Making Your Fertility Treatment Plan: Finding the Right Doctor

Shelley looked toward me. "Dr. Perloe, how can couples find out which doctor to go to?"

"There are a number of alternatives. Resolve's list of physicians is an excellent beginning." I paused. "However, one thing that concerns me greatly is the thinking that says that only a fertility specialist can treat fertility problems. That simply is not true."

"But I wasted over a year going to my gynecologist before I realized he was just bouncing from one thing to another," Shelley said.

"I know that can happen. But even a fertility specialist may use hit-or-miss procedures. You see, there is nothing to prevent any doctor from hanging up a shingle that says 'fertility specialist.' "

"I didn't know that," Debbie said.

"First consult with your family physician or obstetrician-gynecologist. She or he knows your medical history better than anyone. If your problem requires specialized knowledge, ask your doctor to refer you to a specialist.

"Read everything you can about fertility problems and fertility treatment. Talk to RESOLVE members and other infertile couples about their experiences and compare what's happening to you with what you learn. Talk to your doctor. Discuss your treatment plan and ask lots of questions. If it seems to you that your doctor does not have a plan, is not using 'accepted' procedures, or resents answering your questions, you may want to seek a second opinion."

"What if you don't have a doctor?" a woman across the room asked.

"Get a list of names in your area from the American Society of Reproductive Medicine or your local county medical society. Call or write fertility clinics for additional information. Talk to family and friends, too. Perhaps they know someone who's seeing a doctor for fertility treatment. With one in six couples in the United States seeking treatment for fertility problems, help can't be too far away. The best insurance you can have is being prepared_by reading attending workshops, and joining support groups."

In this chapter I will tell you how to find a physician, what types of physicians or clinics to look for, and how to spot the "poor treatment" danger signs.

Consult Your Current Physician First
I encourage you to consult your family practice physician or obstetrician-gynecologist first. Since you've already developed a rapport, it will be easier for you to share personal and intimate facts about your sexual history and habits. Both of these physicians are trained to analyze the results from a semen analysis, blood tests, and X rays. And they know how to administer fertility treatment to both men and women. The following is a more detailed breakdown of different medical specialties.

Doctors Who Treat Fertility Problems
General Practitioner, Family Physician, Internal Medicine Specialist
Family physicians can assess your general health and investigate the potential effects of your medical history, environment, and medications on your fertility. These physicians can determine if a woman is ovulating and if a man's semen is functional. Many common fertility problems may be resolved at this initial level - for example, using a basal body temperature chart to time coitus, changing blood pressure medication, and counseling on the discontinuance of sperm-killing douches and lubricants. If your fertility problem is such that it demands it, your physician should refer you to a specialist. Since your records and test results will be provided to the specialist, you won't have wasted your money by seeing your family doctor first.

Obstetrician Gynecologist
This physician specializes in the study and treatment of women's diseases especially of the genitourinary and rectal tracts. In addition, he or she is concerned with the care and treatment of women during pregnancy and childbirth. Most OB-GYNs, as they are commonly called, also perform surgery. However, depending on their skills, they may or may not be able to perform microsurgery on your fallopian tubes, which is required in about 10 percent of fertility patients. Most OB-GYNs can perform a diagnostic laparoscopy, but if they can't do microsurgery, the laparoscopy may have to be repeated by the microsurgeon so he or she can plan your corrective surgery. OB-GYNs have access to all of the fertility diagnostic tests available including the semen analysis. The OB-GYN should be able to treat anovulation with clomiphene and to perform artificial insemination.

Reproductive Endocrinology and Fertility Specialist
This is an American Board of Obstetrics and Gynecology subspecialty for OB-GYNs who receive extra fellowship training in the endocrinology of women (the study of hormones) and infertility. Generally these physicians are affiliated with fertility research programs at universities, infertility clinics, or in vitro fertilization centers. They have the most up-to-date information on fertility and are skilled in microsurgery techniques. By providing a full range of infertility treatments, the reproductive endocrinologist can work with you to develop a cost effective treatment plan offering you the greatest chance for success. The reproductive endocrinology practice often provides financial counseling to enable you to better plan ahead and make insurance decisions.

