First Fertility Visit: The Next Steps

After your provider gets your history, they're going to talk about your ovarian reserve and what ovarian reserve testing is, and basics about fertility. 

Ovarian Reserve Testing

This is done by an ultrasound, counting the follicles, also known as an antral follicle count, or an AFC, and drawing a blood test for AMH. Utilizing AMH and the antral follicle count together is extremely helpful in understanding where you are in the process of how many eggs you have left, and your outcomes when it comes to IVF or egg freezing. For IVF, I can only get the eggs that are outside the “vault” to grow. I can't tap into the vault. Once I can, that will change the game, but right now, that's something that is still not proven. The more eggs you have, the merrier. When it comes to IVF or egg freezing outcomes, no matter what your AMH is or how many eggs are outside the vault, as long as you're still having periods, you have the exact same chance of getting pregnant as somebody else your age. Think of it this way, if you are 30 and you're ovulating, it doesn't matter if you have 30 eggs outside the vault or eight, you have the exact same chance of getting pregnant because you're ovulating one now the person who has fewer eggs likely has less time to complete their family and is going to get fewer eggs per IVF cycle. If they need IVF to grow their family, they are going to want to do that sooner rather than later. Therefore, there is a benefit to knowing this when it comes to your family plan. FSH, estradiol, and LH are hormones that we tended to check before AMH testing was a thing. FSH really doesn't add much to the picture anymore unless you're to the point where you are not having periods, and we are concerned you're in menopause. Once the brain is secreting extremely high levels of FSH, we now know that I'm not going to be able to get eggs to grow. In order to get eggs to grow, I have to give you FSH. If your brain is already sending out super high levels, and your ovaries not doing anything, it's very unlikely that taking very high levels in a shot is going to do anything either. That is why once you are out of eggs, you're out of eggs. So your doctor should talk you through some version of that. How do the reproductive hormones work? What is egg quantity, ovarian reserve, what is that testing and what are they going to do?

Egg Quality

Egg quality should be mentioned, and it's a very different but related topic. Egg quality really relates to genetic normalcy. So those eggs have been sitting in that vault since before you were born. The chromosomes are held in a certain stage of cell division called metaphase of meiosis. What this means is that your chromosomes are lined up in the middle, one to one with their exact matching pair, and they're held in place by these meiotic spindles, or proteins. Then when you go to ovulate, they split, and that's how you get half of your chromosomes into the egg that then can go be fertilized by sperm. The longer they sit there, the more those proteins break down, and the higher incidence of having aneuploidy or chromosome abnormality is going to be. So the older you are, the increase in abnormal genetics or aneuploidy, increase in miscarriage rate, increase in genetic abnormalities, and decrease in pregnancy rate. You cannot turn back the clock. Age is the number one driver of egg quality, no matter what. However, other things can impact your egg quality, good and bad. In the context of doing what you can, you should know that smoking cigarettes negatively impacts your egg quality. Other environmental toxins impact your egg quality. Things like consuming antioxidants, fruits and veggies, getting good sleep can help your egg quality. Decreasing your inflammation can also help your egg quality. So you should manage your medical conditions. You should pay attention to what you put in and on your body, and try to reduce toxins and increase antioxidants and prioritize your general health and wellness, because it can be reflected in your eggs.

Ovulation

Having regular, predictable periods is a sign that you ovulate. So if you tell me your periods come every 28 days, I know you ovulate and I'm not worried about it. Now, if you're tracking and you have spotting or short luteal phase, I want to know if your periods are coming, but they're really irregular. 24 days one month, then 37 then 27 that is irregularly regular. If they are just truly irregular and you have no idea when they show up, or you skip months, this is not normal, Amenorrhea, or not having a period at all is very abnormal. Those things you should get an evaluation for. It might be PCOS, low ovarian reserve, thyroid disease, prolactin, or hypothalamic amenorrhea. There's a variety of things that can impact the body's ability to ovulate, and remember your period is a vital sign. So be really clear in your period history. If you've been tracking it, tell me what you found. But if you have reflected very regular cycles, I'm not going into a deep dive on, do you ovulate? If I'm uncertain if you're ovulating, sometimes people do what we call a day 21 progesterone test. This is really a mid luteal progesterone or testing a week before anticipated period or a week after anticipated ovulation. This progesterone is not telling us how good your luteal phase is. It is a yes or no. Progesterone is going to rise and fall the entire luteal phase based on LH pulses from the brain stimulating the corpus luteum. So you can see a progesterone anywhere from three to forty nanograms you are good. Anything over three tells me you ovulated, and we are moving on.

