Useful resources and advice for infertility?
January 22, 2020 5:51 AM   Subscribe

My wife and I are unfortunately in the position of struggling to conceive. Do you have any useful practical suggestions for resources and advice?

My wife (34) and I (32) have been trying to conceive since July 2018. For the first six months or so we were simply trying to have more sex around the window of fertility, but since March 2019 we have been using the ‘Clearblue Advanced Digital Ovulation’ detector to have sex daily during the periods of ‘high’ and ‘peak’ fertility. My wife did become pregnant in June 2019, but it was diagnosed as an anembryonic pregnancy and she had a D&C in September. Since then we have had five more cycles without conceiving.

So it’s now been 1.5 years, which means I think it’s time to consult a fertility expert. I really have no idea what that might mean. Do you have any resources or advice about how to navigate this process?

Questions of the sort I’m thinking about: Do we start by making an appointment with the OB/GYN? Skip directly to private fertility clinics? What suggestions for reading material/resources do you have? What kind of interventions are doctors capable of? Will we likely want/need IUI or IVF, or will lesser interventions be enough? Etc.

For the purposes of this question, we are not interested in advice on how to process this situation emotionally.

If it’s useful, we live in Davis, CA and have Kaiser insurance.
posted by anonymous to Health & Fitness (18 answers total) 2 users marked this as a favorite
Hi there, my spouse and I just spent the last year or so going through the process ourselves. It varies for each couple, naturally, but since we are also cis-gendered and in the same age range, I'd expect there to be parallels. Please note, I have interpreted from your question that you are a cis-gendered man, and if you are not then my advice to you below won't apply.

First, your wife should raise the issue woth her OB/GYN. That doctor may need to specifically refer her to a specialist (and can certainly recommend one, even if a referral isn't needed). The OB/GYN can also do some basic tests to get the process started and rule out some obvious issues. The doctor will guide her through the process and through what each test does, as will the fertility specialist if she gets to that point. I HIGHLY recommend picking up a copy of /Taking Charge of Your Fertility/, which is an excellent resource to have around while you are trying to conceive. I personally found the internet too overwhelming when I had questions about specific conditions and tests.

You will also need to see a male fertility specialist, because (as my doctor told me), there's a 40% chance of the issue being with your wife, a 40% chance of it being with you, and a 20% chance of it being both of you. Your wife's OB/GYN can recommend a good male fertility doctor for you, or you can get a rec from your own primary care person.

All of this takes time, money, and many many appointments. Spend some time now examining your insurance benefits, time off work, and cash flow situation.

Best wishes and good luck from this internet stranger. It's a complicated and arduous process, but at 4 months pregnant, I will say that it was worth it.
posted by Temeraria at 6:13 AM on January 22, 2020 [1 favorite]

I'd just start with talking to your regular doctors (probably OB/GYN for your wife) and go from there. You can probably get pretty far within the Kaiser system before needing to see outside specialists. If you haven't done so already, you'll both probably want to get a battery of testing done, and you might want to go a couple rounds of it separated by a few months to make sure you're not getting a weird reading (especially so for sperm count and viability). In the run up to doing anything that's a medical intervention, you can start taking supplements that may have an effect - there's one powder for sperm health that's meant to be mixed with water that's kind of expensive, but you can kind of recreate what's in that powder through various other supplements in pill form (the pills are still kind of expensive, but you can just get them from the vitamin section of your store - CoQ10 is the pricey one). Your test results may indicate what avenue is best to pursue if supplements and timing still aren't doing it. I wouldn't jump straight to IUI or IVF without knowing what my results were and whether either of those methods were likely to be effectual.

My ex and I did 3 IUI and 4 IVF procedures (unsuccessfully); memail me if you want anything more specific.
posted by LionIndex at 6:13 AM on January 22, 2020

Some information from Resolve, the National Infertility Association.
posted by Mr.Know-it-some at 6:16 AM on January 22, 2020

I tried for two years trying to getting pregnant on my own. Then started out with my OB/GYN who ran some labs and tests to rule out issues. I remember getting dye shot through my fallopian tubes to make sure there was no blockage (hysterosalpingogram). My husband also went to a specialist who checked his sperm motility which was fine. I got started on some meds to stimulate egg production.

