toassess. And you certainly can't assess it until you actually go and see the doctor.You may instantly bond with your doctor and then, after a few months, feel differently.Or you may not take to him or her right away, but as you become more comfortablewith each other, you may develop a compatible doctor-patient relationship.
Compatibility is not the same thing as liking or loving. You just have to havea good working relationship, one in which you and your viewpoints are respected,and one in which you participate equally in the major decisions about your treatment.
"The first doctor I interviewed spent an unbelievable amount of time with me, and was very kind. He just listened to me forever with nurses banging on the door. He waited for me to end the interview. Then I went to see the second doctor and he was very businesslike and I was very imp ressed with his technical abilities. But, I felt I really needed someone who was sensitive, and the first doctor just had the edge in that area."
--Sara, a thirty-two-year-old secretary
What about charisma?
Some people think that personality counts when it comes to choosing a doctor,but does it really? A very competent doctor may not be someone you'd want to sitnext to on a twelve-hour plane flight, while a charming doctor may be totally incompetent.So while personality counts to some extent, it shouldn't be overestimated as a majorcriterion for choosing a doctor.
Looking for Dr. Right
Now that you know what to look for in a doctor, how do you go about finding theright doctor for you? Keep in mind that there is no such thing as the best doctor.There are many good, competent doctors, and your job is to find one that is wellsuited to your needs.
Before committing yourself to a particular fertility specialist, make an appointment for a preliminary consultation. It's a good way to assess compatibility before you undergo any extensive testing or treatment.
There are many ways to find a good fertility specialist, and you should probablynot depend on one source. The first step is to collect names. The second step isto check their credentials to make certain they are, in fact, qualified fertilityspecialists. If several names come up repeatedly as good (or bad) doctors, that willhelp you narrow down your list. To collect a preliminary list of names, here's whereto go:
- RESOLVE. Described earlier, RESOLVE is the largest organization for i nfertile men and women in the nation, and is probably your best bet for finding a good fertility specialist. In addition, join RESOLVE (or other similar groups) to get the inside scoop on local fertility doctors.
- Friends. It's a good idea to ask friends who have experienced infertility for recommendations. Keep in mind that a recommendation by a friend, however, is not always an indication of a doctor's qualification as a fertility specialist or even good nonspecialist. Just because a doctor helped your friend get pregnant doesn't mean he or she is the appropriate doctor for you and your particular problem. Physician friends can be especially helpful since not only might they know the names of some good fertility specialists, they can also check out a doctor's credentials and reputation.
- Your personal physicians. Your doctors--especially OB/GYNs, internists, and family physicians--can all be excellent sources of referral. They can also give you feedback on the doctors you're already considering.
- The American Society for Reproductive Medicine (ASRM). Formerly called the American Fertility Society, ASRM is an organization of professionals interested in reproductive medicine. ASRM can provide you with the names of its members in your location. But since professionals from many fields related to infertility can become ASRM members, you'll need to further check out their credentials and particular fields of expertise and interests.
- Local hospitals. You can call your local hospital or medical center to find out which doctors on staff speciali ze in infertility. Again, you should check out their credentials further.
- Yellow pages. If you have no other choice, you may want to consult the Yellow Pages. But a name or an ad in the Yellow Pages is no guarantee that the doctor is indeed a competent fertility specialist.
Go to as many infertility talks or symposia as you can. You'll have a chance to meet doctors informally and ask them questions for free.
Once you have the names of several good fertility specialists, check to see whichphysicians are covered by your insurance plan. Then start calling for appointments.It's best to make appointments with several different doctors for consultations,since you won't immediately know if the doctor you've initially chosen to see isthe right one for you. If you find one you like, you can cancel the other appointmentsif you give them enough notice. However, it may be a good idea to keep the appointmentsfor second opinions or as alternatives if the first doctor doesn't work out.
If you decide to interview several fertility specialists before choosing one, you may be able to consider it as seeking a second opinion --and treat it as such for insurance purposes.
Common obstacles to consulting a fertility doctor
If you're still hesitant about consulting a fertility specialist, it may be helpfulto explore some of the reasons why some couples wait month after frustrating monthbefore picking up the phone and calling a specialist, while others make an appointmentthe minute they suspect a problem.
