David Adamson, M.D., F.R.C.S.C., F.A.C.O.G., F.A.C.S., is a board certified reproductive endocrinologist and surgeon and Director of Fertility Physicians of Northern California in Palo Alto and San Jose, California, a private medical practice specializing in fertility and reproductive medicine. In 1997, he founded Advanced Reproductive Care, Inc., a national network of reproductive specialists dedicated to increasing the value of infertility care through lowering barriers to patient access, information technology, clinical research, and outcomes assessment. Dr. Adamson is a Clinical Professor at Stanford University's School of Medicine and Associate Clinical Professor at the University of California San Francisco's School of Medicine. He has published over 100 peer-reviewed scientific articles, numerous book chapters, and a textbook.

The diagnosis and treatment of infertility is a complex and emotional process.  Numerous factors, such as medical history and behavioral and environmental health risks, can play a part in reproductive health for both women and men.  Therefore, it is important that people who are having trouble getting pregnant seek treatment from a doctor who has the appropriate training and experience, and a communication style that is comfortable to them.

What is Infertility?  Am I At Risk?
The first question people often have is, "How do I know if I'm infertile?" Infertility is defined as the inability to conceive after one year of unprotected intercourse or, when the woman is 35 or older, after six months of unprotected intercourse.  Couples who do not conceive should seek medical assistance.  Women who have two spontaneous miscarriages should also see an infertility specialist.

There are numerous causes for infertility. About 40% of all cases can be attributed to the woman, 30% attributed to the male partner and 20% of cases are caused by a medical problem in both the man and woman.  Ten percent of couples have unexplained infertility, where no medical diagnosis can be found.  However, many couples with unexplained infertility can still be treated successfully.

There are also certain risk factors for infertility.  For women, these include three or more previous miscarriages, irregular or absent menstrual periods, extremely low body fat, endometriosis or tubal damage, or the presence of certain chronic diseases.

Men should be aware of low sperm count, exposure of the testes to high temperatures (such as in a hot tub or steam room), having undescended testicles, a history of genital infection or hernia repair, and having had mumps after puberty.

Who Should I See?
When choosing a physician, it is important to understand the different roles of an OB/GYN and a reproductive endocrinologist.  OB/GYNs are trained to diagnose and treat general disorders of the female reproductive system and to care for a woman during pregnancy, childbirth and during the postpartum period.  Some OB/GYNs do provide limited infertility treatment, but these physicians are not trained in the more advanced reproductive technologies.

Reproductive Endocrinologists (RE) represent a subspecialty of obstetrics/gynecology devoted specifically to treating infertility, and can treat both women and men. Reproductive Endocrinologists are highly trained medical physicians, completing a two to three-year fellowship in infertility treatment, followed by two years of clinical experience. They must also pass both oral and written exams.  This specialized training is above and beyond their 4-year Obstetrics and Gynecology residency training and board certification.

RE's are certified by the American Board of Medical Specialties.  There are about 780 Board Certified RE's in the US.  Another 100 are "board eligible" - that is, they are in the process of completing their clinical experience and have not yet taken the oral exam. 

Interviewing a Physician
Patients may want to have a consultation with more than one physician before selecting the reproductive specialist right for them.  Credentials are just the first step.  Think of your reproductive specialist as a partner in your care, and choose someone you feel comfortable questioning and talking with.  The following are some queries that patients can use as a guide.  RESOLVE: The National Infertility Association (www.resolve.org) also publishes a helpful tip sheet on selecting an infertility specialist¹.

• Where did you receive your medical training?  When?
• Are you a Board Certified reproductive endocrinologist?
• How long have you been treating infertile patients?
• How many reproductive endocrinologists are on staff?  How many will I see?
• Who can I call if I have a problem after office hours?
• Are you affiliated with a hospital?
• Are you a member of the American Society for Reproductive Medicine (ASRM)?
• Are you a member of the Advanced Reproductive Care network?
• What insurance plans do you accept? 
• Do you offer any financing options or payment plans?
• How much will treatment cost?  Does that include lab work, procedures and medications?
• Do you offer the assisted reproductive technologies (ART)?
• Does this practice have a donor sperm/donor egg program?

Ensuring Success
At your initial visit, both partners should be present.  It is important to have a medical history and evaluation conducted for both the female and male partners.  Once a diagnosis has been made and treatment has begun, there are two things patients can do to ensure that their experience is a positive one:

1. Regularly discuss with your partner about whether you both are comfortable with the treatment process and understand your options, feel that your reproductive specialist and staff are responsive to your needs and that you are getting the information you need to make informed decisions about your treatment.  If you are not pleased with the process and the treatment you are receiving, take time to evaluate the situation and, more important, discuss your feelings with your physician.  If that doesn't work, it may be time for a change.
   
