If you've made an appointment with a fertility specialist, congratulations on taking the next step towards getting pregnant! Here you'll learn how a doctor can help, how to talk to your doctor, questions to ask, and what to expect at a fertility clinic.

• How can a doctor help me get pregnant?
• How can I talk to my doctor about my fertility concerns?
• Fertility clinics: what should I expect?

How can a doctor help me get pregnant?

In high school, teachers hammered home the message of how easy it was to get pregnant. Having probably spent your younger years focusing on contraception, now you're actively pursuing pregnancy - but nothing is happening. What should you do?

It may be time to see what your doctor can do for you. A fertility specialist can address your particular concerns about fertility, provide information on fertility, and advise you on the next steps, including treatment options, on your journey to becoming pregnant.

When to see a fertility specialist

If you have been having regular, unprotected sex for a year (6 months if you're a woman over age 35) and you still aren't pregnant, it may mean you are infertile, since this is generally how infertility is defined. It's time to see your family doctor. Women over 37 do not need to wait 6 months before seeing a doctor, because waiting too long to seek help could harm their chances of conceiving.

You'll also want to see your doctor sooner if you have a history of irregular or painful periods, pelvic pain, endometriosis, pelvic inflammatory disease (PID), repeated miscarriages, or if your partner has a low sperm count or a history of testicular, prostate, or sexual problems.

Preparing for your appointment

Although you may feel a bit embarrassed or nervous talking about the subject, talking to a fertility specialist is an important first step. You may find it easier to talk about your fertility if you prepare for the visit in advance. Find out how to get ready for your visit to a fertility specialist.

Don't forget to bring a pen and paper to take notes.

Referrals to fertility specialists

Your family doctor is an important gateway to other specialists, such as an obstetrician/gynecologist (OB/GYN) or a fertility specialist, also called a reproductive endocrinologist (REI). Or maybe you've already see an OB/GYN for your routine Pap tests and you may find it easier to start the conversation with them. Either way, it's important to discuss your concerns about fertility with your doctor and explore the option of seeing a fertility specialist. Depending on your age and health history, your doctor may recommend a medical evaluation. This may be through a referral to either an OB/GYN or a fertility clinic. Some fertility clinics allow for self-referrals so you don't have to go through an OB/GYN or family doctor.

Find a fertility clinic near you.

Your family doctor or OB/GYN may be able to review what to expect at a fertility clinic and various treatment options that may be right for you. Seeking help from a specialist, especially a fertility specialist, is that all-important first step required to start the process towards figuring out your fertility.

How can I talk to my doctor about my fertility concerns?

• Overcoming the emotional hurdle
• Before you make the appointment
• Getting ready for your visit
• Get the most out of your appointment
• Suggested questions to ask your reproductive endocrinologist (REI) or fertility nurse
• Understanding fertility clinic statistics for success rates
• The fertility workup

Overcoming the emotional hurdle

Perhaps you and your partner fit the criteria of couples who should see a fertility specialist about fertility difficulties:

• The female partner is under 35 and unable to conceive after a year of regular, unprotected intercourse.
• The female partner is 35 to 37 and unable to conceive after 6 months of regular, unprotected intercourse.
• The female partner is over 37 (women over 37 do not need to wait 6 months before seeing a doctor, because waiting too long to seek help could harm their chances of conceiving).

Yet it's hard to make that first appointment. You keep putting it off.

Does this sound like you? Your hesitation is understandable. It's common for people to find reasons to avoid going to see a doctor. In many cases a person has a fear of the outcome or diagnosis. You're concerned about how much it might cost. You think the procedures are too involved or too time consuming or painful.

You should know that many people are in a similar position. It is normal to feel overwhelmed, uncertain, or stressed. Consider some facts:

• The majority of infertility cases - 85% to 90% - are treated with conventional therapies, such as drug treatment or surgical repair of reproductive organs.
• Fewer than 5% of infertile couples in treatment actually use in-vitro fertilization (IVF), even though it produces the best results, because it is often perceived as too "high-tech" and too "costly."39
• Your doctor may be able to advise you on whether the fertility testing and/or procedures that you may need are covered by public or private medical insurance. Read "Cost of fertility treatments" to learn more. You should be aware that you may need to contact your own private insurance provider for more information about your own private insurance plan.

