Fertility testing: when, where, how do we start?

September 12, 2018 8:08 AM

After nine months of trying unsuccessfully to conceive, I'm beginning to consider our options for fertility testing, but I have no idea how to begin. Complication: rural area that's underserved healthcare wise.

I'm 32 and my husband is almost 39. We've been trying to conceive since January. No miscarriages or chemicals, just months of negatives.

I track my ovulation through BBT and OPKs so I am confident that I am ovulating regularly. I think that means we can at least rule out PCOS. I never did a pre-conception visit and haven't been to an ob gyn in a couple years.

I think I want to start looking into testing, but what's the first step? See a GP? See a gynecologist? Get a referral from one of the above? Who do I call? What do I say?

Because we live in a rural area with very rudimentary medical facilities, our regular doctor (who we see pretty frequently to re-up on antidepressants) is actually a nurse practitioner. There are 3 ob gyns in town. I think to see a specialist of any kind will be a 1-2 hour drive.

My husband doesn't really want to start getting testing yet because he thinks we should try for the full 12 months and no one will see us until it's been a full year. He is also worried about the cost. He might be right, but my feeling is that statistically it's not very likely to get pregnant naturally within 12 months if we haven't in 9, and the psychological impact of getting those negatives month after month is becoming a lot for me to handle.

This is both emotionally and logistically overwhelming for me. Please help me figure out when & how & where to get started.

posted by the turtle's teeth to Health & Fitness (23 answers total)

Some of the early testing can be done by an OBGYN on your end and a urologist on his (or perhaps even a GP or family practitioner). I would start with what's close and available now and then escalate as the year mark approaches. On your end I believe an OBGYN can check if you have a blocked fallopian tube among other things, and on his end a sperm analysis is critical.
posted by muddgirl at 8:29 AM on September 12, 2018 [1 favorite]

Based on the info on this page the probability that you'll get pregnant each month at your age is somewhere between 10 and 15%. Let's say it's 12%. That means you have an 88% chance of not getting pregnant each month. After nine months, the probability of still not being pregnant is .88 to the 9th power, which is about 32%. So nearly a third of women your age who are trying still wouldn't be pregnant after 9 months. After 12 months, the probability of still not being pregnant is about 22%. Based on that, if I were in your place (which I was, once, except I was older), I would wait a little longer before embarking on testing. When you are ready for some testing, I think an ob gyn would be a reasonable place to start. I would just call up and say you've been unsuccessfully trying to get pregnant and would like to start trying to figure out if there's a reason for that.
posted by Redstart at 8:38 AM on September 12, 2018 [4 favorites]

Best answer: Our first step was to review our insurance, which it turned out definitively wasn't going to cover anything no matter what. So that was frustrating, but important to know. Since it meant referrals weren't necessary, what we did next was go straight to an appointment with a reproductive endocrinologist. The first appointment was free, zero dollars and zero cents, and they were very very frank and upfront about the costs of everything they offered. It was the best experience I've ever had in pricing healthcare, and they were so very kind about it too. Even with our insurance technically refusing to cover fertility care, they did end up being able to bill a lot of services as general-health and/or pregnancy-related, which helped. They also were very honest about what options were unlikely to help, and open to logic like "well two rounds of this unlikely but non-invasive procedure add up to the cost of the more promising but also more involved one anyway, so let's skip to that." In the end, I think one of the diagnostic tests, a hysteroscopy, actually inadvertently cleared out my fallopian tube, because after that I got pregnant without assistance thrice, and the third time stuck. We were driving about an hour for those appointments, but it was absolutely worth it to be with a practice that handled everything so smoothly and confidently.
posted by teremala at 8:40 AM on September 12, 2018 [5 favorites]

Took me 12 months. But yeah, the next step is probably labs to see your hormone levels, and a regular OB could order those. Then the tests start to get more invasive (an ultrasound to look at your eggs, an HSG to look at the uterus and fallopian tubes. Somewhere in there is a sperm evaluation. At some point, you'll probably need a Reproductive Endocrinologist, but I'd start with your local OB and see how far they can get you. On the other hand, this is a field that seems to be developing somewhat rapidly, so if the driving time isn't that hard for you, I agree with the comment above that going straight to the experts could be nice.
posted by slidell at 8:44 AM on September 12, 2018

Best answer: For what it's worth, my very evidence-based primary care doc told me to head to a reproductive endocrinologist after 6 months of active trying when I had been tracking ovulation (both temping and LH strips) and we had been timing intercourse correctly. I was only 34, but she said the "don't worry before a year" was really for people who were more casually trying and potentially missing the fertile window in many/most months. If you're sure you've been hitting your fertile window (the 1-3 days before ovulation) in every or nearly every month for nine months straight and you're still not pregnant, I think it's not crazy at all to head in for a work-up.

