When to see your OBGYN for a basic fertility evaluation
We usually recommend most couples try to conceive on their own for at least a few months before seeking help. But there are some indications it's time for an evaluation..
Go see your OBGYN if:
You're not getting regular monthly periods
OPKs don't turn positive, or are positive too early and for many days
If you are 35 years old or older and have been trying to get pregnant for 6 months
If you have a known history of endometriosis or pelvic inflammatory disease (PID) and have been trying to conceive for 6 months
If you have been actively trying to conceive for a year
The basic fertility evaluation is simple. We just look at the 4 main things you need to get pregnant:
Egg - are you releasing an egg (ovulating) every month?
Tube - do you have at least one open fallopian tube where sperm and egg can meet?
Uterus - do you have anything in your uterus that could prevent an embryo from implanting?
Sperm - do you have access to healthy sperm capable of fertilizing an egg?
So there are 3 basic tests to evaluate these things...
1. Check hormone levels (AKA Day 3 labs) to evaluate ovaries (eggs)
check thyroid and prolactin levels
check certain hormone levels, such FSH and LH and estrogen - need to be done on day 3 - indicates if you are ovulating normally
AMH - optional test; helps tell us how "young" your ovaries are
2. Either a saline ultrasound (sonohystogram) or an HSG (hystero-salpingo-gram) can be used to evaluate the uterus and fallopian tubes
Both of these tests must be done right after your period but before you ovulate
I like to start with a saline ultrasound, which can be done in office. During the ultrasound, we push some water into the uterus and evaluate the shape of the uterus. It also flushes tubes and we can see the ovaries too. (If I'm not sure if tubes are open on the ultrasound, then need to do an HSG.)
HSG is done in radiology department and dye is pushed into uterus and out into the tubes, while an X-ray is taken
Both tests evaluate the uterus. We're looking to see if you have a uterine septum, endometrial polyp or submucosal fibroid causing a problem.
Both tests give the tubes a flush, which can be therapeutic as well. Sometimes there can be some 'schmutz' in the tubes that just needs to be flushed out. I have had many patients conceive on their own after this test.
3. Semen analysis
Your partner will be sent to a fertility clinic to give a sample (you will not feel sorry for him because this is not a painful test at all)
A semen analysis is done over a few days and the sperm are looked at under a microscope. They look at how many sperm he has, if they are swimming, and if they are shaped normally. These 3 factors measure the sperm's ability to fertilize an egg.
So what can be done?
Actually there are some easy things we can help with...
Start thyroid medication if needed. Studies show that subclinical hypothyroidism can inhibit ovulation, so your OBGYN likes a TSH <2.5.
Correct prolactin if needed. An elevated prolactin level will inhibit ovulation and is easy to fix. There are meds for this too.
We can induce ovulation with medication if needed.
We can do a simple procedure to remove a uterine septum or uterine polyps or small fibroids in the lining of the uterus that may interfere with implantation.
We would do surgery to remove any cysts on the ovaries that would not go away on their own and may cause fertility issues.
We can flush tubes to open them or remove a bad tube if needed.
We can do surgery to remove scar tissue if endometriosis is suspected.
We may recommend you send your partner to see a urologist if needed.
He may have a varicocele that needs to be fixed.
There are some medications that can improve sperm quality as well.
Otherwise, we may refer you on to an REI if needed.
REI = Reproductive Endocrinology and Infertility
An REI is an infertility specialist.
They are OBGYNs who then went on to do another 2-3 years of training just in fertility.
They are experts in fertility meds, insemination and IVF as well.
Patients often tell me right off the bat they don't want to do IVF so they don't want a work-up, but many times there are easy things we can help with and pregnancy is just a matter of time.
It's worthwhile to do the full evaluation and see where you stand.
Your OBGYN will be honest with you. If you don't need intervention and it's just a matter of time, be patient. The reward will be so sweet.