By Jessica Joseph, RN, BSN, MHA
The views and opinions expressed are those of the authors and should not be considered medical advice. Always consult your doctor, or a mental health professional, for the most appropriate treatment.
While trying to conceive (TTC), it is natural to feel overwhelmed when things don’t go according to plan. You may not want to share your struggles with anyone for fear of being flooded with unwanted advice. At the same time, you may need help determining which resources to trust. There is so much information available at your fingertips, and that information can at times be contradictory. Seeking professional help can be a sore subject. However, guidance from an obstetric gynecologist (OB/GYN) and a reproductive endocrinologist (RE), commonly referred to as a fertility specialist, can offer valuable resources.
How can my OB/GYN assist my fertility goals?
Most women have an established relationship with their OB/GYN long before considering pregnancy and prenatal care, since OB/GYNs play a crucial role in women’s health journeys. You may have first visited your OB/GYN for routine check-ups, to discuss birth control options, or if you have a history of painful menstrual cycles.
If you’re having difficulty TTC, it is vital to make an appointment with your OB/GYN for many reasons. OB/GYNs typically conduct an overall health assessment and review your medical and family history. They can determine if there are any issues with ovulation, and even recommend ways to encourage ovulation to happen. If you’ve taken birth control, they can advise as to when you can expect ovulation to resume. This can help give you a tracking window for when you can expect to get pregnant, and when to seek further evaluation.
OB/GYNs perform routine testing, such as:
- Pap smears, which can detect abnormal cells and viral infections, such as HPV (human papillomavirus), in your cervix
- Pelvic exams, to rule out conditions such as fibroids, which can prevent embryo implantation (depending on where the fibroid is located)
- Breast exams, to rule out any abnormalities and screen for breast cancer
Addressing these issues before pregnancy is important for the TTC process and helps to avoid unnecessary complications that can be detrimental to a healthy pregnancy.
If you are on medications, your OB/GYN can advise which drugs you should stop based on the pregnancy category assigned by the Food and Drug Administration (FDA). Some medications may have a “teratogenic” effect, meaning they could harm a developing baby. As a result, it’s often recommended to stop taking that medication, or substitute with a different medication before getting pregnant. Other medications may need to be started, especially if your OB/GYN determines you could have an underlying medical issue that needs to be managed before getting pregnant.
Supplement suggestions: prenatal vitamins, vitamin D, iron
OB/GYNs can recommend which supplements to start, such as prenatal vitamins, and can guide you on which one to take based on nutrient levels. For instance, your OB/GYN will ensure that your prenatal vitamins contain adequate amounts of certain nutrients, like folic acid (which is crucial for brain and spinal development in your baby). Some OB/GYNs will also do blood work to check your levels of vitamin D or iron, and may advise you to take additional supplements based on those results.
OB/GYNs can review your immunization records to ensure all your vaccines are up to date. If they’re not, they can administer vaccinations as well. It is vital to receive vaccines for certain conditions, such as chickenpox or measles, since these conditions can harm a developing baby.
Medical interventions: IUIs and medications
OB/GYNs can prescribe certain medications that may help with TTC, including those that stimulate egg development and ovulation to enhance your chances of getting pregnant. They can also perform procedures, such as intrauterine insemination (IUI), a type of artificial insemination in which ovulation is tracked and timed insemination with your partner or donor’s sperm sample is performed.
OB/GYNs typically work closely with a team of providers to optimize your chances of pregnancy. If your OB/GYN suspects underlying issues, they can refer you to a network of specialists. Referrals may include nutritionists, therapists, fertility coaches, and fertility specialists. For some people, simple interventions such as dietary modifications can make a world of difference in achieving pregnancy.
Fertility specialist: the key player in your TTC journey
If your OB/GYN determines you need further evaluation, they may refer you to a fertility specialist. The three main types of fertility specialists are:
- Reproductive endocrinologists, who treat female infertility
- Reproductive urologists, who treat male infertility
- Reproductive immunologists, who treat underlying immunological conditions that may prevent a healthy pregnancy
When you see a fertility specialist, they will likely perform a basic diagnostic screening to rule out any issues or risk factors with physiology, such as hormonal issues or underlying conditions that have not been diagnosed yet. Reproductive health conditions include polycystic ovary syndrome (PCOS), endometriosis, and recurrent pregnancy loss, to name a few. They will also usually try to determine if your reproductive system is functioning well by evaluating your ovaries, fallopian tubes, uterus, and cervix.