OBs can do the initial work-up, but people I know who ended up dealing with fertility issues tended to say they wish they had headed straight for a reproductive endocrinologist (RE) much sooner. I think OBs are also significantly less likely than REs to want to look at your husband's fertility and be able to interpret what might be going on there.
posted by iminurmefi at 8:48 AM on September 12, 2018 [5 favorites]

Best answer: A GYN should be able to do a blood test on the third day of your cycle that will test your FSH, LH, and other hormones. That should be covered by insurance. And your husband should definitely get a sperm analysis, out of pocket or not. A GYN might also be able to prescribe something like Clomid, to see if that helps at all.

But then I would get yourself to an RE (Reproductive Endocrinologist). Yes, it might be expensive, but the earlier treatments for fertility issues are a whole lot cheaper than the costs you start racking up if you have to move onto IVF, if time is a factor in your case. And like you said, the emotional toll of waiting and feeling powerless is serious. Maybe you just need an IUI with Clomid and a trigger shot, so you can hit the best possible timing. Or maybe this is all down to your husband's sperm. The sooner you get the answers, probably the cheaper it will be in the long run, even if you have to travel a bit to get to the RE. Good luck!
posted by thegreatfleecircus at 8:51 AM on September 12, 2018 [1 favorite]

I would start with the OB. I believe it’s generally recommended to see one before even embarking on trying to get pregnant, so they can check if everything is in working order. If they’re a halfway decent doctor they will listen and take your concerns seriously, probably run some tests. If they don’t take you seriously I would try a different OB in your town. Coverage of those tests will probably depend on your insurance. An OB might not refer you to a specialist before a year of unsuccessful trying, but you never know, and it definitely is a good place to start.
posted by permiechickie at 8:52 AM on September 12, 2018

test your FSH, LH, and other hormones. That should be covered by insurance

It was not covered by my Blue Cross plan and together ran around $400-600.
posted by slidell at 9:17 AM on September 12, 2018

You might ask your doctor's how to be as strategic as possible about what gets covered. Some things that fertility docs want tested can also look like part of a general health workup.
posted by slidell at 9:18 AM on September 12, 2018 [1 favorite]

You should absolutely do a pre-fertility check with your GYN anyway, and they might recommend specialists (like maternal fetal medicine) depending on your health levels.

So, I would see your GYN but keep trying normally for another few months. If you are willing to share data with me, I have recently done the cycling tracking/OPK thing and as a 33 year old lady I was successful in 3 months (with one CP in the month before) after getting my IUD removed. I'm a scientist (but not this kind) who has looked a lot of data so I could let you know if your chart looks weird! Feel free to DM me. <3
posted by ancient star at 10:05 AM on September 12, 2018

Best answer: Please get a sperm analysis first. It's the cheapest, a GP can arrange it (hell, Urgent Care can probably ship that off to a lab), and if he does not pass go it's going to change your conception plan and what tests you may/will need. Your early data suggests this may be a/the issue.

The number of people I know who spent $10K+ before that point, because obviously there's no reason to hurt the sperm-carrier's feelings it's definitely the ovarian-owner's failure as a human being, is somehow nonzero. It makes me angry every time I think about it.

If the swimmers are fine, you can start with GP - who will be easier to get an appointment with - or a GYN if you've identified someone you want to work with and they are taking new patients and you can get in this year, and discuss first rounds of testing, which you don't necessarily need a GYN for. Get a physical with a full bloodwork panel first. Go to a GYN when your GP says they've exhausted their procedures. Don't upgrade to an RE (as tempting as that will be because you want ALL THE ANSWERS, STAT) until you have gotten the basics covered at what is likely a lower price point and slightly easier schedule to get into.
posted by Lyn Never at 10:05 AM on September 12, 2018 [13 favorites]

For me, I told my GP, she referred me to a fertility clinic because there was one nearby. They did an intake visit, a collection of blood tests (single visit, on a particular day of my cycle), an ultrasound, a sperm-test visit for my husband, and a follow-up discussion (so that's minimum 3 trips). That didn't turn up anything, so we did the next level of testing (response to Clomid = 3 visits on specific cycle days; checking for open fallopian tubes = 1 visit; checking for uterine polyps = 1 visit) and then went the IVF route, which is uncountably many visits. But there are options before you get that far, for sure.

Start with a phone call to your GP asking if you should talk to them or your gyn about this.
posted by aimedwander at 10:11 AM on September 12, 2018

I hate to be that guy, but reddit has a really active community of people considering what to do in the situation you’re in (I’m there too, btw, although I’m not rural). Consider checking out r/stilltrying and r/infertility.
posted by samthemander at 10:13 AM on September 12, 2018 [1 favorite]

I would head straight to the RE, if financially possible. Non-specialists may not have the best information. It's worth calling sooner rather than later - for me, the next available appointment wasn't for a couple of months. The waiting turned out to be the hardest part. Some tests can only be done at certain times in your cycle; even after seeing the RE, it can be months before treatment begins.

