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The Unofficial Guide Reader's Bill of Rights
The Unofficial Guide Panel of Experts
Appendix A - Glossary
Appendix B - Recommended Reading List
Appendix C - Resource Directory
Appendix D - Important Documents
[Figures are not included in this sample chapter]
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.
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.
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.
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.
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:
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:
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
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.
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:
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.
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.
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.
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.
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.
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:
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.
"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.
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.
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.