Urologist
This physician specializes in the male genitourinary tract. The urologist can perform a semen analysis and can examine a man for a varicocoele, endocrine problems, genetic defects, or other physical abnormalities that may cause fertility problems. In addition, the urologist can perform a testicular biopsy, surgery for varicocoele repair, and vasectomy reversal.

Andrologist
This physician-scientist performs laboratory evaluations of male fertility. The andrologist need not be a medical doctor and may hold a Ph.D. degree in any number of technical areas, including microbiology, biochemistry, or andrology. Many andrologists are affiliated with fertility treatment centers and play a key role in performing in vitro fertilization.

Psychologist/Counselor
This healthcare professional can help you better communicate your feelings and needs to your spouse, family, friends and coworkers. An infertility counselor can help you plan to deal with stress you may encounter during treatment or explore ethical issues surrounding your chosen therapy.

Accept Your Physician's Referral
If you trust your doctor, you'll be inclined to trust the quality of the referral. Referral from another physician is one of the quickest and best ways to find a doctor.

Starting Your Search from Scratch
If you're faced with finding a new physician on your own, you may want to utilize some of these resources:

• RESOLVE, Inc. Contact your local RESOLVE, Inc., chapter or national RESOLVE, Inc., for a referral.

   

• The American Society of Reproductive Medicine and local county medical society. As noted, these organizations can provide you with a list of physicians who have expressed an interest in fertility treatment. Although membership in these organizations doesn't certify fertility treatment competency, this may be a good list to work from.

   

• Fertility clinics. A number of fertility clinics exist across the country. Some of them are for-profit clinics. Others are nonprofit research organizations usually associated with universities. Many of these clinics can perform your fertility workup. If not, they can provide you with a list of physicians whom they work with in your community. Later I will discuss the different types of fertility clinics.

   

• The Endometriosis Association can provide referral to local physicians experienced in managing endometriosis related infertility.

Should You Go to a Specialist?
Through your reading and search for information, you may have noticed that many sources recommend you avoid your family physician and obstetrician-gynecologist and go directly to a fertility specialist. I have heard couples say, "If you go to the in vitro clinic for your workup, you're getting the best." While it is certainly true that you can receive very good care through these facilities, the erroneous conclusion drawn by some couples is: "If you don't go to the in vitro center, you're settling for second best." Or even worse: "If the in vitro center can't help you, that's the final word."

You may also have heard that you can identify a fertility specialist by the fact that he or she "specializes" in fertility and doesn't deliver babies_the logic apparently being that if doctors are busy delivering babies, they're too busy to know enough about fertility to practice it. I don't believe this is an adequate description, however, of a physician who is qualified to treat your fertility problem. So for a number of reasons, which I'll share with you, I disagree with this generalized recommendation for fertility specialists.

Any physician can be listed as a fertility specialist. There is no regulation, licensing, or certification required for advertising this specialty. Before you make your first appointment, however, you can inquire if the physician is fellowship-trained in the reproductive endocrinology and infertility subspecialty.

Membership in the American Society of Reproductive Medicine is available to any physician showing an interest in the specialty. While membership in this organization does not guarantee a known standard of technical competence, it does demonstrate the physician's interest in fertility treatment (a definite plus) Specialists may charge more for the same services. An article in Money magazine stated that fertility specialists may charge up to five times more than nonspecialists. This may be overstated, but before you settle on the physician you want, ask about the charges for common tests and procedures. You may find that you'll pay twenty to twenty-five dollars more for a semen analysis from a specialist, even though the same medical laboratory provides these services to all of the doctors in your community. While a fertility specialist may charge more for a particular test or surgical procedure, that your treatment costs no more. A reproductive endocrinologist can best determine whether surgery or in vitro is a more cost effective option for you and help you develop a treatment plan that avoids wasting time and money on unnecessary testing and outdated treatments. Do a little price comparison first and remember that the lowest- or highest-priced doctor is not necessarily the worst or best.