If you want to conceive, it's important to overcome the emotional hurdles and . The sooner you see a health care provider, the sooner a problem may be diagnosed and treated.

Before you make the appointment

Check into your insurance coverage before you see your doctor. Be sure that you're well informed and find out what your provincial and private medical insurance plans will cover. Your policy will outline the coverage available to you. Read "Cost of fertility treatments" to learn more.

Getting ready for your visit

Preparing for your visit will help reduce anxieties. If this is your first step toward addressing your fertility concerns, take a few minutes to complete the doctor discussion guide and print a copy to take to your doctor.

Knowing what to ask your fertility specialist ahead of time will help ensure you get the most out of your visit. It helps a lot if you write everything down in advance. That includes medical histories and questions you want answered. I'm sure we've all left a doctor's office only to remember a question we meant to ask but forgot! To see which questions your fertility specialist is likely to ask, and which questions you may want to consider asking, see the "Suggested questions to ask your reproductive endocrinologist (REI) or fertility nurse".

Get the most out of your appointment

Many people are shy about asking questions, but you shouldn't be. Your doctors want to make sure you understand your diagnosis and treatment options too! And if you don't understand the answers, don't hesitate to ask your doctor to repeat them.

Here are some suggested questions to print and take with you.

• Suggested questions to ask your reproductive endocrinologist (REI) or fertility nurse

Suggested questions to ask your reproductive endocrinologist (REI) or fertility nurse

Your first visit to a fertility specialist or fertility clinic can be an overwhelming experience. On top of dealing with the emotional issues that may arise with infertility, you now find yourself confronting a new and sometimes scary world of treatment options. Bringing this list of questions to your first visit may help you to keep track of your thoughts and increase your comfort level.

• What specific tests would you recommend to diagnose my infertility? How much do they cost?
• How long will it take to diagnose our problem?
• Based on the results of those tests, what are my treatment options?
• What is the national success rate for those treatments in terms of live births?
• Will my insurance pay for the testing and/or treatments? Will your clinic help me determine what my insurance will cover?
• How will I communicate with you during this whole process?
• Does your clinic provide emotional counselling , or can you refer me to a counsellor who deals with fertility problems?

Understanding fertility clinic statistics for success rates

There are a variety of potential measures that can be used to evaluate clinic success rates of assisted reproductive technology (ART). To learn more, read "Understanding fertility clinic success rates."

The fertility workup

The workup demystified
What happens when you see a specialist for your fertility concerns? Generally, your fertility specialist will conduct an evaluation that begins with a review of your medical and personal histories. You'll likely discuss everything from family medical history to diet and lifestyle to your current sexual practices.

Your doctor will also conduct an exam. Depending on your medical and lifestyle history, they will then conduct some tests, beginning with the simplest and least invasive ones. At a later point, you may need to undergo more advanced evaluation.

What happens during the female exam
The female exam consists of a general physical exam, a breast exam, and a comprehensive pelvic exam. During the pelvic exam, your doctor will determine the size, shape, and position of your reproductive organs. Many doctors will also complete a routine Pap test to detect any infections and rule out cervical cancer. Blood work will also be done to check for sexually transmitted infections like human immunodeficiency virus (HIV), gonorrhea, and syphilis. Individual hormone levels will also be tested. Your doctor may also recommend an ultrasound to look at the ovaries.

What happens during the male exam
The male exam includes a general physical along with an examination of the testes, penis, and scrotum. A sperm sample will also be collected. Your doctor will look for varicoceles in the scrotal sac, which are found in about 40% of men who are undergoing evaluation for infertility. Your doctor may also take a culture from the opening of the penis in order to rule out infection.

What your fertility specialist is looking for
Basically, your doctor is attempting to answer four key questions:

1. Is there an ovulation problem?
   Even when a woman is having her periods, she may not be ovulating. Your doctor will attempt to determine if your ovulation is irregular or if you're ovulating at all. A number of tests can help determine your ovulatory status.

   Some doctors may gather information about the menstrual cycle using a basal body temperature (BBT) chart. You take your temperature each morning and plot its daily changes. After a few months of charting, your doctor can often determine if ovulation is happening and if problems are occurring within the cycle.

   Blood work may also be performed to determine if hormonal imbalances exist.