And I know it's overwhelming, but I suggest trying to gather as much information as possible ahead of time so that you can more effectively advocate for yourself. Take care, and good luck.
posted by cat potato at 10:29 AM on September 12, 2018 [1 favorite]

I have been to a reproductive endocrinologist, not for fertility treatments but to be treated for PCOS. One thing I learned (from a billing error) there is that if anything they do is charted for fertility treatment purposes, it falls under "fertility treatments" and your insurance may have some restrictions on what it covers. (Which I know is ultimately what you want, but follow me for a second...)

I would call the three OBGYNs near you (if they are in network with your insurance) and ask how they handle fertility problems. One might say "we don't do any of that", while another might say "Oh we can do X, Y, and Z here and then refer to this particular Reproductive Endo for more invasive stuff". If you get the latter, it might be worth going to that one for a checkup so that they can do some of the hormone tests, ultrasounds, etc. that your insurance might not cover under "fertility treatments".

Now, insurance and cost concerns may not be something you worry about but if it is, see if you can start with the OBGYN and find out what turns up. And yes...have your husband get a sperm count as well from his doctor...no reason to wait on that and it (or a testosterone level?) may change how you approach everything.
posted by MultiFaceted at 12:49 PM on September 12, 2018

Best answer: Recently went through this with an RE (which I would recommend over an OB as OBS know surprisingly little about how baby is conceived.. Like the hormones and the potential issues.)

Regardless you will want
- AMH blood levels measured for egg reserve / egg health ($150?)
- ultrasound before ovulation to look at them follicles ($200?)
- sperm analysis for him ($150)
- HSG where they make sure your tubes aren't blocked and everything is shaped OK (about $500 before insurance)

Once you have that info you can figure out where to go from there. Don't let an OB start you off on clomid or other drugs till you've done some baseline testing like above. Good luck.
posted by St. Peepsburg at 4:35 PM on September 12, 2018 [2 favorites]

BTW the Dr told me at 33% of infertility is due to lady issues, 33% due to gentlemen issues and 33% is ¯\_(ツ)_/¯ so good luck and keep trying.
posted by St. Peepsburg at 4:39 PM on September 12, 2018

It may take a while to get an appointment, particularly if as you say, there are few practitioners in your area. Why not start making inquiries and appointments now? It may be a month or more before you can be seen and by then you could well be at that "trying to conceive for a year" point.
posted by Kangaroo at 5:14 PM on September 12, 2018

Definitely a good idea to start lining up testing as soon as possible- charm your way in asap, rather than politely waiting for their eligibility guidelines.

And, anecdata: my friend's advice is to ignore the standard advice to "have sex every second day and try to hit the ovulation day, in order to help his sperm counts peak". Instead, she swears by "as soon as your period ends, have sex every day for 10 straight days, and each time, lie on your back with your legs up against the wall for half an hour, and don't pee for as long as possible". Several of our friends finally conceived by following this advice.

Good luck!
posted by pseudostrabismus at 12:42 AM on September 13, 2018

as soon as your period ends, have sex every day for 10 straight days, and each time, lie on your back with your legs up against the wall for half an hour, and don't pee for as long as possible

OP, of course you know that this advice is partially flawed. If someone's period ends on Day 4, and they have 36-day cycles, which is true for me about half the time, under this plan, they'd have sex on Days 5-15. Some sperm can theoretically maybe live up to 5 days = Day 20, which still won't fertilize the egg that's likely released on Day 22.
posted by slidell at 5:44 AM on September 13, 2018

Response by poster: Thank you so, so much everyone for your suggestions and advice. I feel much better after seeing a lot of practical options laid out like this. I decided to start by calling one of the local ob gyns. My husband will come with me to the appointment so we can talk to her together, and we will prioritize getting the sperm analysis done.
posted by the turtle's teeth at 8:47 AM on September 13, 2018

Response by poster: Update: So, funny story. When I typed this question up, I was having bad cramps and assumed my period was coming on AGAIN. I thought I'd try to manage the inevitable disappointment and sadness by working on a plan to be proactive. Turns out those weren't period cramps, and I found out I was pregnant a few days later. I'm now 15 weeks along and things seem to be going well.

So, in this specific instance, the answer actually was "Just be patient" (and yes, my husband was right, so rude). Perhaps that may be encouraging to anyone reading this question in a similar situation.

Thank you again MeFi for all for your help and support.
posted by the turtle's teeth at 8:31 AM on December 1, 2018 [2 favorites]

Congratulations!
posted by slidell at 10:47 AM on December 1, 2018