On e of the most common reasons people put off seeking infertility treatment isdenial. Most of us have a hard time admitting to ourselves that we can't do whateveryone else seems to do with ease--reproduce. It's also easy to be in denial whenthere are no physical symptoms present. Most people go to doctors because they havephysical pain or discomfort, but this is rarely the case with infertility. Althoughinfertility is a physical disorder, most patients do not suffer physically. Rather,their suffering is primarily emotional--caused by feeling deprived of having children.Because there is usually no pressing need for physical symptom relief, people sufferingfrom infertility can postpone going to the doctor indefinitely. But this form ofdenial can't last forever. When their emotional pain or frustration becomes too great,they seek medical treatment.
When a person consults a fertility doctor, it's an admission that something isprobably wrong with his or her reproductive system. That person is then faced withthe possibility of not only potentially painful and expensive diagnostic tests andtreatment, but the more painful possibility of never being able to have a biologicalchild. But remember, if you delay consulting a doctor, you'll be wasting precioustime. And you won't be any closer to conceiving.
Many people also find the label "infertility" very stigmatizing andembarrassing. Both men and women often see infertility as a reflection of their sexuality--aman may feel less of a man, and a woman less of a woman. Men tend to see their inabilityto impregnate their wives as a direct reflection on their masculinity--they equatefertility with virility, and infertility with impotence. While th e ability to haveand maintain an erection is an advantage when it comes to getting a woman pregnant,it's not a necessity. Many infertile couples conceive through artificial inseminationwith the husband's sperm, regardless of whether the husband is impotent. (See thediscussion on artificial insemination in Chapter 5.)
Some men are so embarrassed by infertility--even when it's their partner who hasthe underlying physical problem--that they're reluctant to consult a specialist.Some are afraid that if they consult a fertility doctor, they will have to discusstheir sex lives with a total stranger, often another man, and they find that prospectthreatening.
Making the most of your consultation
When you finally do get to the point of seeing a specialist, you want the consultationto be as useful and informative as possible. The following suggestions will helpyou get the most out of both an initial consultation and subsequent office visits.
- Bring your partner. It's important both medically and emotionally to involve your significant other right from the beginning.
- Write down your questions ahead of time and bring them with you whenever you see the doctor.
- Both you and your partner should take notes and jot down any questions or concerns that occur to you during the consultation.
Call at least one week ahead of time to make sure your new doctor has received any past medical records. If they haven't, make sure they get there before you do--even if you have to get them yourself.
Not being taken seriously
There is another obstacle to initiat ing infertility treatment many couples face,and that is going first to a doctor who does not think they have a real problem.When a couple finally consults a doctor about infertility, they expect somethingto be done about it. The woman is usually ready to begin her infertility workup sothat her problem can quickly be diagnosed and treated. But some OB/GYNs may not takethe couple seriously. This is another reason it's important to see a fertility specialist.
A related problem that many older women face is that despite the evidence thatinfertility increases after the age of thirty, many doctors treat their older patientsin much the same way they treat their younger ones. They follow the general rulethat you wait one full year before initiating an infertility workup or treatment.Most fertility specialists, however, believe that a woman over the age of thirtywho has not conceived in six months probably should start an infertility work-up,and any woman over thirty-five should definitely consult a specialist after six months.If your convinced you have a fertility problem and your doctor isn't, find anotherdoctor--someone at least willing to explore the possibility that you have somethingwrong.
Taking charge of your infertility treatment
Once you've settled on a good fertility specialist, you may be tempted to sitback and let the doctor do all the work. But infertility, like any important issuein your life, requires you to make important decisions. While many people preferto have their doctor call all the shots (since the doctor is, after all, the expert),keep in mind that you're ultimately responsible for your own health care. This, however,does not mean that you become your own doct or. It does mean that you becomean active participant in your treatment. You and your physician form a partnership,based on mutual cooperation and respect. As an equal partner in that relationship,you have important responsibilities. For example, it's up to you to provide accurateinformation to your doctor and ask questions when you don't understand something.
Infertility treatment requires your full participation. You have to constantlyevaluate and re-evaluate the situation so you can make the best decisions for yourself.This can only be done with the help and support of your doctor and, ideally, yourpartner.