The Private Physician vs. the Fertility Clinic
Another question that arises is whether to consult with a private physician or go to a large fertility clinic. A private physician can treat most fertility problems. The additional skills and expertise provided by in vitro centers and large fertility clinics are needed only for about 10 percent of fertility problems. I have some additional ideas on this matter that I'd like to share with you:

For-profit fertility clinics and in vitro centers are not certified. Fertility treatment has become a big money making business. It's little wonder that the clinic's interest in attracting customers influences the way in which they may report their pregnancy success rates. For example, a clinic may report that 50 percent of their patients get pregnant within two cycles. So you may assume that you have a one in two chance of pregnancy if you go to them. These could look like pretty good odds to some couples. However, the clinic's statistics do not show that they eliminate more than half of the applicants before completing the in vitro procedures. In fact, some clinics quote success rates based on a positive pregnancy test rather than babies delivered. The Society for Assisted Reproductive Technology publishes an annual clinic specific report documenting success rates at each clinic. While this report ensures that each clinic defines success in a similar fashion, it may still not provide all the information you need to base your decision. At first glance, a program with a high success rate may seem the obvious choice. But, after a closer look, you learn that the clinic with a lower success rate treats older patiing.tonents with more severe fertility problems while the clinic with the better pregnancy rates refuses women older than 35 and any couple with an abnormal semen analysis. Don't get me wrong: Reviewing statistics is important. Just try to be objective when you read or hear about success rates.

Research-oriented clinics may perform unnecessary tests and procedures to meet research criteria and to pay their expenses. In order to conduct scientifically sound fertility research, medical professionals must have similar information about each couple. Thus this kind of clinic may perform expensive tests not only on patients who warrant them but also on those who do not need them. In this way the researchers can compare their results between "abnormal" and "normal" populations. Consequently the research clinic may not tailor your workup to your unique set of problems. Money charged for these "extra" tests also helps pay the bills for expensive laboratory and research capabilities which may not be needed for your basic diagnostic workup. Before signing up with a research clinic, find out what diagnostic procedures they recommend and how much they charge. If this information doesn't correlate with what you've learned about fertility treatment, you may wish to get a second opinion.

Larger clinics may contribute to your feeling of isolation and anonymity. Often couples who have gone to large clinics complain that they didn't receive much of the physician's personal time; no one in the clinic knew them by sight; and a different resident physician saw them at each visit. Also, many people who travel considerable distances to these clinics don't feel comfortable expressing their concerns: they feel isolated and dissatisfied. One patient said, "I feel like I'm being herded like cattle." If that's the way you feel, you probably are not getting the personal attention you need, and the clinic you're going to may be too large. I must say, however, that a number of large clinics provide services that many smaller organizations cannot: educational videotapes, nurse practitioners to answer questions, on-site X-ray and testing laboratories, and counseling and support groups_all of which can be of great value.

Many communities are not large enough to support fertility specialists and in vitro clinics. Traveling to distant medical facilities may add unnecessarily to your out-of-pocket expenses, absenteeism from work, and overall level of stress. If you have a good family practitioner and/or OB-GYN in your community who knows quite a bit about fertility treatment, I'd encourage you to begin there rather than travel hundreds of miles to a stranger. The "expert" isn't necessarily better just because he or she is located over one hundred mile s away. Often, you will find that your physician can work together with a fertility specialist to minimize your travel, expense and time.

A Final Note About Selecting a Doctor
Fertility treatment isn't magic. It is a structured, organized investigation. An obstetrician-gynecologist working together with a reproductive endocrinologist or urologist can diagnose and successfully treat the majority of people with fertility problems.

Ultimately you should judge any doctor's ability based on the treatment plan he or she outlines especially for you and on the doctor's responsiveness to your problems and concerns.

Continued