Anatomical Testing

Structural anatomic problems is something we want to evaluate. This is your uterus and fallopian tubes. This can be evaluated a variety of ways. A transvaginal ultrasound allows you to see the muscular component of the uterus and the ovaries. It can tell you things like uterine fibroids, and count your follicle number. Do you have any cysts in the ovaries? Most of us love a transvaginal ultrasound. I'm going to get an antral follicle count with that. I will also look structurally at the muscular part of the uterus, but a transvaginal ultrasound alone does not tell me anything about the inside of the uterus. I will not know if there is a polyp, scar tissue or a septum. So you're going to need some other imaging of the inside because the uterus is a potential space. This means that you need to expand the uterine cavity with some type of liquid in order to be able to see inside. This is typically either with a Hysterosalpingogram, an HSG, a saline sonogram, or an SIS with a Femvue test to see the fallopian tubes, also known as the bubble test, or with surgery. Those are the options. So an HSG is also known as an x-ray dye test. This is where you are going to place a speculum in the vagina, a small catheter to the cervix, and inject dye into the uterus while watching with x-ray. This dye will separate the uterine walls from each other, and you can see filling defects or areas the dye did not go and then the dye will move to the fallopian tubes, and you can see their structure. This is great for the tubes. It is not as good for the uterus, but it's a very appropriate for a screening test. A saline sonogram is much better for the uterus, but does not tell you anything about the tubes With a saline sonogram you're putting water in and watching with an ultrasound so you can see both the inside and the outside of the uterus. This does help differentiate certain types of uterine conditions, and ultimately gives you information about what is causing the problem, not just that there's a defect where there's no dye. If you have an abnormal HSG of the uterus, you might have it followed up with an SIS to evaluate what is going on before you go and see if you need surgery. With an SIS, if your doctor or your clinic is skilled or has it available, you might be able to do a femvue test. A femvue is a device that mixes air bubbles inside that saline and those air bubbles can travel through the fallopian tubes in experienced ultrasound operator's hands. This can be a great way to see the fallopian tubes. When you combine an SIS and a femvue, you get a lot of great information. If the tubes cannot be evaluated with a femvue, you might have to follow it up with an HSG, so they both have their places. Neither is perfect for either of these tests, you need to do it when you can see the best, which is after your period, but before you ovulate in that late follicular zone. For most people, this tends to be the five days after your period, or day six to 10 of your menstrual cycle. You’re gonna find that you'll have to notify somebody when your period starts to then get that test scheduled. The other option is to get it done while you're on birth control pills because the progesterone and the birth control pill keeps the lining thin so you can see everything. It's not that we're trying to be mean by doing it at this very narrow window, but we need the lining thin enough so that there's not a polyp that's just getting obscured by thicker lining. Surgery used to be part of the diagnostic process, but it's really gone away as technology has gotten better. We can do these screening exams that are much less invasive than going to surgery. Ultimately, the gold standard for evaluating the inside of the uterus is hysteroscopy camera inside the uterus. You put a camera in you can see what's going on. You can combine that with laparoscopy or a camera through the belly button, so you can see the abdominal cavity outside of the uterus, the ovaries, the fallopian tubes. Again, very rarely is somebody going directly to surgery for their diagnostics. Nowadays, typically you're doing lesser invasive testing and then going to surgery once you have an indication to do so. Every doctor is different, and if somebody is recommending surgery as your evaluation, I'm not saying it's wrong, but ask why. What in your history made them want to go right to that.

Male Fertility

You're also going to do a semen analysis. After two to three days of abstinence, you're going to get an ejaculated sperm sample. You're going to want to know where is this collected, on site or at home. You're going to usually need an appointment to come and bring it a certain collection kit, and then the lab is going to be looking at how much specimen there is, what the concentration of sperm is, how the sperm move, and the morphology, or the shape of the sperm. Not all semen analysis test morphology. If they don't, you're not getting a full assessment, and you should get it done somewhere else. All fertility clinics are going to do a morphology, but sometimes you'll see random labs like CPL or mail in tests that don't do a morphology. I would not waste my time doing that. That is typically the screening test for sperm. So if that's perfectly normal, the evaluation tends to stop there. If that is very abnormal, then you're going to undergo hormonal evaluation and try to see what's going on. If you have problems that reflect a hormonal evaluation anyway, like you cannot get or maintain an erection, cannot ejaculate, have a scrotal mass or testicular pain. Also if you’re uncircumcised with phimosis, which is very restrictive and painful. Those things should be told, even if they're embarrassing, because you might need to see a reproductive urologist on those issues alone, regardless of what the semen analysis says.

Preconception Testing

Also, almost all fertility clinics are recommending preconception testing to make sure everything else is functioning. This varies clinic to clinic, but typically this is your blood type checking rubella and varicella status, trying to see if you're anemic, checking infectious disease testing, vitamin D and your thyroid. Then preconception genetic carrier screening. I have had some of the most sad cases of my career for people who got pregnant and ended up having a baby with a terrible genetic, lethal disorder that both partners carried, and they had no idea. They come to me for IVF for genetics so we can prevent that from happening again. If you're in my clinic for any reason, most likely things are not going to plan because most people don't see a fertility doctor, and I do not want to put you through that experience that those other patients are having. So if we do genetic carrier testing, we are looking for autosomal recessive or silent carrier diseases. What we are finding is that if two people carry a disease, you should talk to genetics. There is often the opportunity to do pre-implantation genetic testing for that disease where we can make a probe to test this disease in an embryo, and then selectively transfer embryos that do not have the disease at all, or that only carry one gene in our carriers but will not be affected with the full spectrum disease. This can be life changing for families, but you don't know unless you check most of the time that genetic carrier testing is covered by insurance, and I'm a big believer in it.

So everybody comes in a little bit different. If you've had prior cycles, often, I'm not spending my time walking you through all those diagnostics like I just did. We are diving into your cycles. What was good, bad, ugly, what I would do different, and running through that. If you are brand new, and you're here for diagnostics and follow up, which is where a lot of people are, that is what the new patient consults going to look like we are going to roll through these things. You will then come in for testing or have testing done, and then we will meet for a follow up after testing, going through all of the results and talking through what you should do next at any clinic.

Understanding the Billing and Communication
You want to know who you are talking to about finances. Is there a billing team or a certain finance person? Who is that going to be? Who can walk you through that part of the journey? How do you communicate with your team? If your clinic calls, and that's the only way they communicate results and next steps, and you do not ever pick up the phone, then that's not going to be highly compatible. So you need to think about that. Do they use email? Do they have a portal? What is the messaging system? Make sure it's something that will work for you or you're willing to modify in order to have it happen. The fertility experience is unique. You cannot compare yourself to other people because everybody has a different experience. Knowing that you're in good hands, trusting the team that you're with being prepared and educated about what's to come that, in my opinion, are some of the most important parts of the journey