I was recommended to go to a very large group who specialized with infertility issues - the thinking was have 10 specialists with lots of experience figure out what was going on. I did 7 IUI procedures. I hated seeing a different face between my legs with every visit and it felt like a factory.

Skipped to a one man specialist who figured out my main issue was. I felt seeing him was a game changer because he was quite invested in my story. He also told me other patients donated leftover medications if cost was an issue. Changed my treatment plan aggressively and I got pregnant with the last IUI my insurance covered.

It took a total of 3 years of actively trying to get pregnant. We did not go through IVF because with our insurance it was cost prohibitive. Emotionally, we were okay if we didn't get pregnant.
posted by IndigoOnTheGo at 6:16 AM on January 22, 2020

For reading resources, Taking Charge of Your Fertility is really helpful and always the first book recommended for folks trying to conceive. It specifically discusses other items to monitor (cervical mucus, basal body temps). BBT (basal body temp) can actually confirm ovulation has occurred, because the ovulation prediction kit are just looking for the spike in hormone that happens prior to ovulation. But BBT spikes after ovulation has occurred, so it's entirely possible to have a positive ovulation kit without ovulating. The book also talks about when to time sex, different things to try, and using the charts to evaluate potential conditions -- think of it as both a timing resource and as a resource to get more info about what's going on physically and what doctors may need to try. It also talks about potential male infertility issues, as well as things that may be decreasing sperm mobility/motility, which can be the cause. As a note, try to ignore the "traditional medicine prosecuted me" bit, because I think that's usually nonsense and just a ploy to sell books, but this book is actually incredibly informative and the most accessible book on fertility issues for lay people. It also notes that it should be used as a supplement to doctor's, not in lieu of doctors, which is an important distinction.

You'll also need a basal body thermometer - I've had this once since 2014 (bought by accident because it was cheaper than the regular thermometers...) and it's still going strong, it was handy to have when I needed it to track BBT. They have much fancier ones that will work with apps/bluetooth, but it worked for me.

From people in my trying to conceive group who have been trying for a while, I believe they first start with medicine that can trigger ovulation (Clomid, I think) and/or supplement post-ovulation progesterone, and try that for several months. They'll also have you do a sperm analysis as fertility can be caused by either partner. That's also why it's helpful to chart, as it's easier to identify the actual fertility issue -- is it a lack of actual ovulation, short luteal phase (the progesterine heavy phase after ovulation that needs to be long enough for implantation to occur), is your timing off, or does everything look normal thus pointing to another issue like a blocked tube or sperm mobility/motility issues.
posted by DoubleLune at 6:16 AM on January 22, 2020

In the US your options are going to be highly limited by insurance and cost. What is covered and what you can afford is really going to dictate what options are in the long term. Knowing that up front is important because after the initial tests costs just start increasing and then they are basically monthly until something happens . I suggest you set a cost limit ahead of time or a number of tries because it's just so easy to keep trying and keep throwing money at the problem and holding on that next time it will be better. But IVF can bankrupt you and there are no guarantees.

For a long while pretty much all our discretionary income was going to IVF. We needed a donor so those costs also were very expensive and not covered by insurance at all. My insurance was actually fantastic, and covered ivf at something like 90%.For us, it is definately cheaper to take care of a kid than the IVF process because it was just insanely expensive.

In other advice
You will both need testing . Logs are useful for monthly ebbs and flows for her especially.

The ups and downs of each month are very real. Testing, and waiting are really emotionally taxing for the both of you . Figuring out how to support eachother and get through this is so important . Oh and the medications are tough, so be nice to eachother.
posted by AlexiaSky at 6:46 AM on January 22, 2020 [1 favorite]

Our tale, FWIW:
We tried for about the same length of time as you and then our family doctor referred us to a fertility specialist. The specialist told us to stop tracking temperatures or using ovulation strips - he said in his experience it just stresses couples out and isn't effective.