   
2. Seek support and information.   Fertility treatment is an emotional process.  I always advise my patients to contact RESOLVE.  As an organization devoted solely to the needs of infertile men and women, RESOLVE can help people understand their options, learn how to advocate for their care, and become connected with others who are experiencing infertility.  The American Society for Reproductive Medicine (www.asrm.org) is also a great resource for information on the latest medical advances, current treatment options and the basics of reproduction.

Many patients will become pregnant using relatively simple, "low tech" procedures or drug therapy.  A small minority of patients will seek treatment with the Assisted Reproductive Technologies (ART), such as in vitro fertilization (IVF), procedures that effectively unite sperm and eggs for fertilization in the laboratory, followed by implantation in the uterus.

Patients should seek an IVF clinic that is conveniently located near their home, with qualified, experienced and supportive medical professionals.

Factors to Consider When Choosing an IVF Clinic
There are 375 IVF clinics in the United States. While the average success rate for the assisted reproductive technologies is approximately 28% (that's about 50% higher than unassisted conception in any given month), success rates vary among individual practices.  Cost is another important factor and can vary by region and practice.   Additionally, not every clinic offers the same procedures or services.

Understanding Success Rates
The Centers for Disease Control (CDC) and the Society for Assisted Reproductive Technology (SART) publish "The Assisted Reproductive Technology Success Rates in the United States: National Summary and Fertility Clinic Reports."  I encourage patients to look at this report.  However, it is very important to understand that many factors influence success rates.  For example, clinics treating female patients who are older or have more severe infertility problems will usually have a much lower success rate than those treating younger women with less severe problems.  All SART member clinics provide success rates for inclusion in the CDC report, and patients can use these statistics as a starting point for discussion with their physician.  Be wary if the staff is unwilling to discuss or explain its success rates.  

Some specific questions to ask about success rates are published online by ASRM at www.asrm.org ("Selecting an IVF/GIFT Program"); and in its patient information booklet, "IVF and GIFT: A Guide to Assisted Reproductive Technologies-A Guide for Patients" (1995).   Following is a sampling of these questions:How many babies have been born through this IVF program?

• How many babies have been born to women 40 and above?  30 to 39?
• How many treatment cycles of IVF have been initiated by this program in the past two years?
• How many pregnancies have resulted from the IVF program in the past two years?
• How many deliveries were multiple births?  Singletons?

Accreditation & Affiliation
Be sure the IVF lab is accredited by the College of American Pathologists, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or the state.  Ask, also, if the program follows guidelines for IVF set by the American Society for Reproductive Medicine (ASRM).  Membership in the Society for Assisted Reproductive Technology (SART) is another positive sign that the clinic is keeping abreast of the latest advancements in treating infertility.  

Getting the Facts
Other considerations when selecting an IVF center relate to cost, convenience and services.   The questions below can be used to assist in the interview process³.

• What procedures are offered by the clinic?  Are they performed on-site?
• How many Board Certified reproductive endocrinologists are on staff?
• Is there a laboratory on-site?
• Does the clinic offer counseling?
• Is the clinic affiliated with a hospital?
• Is the clinic open on weekends? Offer extended hours?
• How much does treatment cost, including drugs and lab work?
• What insurances are accepted? 
• How are payments structured?
• Are donor eggs or sperm available through this program?
• Do you prepare a treatment plan for your patients? 
• What kinds of patient education are available to me?

Consider All Your Options
Before undergoing fertility treatment, I recommend becoming informed about all of your treatment and lifestyle options.  Many women and men find that they can be happy living without children.  Others adopt.  Whatever your choice, get the facts, find an experienced and qualified reproductive specialist if you choose to seek treatment and develop a network of friends and family who will support your decision.

For further information on infertility, click here.
For further information on how to choose a gynecologist, click here.

¹    Diane N. Clapp, BSN, RN, Fact Sheet 16, "Selecting an Infertility Physician," RESOLVE, 1980, Available online: www.resolve.org.

²    Fact Sheet: IVF, ASRM, 2000.

³     "IVF and GIFT: A Guide to Assisted Reproductive Technologies-A Guide for Patients," American Society for Reproductive Medicine, 1995.

Created: 11/15/2000  -  David Adamson, M.D., F.R.C.S.C., F.A.C.O