Seeking Help with Infertility: When to go and Where to go
Dr. Daniel E. Stein
Director of RMA of New York’s Westside office
Chief of Reproductive Endocrinology at Mount Sinai West Hospital.
Infertility is commonly defined as failure to conceive after twelve months when the woman is 35 years of age or younger, or after six months when the woman is older than 35. In about 60% of all cases the cause of infertility involves, at least in part, reproductive issues in the woman. The stress and distress this causes women can be devastating. Fortunately, for many women, help exists and successful conception can be attained.
For women 35 and under who have been trying to conceive for one year, have regular menstrual cycles, and no history of sexually-transmitted diseases, pelvic pain or pelvic surgery, the obstetrician gynecologist (OBGYN) doctor can be an appropriate first resource to begin the evaluation of the causes of infertility including semen, ovulation and fallopian tube testing. Some OBGYN doctors are comfortable treating ovulation disorders with medications like Clomiphene Citrate or Letrozole. OBGYN doctors are experts in managing pregnancies, office gynecology and some pelvic surgery. They receive, however, only a few weeks of training in reproductive endocrinology and fertility and therefore typically refer patients with infertility to Reproductive Endocrinologists.
What is a fertility specialist and when should I see one?
Any physician can state that she or he is fertility specialist; however, true specialists are called Reproductive Endocrinologists (REs), physicians who are fully-trained in both Obstetrics and Gynecology, and in Reproductive Endocrinology and Infertility. After completing a residency in OBGYN, REs complete three years of additional fellowship training in the diagnosis of complex reproductive disorders and their treatment, including assisted reproductive technologies like in vitro fertilization (IVF), egg and embryo freezing, egg donation, and reproductive surgery. It is beneficial for all with infertility to see a reproductive endocrinologist, but in the following conditions a woman should see a Reproductive Endocrinologist as soon as possible:
-If the woman is 35 or older and has tried to conceive for 6 months or longer
As women age, the number of eggs in the ovaries decreases and an increasing proportion of those eggs are genetically abnormal. Fertility rates decline and rates of miscarriage rise as women enter their thirties, and the decline is rapid as women approach 35.
-A woman with a mother or sister with menopause at age 45 or younger
Menopause is the time at which a woman is depleted of functional eggs and is therefore no longer able to conceive. The age of menopause depends on the number of eggs a woman is born with. Women born with more eggs go into menopause at an older age than women born with fewer eggs. The average age of menopause is 51. Women with a mother or sister with early menopause (prior to age 45) are at risk of experiencing early menopause themselves.
-A woman with a history of pelvic surgery or pelvic diseases
Sexually-transmitted infections like Gonorrhea and Chlamydia, endometriosis, and pelvic operations (e.g. appendectomies, removal of ovarian cysts or uterine fibroid tumors) can be destructive to fallopian tubes and can damage ovaries leading to depletion of eggs.
-A woman with ovulation dysfunction who failed to conceive with Clomiphene or Letrozole
-A woman with a history of two or more miscarriages
Chromosome abnormalities in embryos, uterine masses or malformations, and immunologic or hormonal abnormalities can contribute to repeated miscarriages.
-A woman who is a carrier of a dominant genetic disease
-A woman planning to start chemotherapy for cancer or autoimmune disease
-A woman over 30 who is planning to delay childbearing
Women with one or more of the above criteria should make an appointment with a reproductive endocrinologist. Finding the right specialist can be challenging and stressful. Biographies of REs are usually available online. It is important to choose a RE who has passed a vigorous series of examinations over several years to achieve and maintain board certification in both Obstetrics and Gynecology and in Reproductive Endocrinology.
Furthermore, the fertility center that your doctor is part of is critical. The quality, experience and expertise of fertility centers varies widely. The Society for Assisted Reproductive Technology (SART) website (www.sart.org) lists local centers by zip code and allows prospective patients to view important information and statistics about each center. SART and the Centers for Disease Control (CDC) publish pregnancy data each year for almost all IVF clinics in the United States. Patients should only go to centers that publish their pregnancy data, and preferably centers with many years of such reporting. While patient populations vary among clinics making direct comparisons of pregnancy rates limited in value, centers with consistently high pregnancy rates and a high volume of patients are typically favorable centers to consult with.
Women typically rely on their OBGYN physicians to refer them to a fertility center, or their insurance carriers who often list Centers of Excellence. Some women rely on Yelp, RateMDs, Fertility IQ or other internet sites. Castle-Connolly and other groups create a list of Top Doctors or Best Doctors in each field annually. Word-of-mouth is also a common way in which women find fertility doctors. No matter how the selection of a doctor and/or clinic is made, meeting the doctor and visiting the center for an initial consultation will help prospective patients determine if that doctor or center is a good fit for them to begin their journey to successful reproduction.
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Dr. Daniel E. Stein is the Director of RMA of New York’s Westside office and is Chief of Reproductive Endocrinology at Mount Sinai West Hospital. Dr. Stein has over twenty years of experience as a Reproductive Endocrinologist and fertility specialist and served for eight years as Medical Director of the In Vitro Fertilization program of the former Continuum Reproductive Center before joining RMA of New York. He is board-certified in both obstetrics and gynecology and reproductive endocrinology and infertility. For the past several years Dr. Stein has been recognized by New York Magazine and Castle Connolly as one of New York’s “Best Doctors” and has been named a “Top Doctor” by US News and World Report. He has also been included as one of the Best Doctors in America. He has received multiple awards from patient advocacy groups for his years of service in the fields of reproductive medicine and fertility.
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