The first step was some tests - we had LOTS of blood drawn, and husband gave a semen sample. All tests were basically fine at this level - my base hormone levels were good, his sperm count and motility were good.

Then, a tracking cycle for me - I went in early in the morning for a blood test and transvaginal ultrasound 3 days after my cycle started to get a base line, and then once a week until the hormones started rising around ovulation, and then once every couple of days until ovulation, when we were instructed to have sex for 2-3 days. All of this was coordinated via an app from the clinic.

(I didn't expect this monitoring cycle to be as draining as it was, but getting a blood test and a transvaginal ultrasound 10 or so times in one month did start to grate - I had to look up relaxation techniques to get through it).

When that first month didn't take, I think husband's sperm was sent for a second level of testing - DNA fragmentation. We were also informed that our beta-carotene was high, possibly because we were pescetarian. We started eating a bit more meat at our specialist's suggestion (I don't entirely buy into this but we agreed we'd go along with his suggestions for a while), and also were taking Coenzyme Q10 and vitamins.

I got a tubal flushing - saline pumped through the fallopian tubes - to assess if there were any blockages and to 'clear the pipes'. That was a little weird and uncomfortable, but not awful.

Test results came back and it seemed that DNA fragmentations with the semen were our issue - count and motility were good but on closer examination, the vast majority of sperm was compromised at the DNA level and unlikely to survive. Husband was told to take a Carnatine supplement as that might help, but that it was unlikely we'd conceive without IVF, to carefully pick out the good sperm. IUI wasn't an option because there were so few sperm available. We were told to come back in three months for a retest, and then we'd start the IVF process.

Based on a bit of googling, I suggested that husband start ejaculating on a daily basis, as some studies seemed to indicate that helped with DNA fragmentation issues.

Surprisingly, we got pregnant the next month - totally by accident, we'd stopped tracking anything at that point. The clinic tested and confirmed, and sent us on our way. Otherwise we would've probably done one round of IVF and then stopped due to financial constraints.
posted by stray at 7:15 AM on January 22, 2020

I recommend starting with your OB/GYN, but moving on to an RE sooner rather than later if you’re not immediately successful. I wasted a lot of time on Clomid cycles with my OB/GYN and it turns out I pretty much would never get pregnant with that — I needed the interventions that an RE could provide instead (namely, injectable medication to grow more follicles, and then ovulation triggers). I still feel bad about the decision to stick with my OB for all that time.

We ultimately ended up with IVF after a few failed medicated IUI cycles (well, I guess since one resulted in a chemical pregnancy, that almost counts). I got pregnant on the first try with IVF, but not everyone’s that lucky. And then I got doubly lucky — that successful pregnancy apparently kicked my ovaries into gear and I got pregnant naturally the second time. But that definitely doesn’t happen for everyone.
posted by liet at 7:20 AM on January 22, 2020 [1 favorite]

Thirding "Taking Charge of Your Fertility," along with Lisa Hendrickson Jack's "Fertility Friday" podcast.

As DoubleLune points out, OPKs only tell you part of the story, so understanding how to monitor your own signs will add lots of useful information to verify she's actually ovulating, and when. We're all taught that cycles are 28 days, but they can vary tremendously -- which affects when you actually ovulate. In my case, my cycle is 24-25 days, and I ovulate around day 9 or 10 - much earlier than most resources would tell you to try.

I would start with your wife's OB to run some basic tests. Check thyroid function, as TSH levels that are too low can cause fertility issues. She might also do a full blood panel just to make sure everything else is as it should be - Vitamin D, iron, etc levels. From there, she can ask for a recommendation of a reproductive endocrinologist who can do more extensive testing. I had a saline ultrasound to examine the uterine cavity and a hysterosalpingogram to make sure my tubes were open. My husband had a sperm analysis. In my case, the saline ultrasound found scar tissue in my uterus (due to a previous stillbirth) and the hysterosalpingogram found one of my tubes was blocked (due to scar tissue from previous surgeries).

