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Monday, March 19, 2007


Reproduction is a normal physiologic event that is absolutely necessary for the survival of the human race. Therefore, infertility is a "real" medical problem that is the result of real pathology.

Infertility is not uncommon, affecting about 10-15% of reproductive age couples (roughly 1 in 7). The remarkable advances in In Vitro Fertilization (IVF) and the Assisted Reproductive Technologies (ARTs) have resulted in the birth of several thousand "miracle babies" over the past few decades. There is also a growing desire for pregnancy in women over 35 years of age, many of whom have postponed their childbearing until they have acheived career stability. For these reasons, the number of couples seeking medical attention for infertility related problems has rapidly grown and the medical community has responded with rapidly developing technology.

The causes of infertility for a specific couple are not always easily recognized. However, if the couple decides to undergo a series of basic diagnostic tests then specific treatable abnormalities associated with infertility may be discovered. Following a full basic evaluation only 5-10% of couples will still have "unexplained infertility."

Treating infertility can also be difficult. There are frequently several accepted alternative treatments for any given abnormality that is discovered. The "optimal" treatment is often controversial since there is usually little reliable scientific data to support one treatment plan over another. Therefore, the physician must use his (her) own experience with the available treatment options for guidance. Relying on the advise of a seasoned and well trained professional is therefore very important.

When to Go for Invertility Care?

Infertility is generally defined as the inability to achieve a pregnancy after one year of regular intercourse without contraception.

Despite this general definition, an evaluation may be appropriate before a full year has passed. This decision depends on the couple's situation. For example, if the woman is older than 35 or 40 it may be prudent to check a basic evaluation soon after deciding to have a baby. If the husband has had a vasectomy, or the wife a tubal ligation, then consultation and consideration of treatment options does not need to be delayed. If the woman desiring fertility has very irregular or no menstrual cycles then immediate consideration of diagnostic tests and treatment is appropriate.

Recurrent pregnancy losses (miscarriages) are sometimes considered a part of infertility since the couple is not able to carry a pregnancy to viability. Once a couple has had two or three consecutive pregnancy losses, it is appropriate to consider a thorough evaluation.

Who is Available to Help Care?

A couple decides early on who will be chosen to help them with their infertility. This selection dramatically effects the treatment plan that is developed. Therefore, careful consideration of the alternatives is advisable.

Not everyone turns to medicine for help. Some couples choose a relative, like a mother or a grandmother. This is generally someone who has a large family with clear success in terms of their own reproduction. Others may turn to religious figures and entrust their fertility to a higher being or guidelines set by an organized religion. I beleive that physicians also have an important role in the care of these couples. Infertility usually involves medical conditions that are now treatable and professional advice is generally available.

Differences in training among the available physicians will be the focus of this section. All physicians treating infertile couples should share certain basic characteristics, including:

Compassion and the willingness to listen.

These are important qualities in an infertility doctor. As you discuss your situation with your doctor, you should be able to identify a willingness to listen to your concerns.

Recent dramatic changes in health care have essentially limited the time that is spent with patients by rewarding the number or "volume" of patients seen rather than giving "the personal touch." Infertility patients may come to resent their doctor if (s)he doesn't address their unique needs or they may change doctors frequently in an attempt to find one who will "hear their concerns." This can be frustrating for both the doctors and the couples.

Expertise in the rapidly changing field of infertility.

Book knowledge coupled with insights gained from extensive clinical experience is a powerful combination.

  • The doctors. All doctors are persons skilled in the healing arts who have completed a defined rigorous course of study (typically 4 years). Doctors have been duly licensed by the State's Board of Medical Examiners to practice within the profession. Therefore, many couples believe that "any doctor" will be expert in the treatment of their fertility issues. This may not be so. Most graduates of medical school will have delivered (or helped deliver) a baby and helped to perform (or watched) a hysterectomy. However, many doctors have had no exposure to infertile couples undergoing evaluation. Nevertheless, in many areas of the USA the family doctor (either a family practitioner or internist) is the initial contact for the infertile couple. This physician will then consider whether (s)he is comfortable with ordering the basic infertility evaluation and when to refer the couple for care with an infertility specialist.
  • The Obstetrician Gynecologist. The obstetrician gynecologist is a doctor who has completed medical school as well as an additional defined training program (typically 4 years) in Obstetrics and Gynecology (Ob-Gyn). To become board certified in Ob-Gyn, the "American Board of Obstetricians and Gynecologists" requires candidates to pass a written exam as well as an oral exam. The oral exam is given by recognized authorities in the field and covers all areas of Ob-Gyn including infertility. Therefore, Ob-Gyns are well trained in the theory of infertility and many will have significant clinical training and experience as well. When the obstetrician gynecologist is the initial contact for an infertile couple there is usually an organized approach that has been established. At some point in the infertility care, the Ob-Gyn may suggest referral to an infertility specialist.
  • Infertility specialists. Infertility specialists are doctors who should have completed medical school, a residency training program in Obstetrics and Gynecology, and an additional training fellowship (typically 2-3 years) in Reproductive Endocrinology (male and female hormones) and Infertility. This subspecialty fellowship can provide an intense clinical exposure to infertility care that dramatically redefines the physician's approach to the infertile couple. The infertility specialist's approach typically complements the Ob-Gyn's care.


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