LET'S TALK FERTILITY CONSULTATIONS: DO YOU KNOW ABOUT REIs?

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Though fertility has been getting so much more attention over the past few years, it’s still very tricky to navigate through all the noise of conflicting online advice, commercialized medical practices, and constant ads for relevant apps or wearable devices. So, today’s task is to get down to the basics: what does a fertility consultation entail and when should you consider it?

FERTILITY CONSULTATIONS, THE ROUND-UP:

  • REIs (Reproductive Endocrinologists) exist! And they are likely more specially trained in fertility than your typical GYN.
  • When to go: If you have had 2 or more miscarriages, have been unsuccessfully trying to conceive for a year or more (6 months or more if you’re 35 or older), want an in-depth conversation about the fertility ramifications of your fibroids/endometriosis/PCOS, or are looking for a detailed discussion about getting pregnant now or egg or embryo freezing, seeing a REI might be appropriate.
  • On your first appointment, you should get about an hour with the doctor to talk through your situation and concerns and have a vaginal ultrasound to evaluate your uterus and ovaries.
  • If you have had vaginal trauma, the ultrasound probe can be triggering. There are other options. Let your practitioner know!
  • Make sure you feel confident that they’ve explained all charges (doctor’s fees, facility or anesthesia fees, ultrasounds and bloodwork, medication, and so on).
  • If the first appointment doesn’t feel great, or your concerns aren’t addressed, you can always pursue a second opinion before starting any treatment!


NOW MORE IN DEPTH, WHO TO SEE:

While some basic questions may be well-handled by your primary gynecologist or midwife, research demonstrates that many feel uncomfortable bringing up fertility, may not have the most up-to-date statistics on success rates, or feel strapped for time in the midst of all the other important topics they need to address at your annual exam.

REIs (Reproductive Endocrinologists) on the other hand, not only complete an OB/GYN residency, but also do 3 years of fellowship to handle the management of hormonal or fertility-relevant issues and treatment.

Feel it out with your GYN or midwife and take it from there!

Editor’s Note: Acupuncturists, herbalists and Fertility Awareness Practitioners can also be very useful in these discussions and can pair nicely with your REI!

HOW TO FIND THEM:

Picking an REI to fit your needs is critical, and a referral from a good friend can go a long way. Though many of us love to go through the nitty-gritty details about your cycle, consider more and less aggressive treatment options, and offer counseling on complementary treatments like acupuncture or supplements, these are by no means standard across the board. If you aren’t sold on a recommendation from your GYN or friends, often times, the doctor’s website biography, prior research or publications, or social media presence might clue you into whether their vibe matches yours! Asking the scheduling staff about topics that are really meaningful to you might also reassure you about the right fit.

And remember - if the first appointment doesn’t feel great, or your concerns aren’t addressed, you can always pursue a second opinion before starting any treatment! If you think you may choose treatment that involves assisted reproductive technologies (ART), like in vitro fertilization (IVF) or egg freezing, know that the CDC and the Society for ART (SART) collect data on success rates, all freely available online. Though these reports can be tricky to read, comparing the live birth rates for women in your age group might be one place to start. Some minor differences may be explained by variations between practices, but you can potentially eliminate some places with results below the national average.

WHAT HAPPENS AT THE CONSULT:

If you have a partner, and you feel comfortable sharing your entire history with him or her, then it’s often best to attend together. You can both ask questions and understand the counseling. If that doesn’t work out, a follow-up phone or in-person visit, or email correspondence, can ensure you both feel informed and confident about your plan. My usual explanation is that the first visit is one big information-gathering session. You should get about an hour with the doctor, to talk through your situation and concerns and have a vaginal ultrasound to evaluate your uterus and ovaries.

Many people are taken aback by the vaginal ultrasound probe – it looks more uncomfortable than it is, but particularly for those who are virginal or don’t have penetrative vaginal intercourse, or have vaginismus or prior sexual trauma, it can be daunting. Please bring up this history if you have concerns – there may be alternative ultrasound probes, or the ultrasound can be done on a different day once you feel more comfortable. It 100% does not matter where you are in your cycle, so don’t worry – but if you’d rather avoid an ultrasound on your period (we don’t care, though, I promise!) then keep that in mind.

Basic bloodwork will provide additional information necessary to round out the initial consultation, and remaining tests - like a semen analysis, or HSG (the “dye test” that confirms your tubes are open) – can be scheduled. You should also have the opportunity to meet with a financial consultant to explain which parts your insurance will cover, and the final price of any treatment plan you’re considering. Please make sure you feel confident that they’ve explained all charges (doctor’s fees, facility or anesthesia fees, ultrasounds and bloodwork, medication, and so on). Some places are notorious for charges that show up later on, and you don’t want that kind of surprise!

If you’ve been having trouble conceiving, the above steps typically give us all the information we need to craft a plan with which everyone feels comfortable. Often times, it’s simpler, like monitoring your natural cycle, or using a few simple medications or adding an insemination. In other cases, we might recommend IVF, which is more involved but also has higher success rates and other advantages (like allowing you to freeze extra embryos for a future pregnancy!).

THE LAST WORD:

You should not feel railroaded into a plan – choose a place where you feel a collaborative environment. I often say that no one really wants to have to come see me, but I also try to help my patients see the silver lining in their fertility journey. In many instances, we can identify problems before they might have been picked up in a spontaneous pregnancy (for example, through genetic carrier screening – ask about this testing!). You should certainly walk away with a much deeper understanding of your body. Many women or couples delay seeking treatment because they assume we’ll have bad news, or that treatment will be too invasive or expensive – but again, just remember that the first consultation is for you to gather all the relevant information about you, and help you to make an informed decision that fits your values and priorities!

Written by: Dr. Rashmi Kudesia, MD MSc.  Fertility specialist & women's health educator in Houston, TX