A good RE can evaluate all your options, which may or may not include IVF or IUI. Some of that decision may be covered by insurance. In our case, insurance would cover some of the fertility drugs (like Clomid, which can help if you're not ovulating), but it won't cover IUI or IVF. My RE recommended taking Co-Enzyme Q10 (Ubiquinol) and a Vitamin D supplement, and did surgery to clean up the scar tissue. We were about to start (and pay for) IVF when I did get pregnant. We also lost that baby to stillbirth, and now appear to be infertile yet again.

Be kind to each other through this. It's a really tough road, and very frustrating when you feel like you have no control or autonomy - especially if insurance tells you that they won't cover your best options but would be happy to pay for things that won't likely help. The frequent tests are no fun and can be very invasive.
posted by writermcwriterson at 9:25 AM on January 22, 2020

Fourthing Taking Charge of Your Fertility. In conjunction with reaching out to your wife's OB to start the process of testing for potential problems, I would suggest she start charting to get a clearer picture of how and when her body is ovulating, if at all. Tracking my basal body temperature confirmed that I ovulate earlier than average (day 11) even though I have a 28 day cycle. Tracking your temperature can also give you an idea if you're having chemical pregnancies or not, which you might not otherwise know about. That is all good data to share with doctors as they figure out what the problem could be.
posted by lydhre at 9:51 AM on January 22, 2020

My wife and I went through a similar sort of process (we were a little older) with Kaiser. We started with her OB/GYN and we both had tests. Exactly what options are open to you is going to depend on what those tests find. We were prepared to got IVF if things didn't work out, but we tried AI first and were successful relatively quickly (we were also, surprisingly, successful later on with the traditional "banging like teenagers at band camp" method. Yay, us!).

We stayed entirely within Kaiser, although there was a certain amount of driving around to different facilities as our local one didn't have everything we needed. Our experience with Kaiser was positive.
posted by It's Never Lurgi at 10:58 AM on January 22, 2020

I would ask your wife's Ob/Gyn for a referral to a Reproductive Endocrinologist (RE) ASAP - these are the "fertility doctors". The RE will be able to work with both of you for testing and analysis, you don't need to see a separate doctor unless the RE refers you to an additional specialist. You'll both undergo testing and then, hopefully, the reason for the fertility issues will be identified. I know women who wasted a lot of time working only with their Ob/Gyn and did many cycles of Clomid instead of identifying the actual issue, much to their detriment. Be firm that you'd like to see a RE immediately.
posted by quince at 12:20 PM on January 22, 2020

Our situation was good quality sperm, but borderline fertile age lady with fibroids.
After trying the normal way and then multiple rounds of IUI and IVF and then giving up I can tell you what actually worked for us.

She started taking baby aspirin every day (famous fertility doc advised this).

Whatever position is not working, flip it around.

It’s possible that just the fact we stopped trying and both relaxed, helped. So try not to stress about it.
posted by w0mbat at 5:16 PM on January 22, 2020

A friend recommended the Reddit fertility threads, but I don’t Reddit so I can’t really tell you where, exactly.
posted by nat at 7:29 PM on January 22, 2020 [1 favorite]

It is important to dig around your insurance providers to know what is covered. However, REs are well versed in coding so that more stuff will be covered than you expect.
There is a long road to IVF and it is possible that there will be cheaper and less invasive things that can be done.