Standard tests for ovarian function include blood work to test for certain hormones, such as anti-Mullerian hormone (AMH) and follicle-stimulating hormone (FSH). These hormones help indicate ovarian reserve and predict the response to ovarian stimulation. An ultrasound may also be performed to determine the number of “antral follicles,” or the number of small follicles visualized typically at the beginning of your menstrual cycle, which can help predict egg yield in response to ovarian stimulation. If not done with your OB/GYN, other blood work may also be performed, such as checking hormone levels for thyroid-stimulating hormone (TSH) and prolactin, immunity for specific conditions such as measles, mumps, and rubella, vitamin D levels, and tests for infectious diseases such as gonorrhea and chlamydia.
Fertility specialists also want to determine if there are any obstructions in the fallopian tubes (where sperm needs to go to meet the egg to become an embryo) by performing an HSG. This test is typically performed at a radiologist’s office (but may be done at your fertility clinic) and involves a dye being administered to visualize the patency (openness) of the fallopian tubes.
Men will be given guidance on how to get a semen analysis. Most fertility clinics have andrology labs where a basic semen analysis can be performed. Some fertility centers also employ reproductive urologists or will refer a patient to a reproductive urologist if further evaluation needs to be made.
Sonohysterogram or hysteroscopy
To rule out uterine abnormalities, such as fibroids and polyps, a sonohysterogram or hysteroscopy may be performed to visualize the uterus. This procedure is typically done at the fertility clinic or may be scheduled separately at a surgery center. If polyps or fibroids are seen during these tests, depending on the size and location, fertility specialists may perform additional procedures, such as polypectomy (polyp removal) or myomectomy (fibroid removal).
Several interventions are available for couples trying to conceive for 6 months to 1 year without success (depending on age, medical history, or physical findings). Despite popular belief, fertility specialists are not typically looking to fast-track everyone straight to in vitro fertilization (IVF). Most REs follow a regimented step therapy protocol based on the diagnostic screening results. Step therapy involves starting with modest treatments before advancing to more involved procedures. This type of therapy is usually the preferred protocol by fertility specialists if there are no underlying issues that would warrant moving directly to IVF, such as blocked fallopian tubes or poor sperm quality.
Types of fertility cycles
Fertility specialists might start with conservative treatment cycles such as ovulation monitoring cycles, which involve tracking your hormones for ovulation and advising timed intercourse based on blood work and sonogram results. If unsuccessful, the fertility specialist may advance treatment to medicated IUI cycles. This involves taking a short course of medication to stimulate egg growth, coming back periodically for blood work and sonograms, and taking a trigger injection to induce ovulation so an IUI can be performed. The partner’s or donor’s sperm sample will be injected through the cervix into the uterus to improve the chance of fertilization and a successful pregnancy. Typically 2 to 3 cycles of IUI are done before advancing to IVF.
In vitro fertilization (IVF)
IVF involves taking a short course of injectable hormones (typically between 8-12 consecutive days) to stimulate the ovaries to produce multiple follicles. Periodic monitoring is performed to check hormone levels via blood work and sonogram to inspect the ovaries for follicle development. These tests are performed to see how your body responds to hormone injections. Fertility specialists will adjust your dose of hormone injections based on the results of these tests. Once the hormones reach a certain level and the follicles reach a certain number and size, the fertility specialist will instruct you to take an injection to trigger ovulation, and the egg retrieval will be performed 2 days later. On the day of the egg retrieval, an embryologist will fertilize the eggs by incubating the sperm with the eggs or by injecting the sperm directly into the egg. A few days after the egg retrieval, the embryologist will inform the team how many embryos have developed, and you will get a phone call alerting you of the status and instructions for the next steps. The next steps will vary depending on whether you are doing a fresh embryo transfer or a frozen embryo transfer (FET).
Fresh or frozen embryo transfer
Embryo transfer cycles are less elaborate, as they do not involve anesthesia, and most of the medications are either oral medications or vaginal suppositories. For a frozen embryo transfer, you will be advised to call on the first day of your period to start monitoring. If you are doing a natural cycle, ovulation will be tracked, and the embryo transfer will be done in the luteal phase, which is the time period after ovulation. If you are doing a medicated embryo transfer cycle, you will start a course of hormone medications to thicken your uterine lining and prevent follicle formation and ovulation. Once your hormones are a certain level and your uterine lining is a certain thickness, the fertility specialist may advise starting progesterone and will time the embryo transfer based on the progesterone start date.
Making your OB/GYN and fertility specialist part of your TTC team opens new doors for your path to parenthood. These highly trained healthcare providers verify useful information, perform practical assessments, and can come up with a game plan to maximize your chances of a healthy pregnancy.
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