Becoming medically knowledgeable about infertility is perhaps the best way towork positively with your doctor toward your ultimate goal--achieving a successfulpregnancy. Remember, knowledge is power. And most doctors will appreciate an involved,well-informed patient. Here are some ways that can help:
- Keep a copy of all your medical records at home.
Many doctors charge by the page to copy medical records. Request that the records go to you, and you can make as many copies as you want more cheaply on your own. Not only will you save money, you'll have a full set of records for your own use.
- If you have any questions or concerns about tests or treatments, call your doctor. Make sure all your questions get answered.
- Always weigh the pros and cons, the risks and benefits of every test, drug, and treatment your doctor recommends.
- Read everything you can on infertility. Go to bookstores, medical libraries, public l ibraries, and the Internet.
- Become an expert on your and/or your partner's particular problem.
- Go to RESOLVE meetings and infertility seminars and symposia.
- Join a RESOLVE or other support group.
- Talk to as many people as you can who have had or currently have fertility problems.
- Trust your instincts. If you have doubts about your doctor, find another one.
"As an informed patient, I think I was able to add to my treatment. I think that we had quicker success because I was participating. I had some good ideas about my own treatment and my doctor was never threatened by it. He was always receptive to my suggestions."
--Karen, a thirty-eight- year-old administrator.
The doctor-patient relationship
Your relationship with your fertility doctor is a partnership based on mutualcooperation and it should be a smooth one. After all, you both are working towardthe same goal. But, as in every relationship, there are times when things don't goso smoothly. If you have a difference of opinion with your doctor, discuss it withhim and try to resolve the issue.
"We had lots of discussions where we disagreed with our doctor, asked questions, or wanted to try something different. She's really met all our questions or disagreements with solid evidence for what she's doing. She wanted to do a laparoscopy and I said I didn't want to do that right away. She said that was fine--we'd do it when I felt ready for it."
--Julie, a thirty-five-year-old teacher
You might feel intimi dated about discussing your differences. But keep in mindthat you have nothing to lose and a lot to gain. Discussing these issues can helpyour doctor better understand you and your needs. But if you find that you and yourdoctor repeatedly have unresolved differences, you may want to consider finding anew doctor.
Make an appointment periodically just to talk to your doctor so you can both reevaluate your situation and discuss your options.
Switching doctors or doctor hopping
Infertility patients are notorious for doctor shopping and doctor hopping. Patientsoften switch doctors if they feel their doctors can no longer help them. When conflictscannot be resolved, or you believe your doctor can't help you conceive, it may betime to change doctors.
How can you tell if your doctor won't be able to help you conceive? If you feelthat you aren't making progress--that you're no closer to a pregnancy or a clearunderstanding of why you're not getting pregnant after a reasonable period of time--it'stime to move on to another doctor, or at least get a second opinion. Whether or notyou stay with your doctor or even continue treatment varies from patient to patient.It depends on your age, diagnosis, prognosis, and emotional and financial limits.What is shouldn't depend on is false hope, or unrealistic expectations about yourdoctor's abilities. No fertility specialist--no matter how famous or well-qualified--canhelp every patient. Sometimes even the best doctor can miss some subtle aspect ofa medical condition. That is why second opinions can, at times, be extremely helpfulto both you and your doctor.
Countless patients have wasted considerable time and money by sticking with theirOB/GYNs--or even fertility specialists--when they should have moved on to anotherdoctor. On the other hand, skipping from doctor to doctor can be counterproductive.It may take a doctor many months or even years to help you achieve a pregnancy. Whatis important is that you feel that you are making progress, that another piece ofthe puzzle has been found, and that different treatment methods are tried.
Just the facts
- If you're seeing your regular OB/GYN, it's time to move on to a qualified reproductive endocrinologist.
- Shop around until you find a doctor who has the right credentials, has a convenient location and hours, and with whom you feel compatible.
- Take charge of your fertility treatment--read, ask questions, and communicate with your doctor about your concerns and suggestions.
- Get a second opinion if either you or your doctor feel it is warranted.
- Switch doctors if you feel your doctor has not given you the care you deserve or if you feel you're making no progress with your doctor.