Your wife should be charting more precisely. Try Fertility Friend. If money is not an issue, the Ava bracelet makes things easy.
posted by k8t at 8:53 PM on January 22, 2020

Sorry to hear you are going through this -- it is very hard. We tried for 3 years and did eventually "succeed" with our first IVF (the first lucky shot we ever had). Lots of practical suggestions above, but want to echo:
- yes to moving to RE/fertility clinic sooner rather than later
- yes to stray's comment about not bothering with obsessive tracking -- that way madness lies -- once you are in the fertility system leave the tracking to them

You will get (and are already getting) a barrage of advice, but the fact is you will never know what is the "silver bullet." For instance, I got pregnant during the most horrifically stressful work period of my life. Like, the world's worst time to try IVF, and yet it worked. Yet years of relatively stress-free trying were fruitless. So don't get too hung up on the "one weird trick".

Most important thing is for both of you to be in a good place with each other, to discuss what your desires are and how far you are willing to go to achieve them, how you will know when to "throw in the towel" (and of course realize that your answers may change through the journey). It's a bad situation full of caprice and chance, but modern medicine is also truly wonderful! If you have any specific questions, always happy to discuss through DM.
posted by Mrs. Rattery at 7:51 AM on January 23, 2020

My husband and I were in a very similar position two years ago M (32) F (34) and were lucky enough to have success with our third IUI.

I would like to n-th the recommendations to skip straight to a fertility clinic if your insurance covers it/finances permit. It has been my experience that getting a new patient appointment with a good clinic can take a few months, so it might be a good idea to get an appointment, and if it is a while away, see what the Ob-Gyn can do for you in the meantime.

I started with an RE based in an Ob-Gyn office, and while she prescribed the right tests, she made my husband go to a urologist for his semen workup, and the initial testing took place over the course of three months, which was a lot of wasted time and stress. The nurses and other doctors at the practice were also very bad at helping me understand the results, so when I did not see my own doctor due to schedule conflicts, I received a lot of misinformation which increased my stress levels exponentially. When we finally started at a fertility clinic, things moved much faster and the doctor was much more qualified to tell me what chances we had of eventual success. I should third that my fertility doctor told me not to bother with temping, and said that they could do a much better job of monitoring my ovulation via blood tests.

As far as possible interventions, it will depend on what the diagnosis is, but both IUIs and IVF are possible. Both of these involve medication, either oral (clomid or letrozole) or injectables in order to stimulate/strengthen ovulation. All of these interventions require several trips to the clinic during the cycle for monitoring, which consists of trans-vaginal ultrasounds and blood draws.

Many insurance companies will require a certain number of rounds of IUI before approving IVF - a lot of fertility doctors will advise you to skip these if your insurance does not require it, but medicated IUIs help the doctors see how the a woman's body is responding to the fertility drugs, and IUIs are much less involved then IVF. I have a number of friends who were advised to go straight to IVF who did have success with IUIs when they insisted on a few rounds first. Statistically, couples are much more likely to have success with IUIs in the first three to six cycles.

While I was waiting to see my fertility doctor, I found it both useful and slightly terrifying to hang out at r/infertility and read their daily treatment threads. Many of the members have been through/are going through multiple rounds of IVF, and "banking" embryos, and the daily threads will help you understand the range of issues, treatment possibilities, and challenges you might face. r/stilltrying is a little less intimidating, but many of the members are engaged in fertility treatments. I also found "It Starts with the Egg" by Rebecca Fett useful, and I implemented a number of her suggestions.

Please feel free to reach out over memail if you have specific questions.
posted by MFZ at 7:53 PM on January 23, 2020

Mod note: This is a followup from the asker.
Based on the advice of this thread, my wife and I got _Taking Charge of Your Fertility_, which we were rather disappointed by. We found it a little crunchy and thin on evidence for our tastes. We were also hoping for more concrete information on the IUI and IVF process, which the book dismisses in favor of natural solutions. Plus, paying attention to her bodily signals didn't seem to provide any more information than the Clearblue fertility monitor.

But we were very lucky and my wife got pregnant without intervention on the second cycle after I wrote this question. She's now almost in the third trimester, and (knock on wood) the girl is due at the end of December.
posted by cortex (staff) at 5:36 PM on September 2, 2020 [3 favorites]

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