2. Is there a sperm problem?
   A man will be asked to provide a semen sample to determine the quality, volume, concentration, and motility of his sperm. Blood tests may also be conducted to check FSH (follicle stimulating hormone), LH (luteinizing hormone), and testosterone levels (see the Fertility glossary for information on these hormones).
    
3. Are the egg and sperm able to unite?
   A number of factors can make it difficult for the sperm and egg to come together.

   Sometimes the mucus around a woman's cervix prevents sperm from reaching the fallopian tube. In rare cases, if your doctor suspects a problem, they may order a cervical mucus or postcoital test to determine if the quality and consistency of the mucus is allowing this to happen.

   Often, sperm and egg can't unite due to structural problems in the reproductive organs. Your doctor might perform tests to look for blockages within the uterus, fallopian tubes, or pelvis. One of these tests is an X-ray procedure called a hysterosalpingogram (HSG) that allows the health care provider to assess the contour of the inside of the uterus and determine whether or not the fallopian tubes are open. Your doctor may also conduct tests that look for polyps or fibroids. Surgical procedures may help overcome these conditions.

   Your doctor may also order a laparoscopy to detect tubal disorders, scar tissue, or endometriosis (the presence of uterine tissue outside the uterus). This surgery, however, is usually performed late in the workup, if at all.

4. Can the embryo implant and be sustained in the uterus?
   Even if the sperm and egg are able to unite, the embryo may have difficulty implanting and sustaining itself in the uterus. Your doctor may also obtain a tissue sample, often referred to as an endometrial biopsy, from the uterine lining to see if it is developing properly or a conduct an ultrasound to see how thick the uterine lining is.

Fertility clinics: what should I expect?

If you're preparing to visit a fertility clinic, you probably have hundreds of questions - they likely didn't cover this topic in health class in high school! And it may not be a topic that comes up often among your friends or at cocktail parties. Even in our tell-all society, it can still be challenging to discuss fertility issues and treatment openly.

Find a clinic

Maybe you're still in the investigation and fact-finding stage - you think you want to visit a clinic but aren't sure where to start, or how to even find a clinic. You can start by using the fertility clinic locator to find a fertility clinic near you.

What clinics can do

Often, the reason you are not getting pregnant is treatable. Problems conceiving may be due to a single cause or a combination of factors that may prevent a pregnancy from occurring or continuing. A fertility specialist may be able to determine what the cause is.

At the fertility clinic, you will be presented with different treatment options suitable for your condition. There are many safe and effective therapies that can help you become pregnant. When women of past generations were trying to get pregnant, fertility conversations, if they happened at all, were confined to the family doctor. There was no proper fertility care available to those in need. Now there are modern fertility clinics in most major cities and hospitals in Canada and around the world. Use the fertility clinic locator to find a fertility clinic near you.

What to expect from a clinic

When you first visit a fertility clinic, you may be able to sign up for a free information session. You will also be able to set up personal consultation meetings where staff will be able to answer your questions about the steps of fertility evaluation (testing), diagnosis, treatment, and costs. Often, both partners are encouraged to attend these meetings. They'll provide you with information on the factors that are important when trying to conceive and show you how to maximize your chances of success. You will also have the opportunity to talk with a fertility specialist who can discuss the various treatment options available to you, the specifics of each, and their advantages and disadvantages. Many fertility clinics also recommend or require a consultation with a psychologist or a fertility counselor, who may also be on staff at the clinic.

Testing and diagnosis

In the testing and diagnosis stage, the doctors at the clinic may need to do tests to diagnose the possible cause of your difficulty in conceiving. There may be several tests but they are all important and designed to look at four key factors in successful conception:

• the right hormone balance
• information about your ovaries and ovulation
• sperm quality and quantity
• male and female reproductive factors affecting fertilization

Your fertility care team will be able to tell you exactly what tests are involved in your case. You can refer to the Fertility workup section for more information.

Treatment options

After testing and diagnosis, you will have a variety of treatments to choose from depending on your results and particular situation. You'll want to learn about a variety of factors for each treatment option [link to "Fertility treatment options" section, section 5 of this segment], including:

• cost
• duration
• possible side effects
• chance of conception success
• available support or counselling

Asking questions

While at the clinic, ask as many questions as you like. It may be helpful to request fact sheets or literature about each of the options discussed so you can review them later. Remember, everyone at the fertility clinic is there to help you, so take advantage of their knowledge, experience, and expertise - you're not in this alone.

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