Fertility treatment can be confusing if you can’t find the right information.
We regularly update our FAQ section to keep patients informed. All answers are based on the best available medical evidence and from sources you can trust. Have a question? E-mail us at firstname.lastname@example.org
1. How can I tell if we’re having fertility issues?
Infertility is generally defined as the inability to conceive after one year of trying. However, if there are obvious issues (lack of a menstrual cycle, advancing age), it is totally appropriate to present for care prior to one year. We encourage any patient who is concerned about their ability to conceive to book a Reproductive Counseling session. These non-stressful sessions allow you the opportunity to assess your reproductive potential without feeling pressure to pursue treatment. Non-invasive diagnostic testing is ordered as necessary. Sometimes a little helpful advice from a trained physician is all you need.
2. Do I need a doctor’s referral to be seen?
No. We are sensitive to the fact that many families in Ontario do not have a family doctor, so we welcome self-referrals from appropriate patients. We ask that you fill out our self-referral questionnaire prior to booking an appointment. Similarly, if there is a lengthy wait to see your family doctor, we will see you without a referral. To be fair to your family doctor, we try to involve them in the process as much as you are comfortable with.
3. Do I need to bring my spouse?
If you are married or common-law, we encourage you to bring your partner to as many visits as possible. If your spouse is male, we at the very least need to see them for a semen analysis. Same sex couples are welcome. Single women who wish to become mothers are also welcome.
4. Is there a charge for visits?
No. If you have valid Canadian health insurance, the cost of visits and most diagnostic testing is covered by OHIP. In fact, most aspects of fertility treatment, with the notable exception of IVF and ICSI, are covered by OHIP. Fertility treatment doesn’t have to be expensive!
5. What can I expect on my first visit?
On your first visit to Fertility Ontario, you will meet with one of our REI physicians to review your case and take a detailed history. Investigations such as an ovarian hormone profile, semen analysis, and tests of the fallopian tubes are usually planned at this time if they have not been performed already. If you have received fertility treatment at another center, it is very helpful if we have this information prior to your first visit. If not, you’ll be asked to sign a record release at your first visit. If you come from a distance, we may also perform a pelvic ultrasound at your first visit rather than have you return specifically for that procedure. Some of our hormone testing and ultrasound procedures have to be done at specific times of your reproductive cycle and cannot always be completed on your first visit.
6. When will I get my results?
Your ovarian hormone profile is performed right here in our laboratory and we usually get the results the same day. Advanced testing such as an AMH level may sometimes take 2 to 3 weeks. Semen analyses performed at community labs are generally available within a few days. Advanced semen analyses performed at London Health Sciences Center are available the same day that they are produced. Tests for fallopian tube function are performed by our physicians, who will notify you of the results immediately after the procedure.
7. What is the first step in treatment?
The first step in treatment is different for everyone. The importance of the diagnostic tests that we perform is the ability to choose a treatment that’s right for you. For some patients, treatment is as simple as lifestyle modification and techniques to enhance natural pregnancy. Other patients can be treated with oral medication that requires little monitoring. If our doctors determine that you require more advanced treatment, you will have an orientation session and be assigned an individual caseworker to make sure that your treatment go smoothly.
8. What is Day 3 Blood work?
Day 3 blood work is a set of ovarian hormones that is drawn in the early part of your menstrual cycle. Although we refer to it as day three blood work, it can be done anywhere from Day 2 to Day 4 of your cycle. Typically, in this stage of the menstrual cycle, called the early follicular phase, the estrogen level is very low. By measuring ovarian hormones in this low estrogen state, we get a rough idea of what your ovarian reserve is. We usually couple this blood work with an antral follicle count, which is an ultrasound measurement of ovarian reserve. We also test thyroid function and prolactin production, as abnormalities of these have been shown to inhibit ovulation. Results are usually available the same day and will be relayed to you by telephone.
9. What is ovarian reserve?
Ovarian reserve is a poorly defined term that relates to the number of eggs that remain in the ovaries. From the moment that a woman is conceived, there is a finite number of eggs that exist in the ovaries. Whether you are getting pregnant, ovulating naturally, or on birth control, these eggs are depleted at a constant rate. The last of these eggs that remain in the available pool tend to be of lower quality than eggs from earlier in life, although this is not a hard and fast rule.
To be fair, these tests do not predict whether or not you can become pregnant. They might be more accurately described as tests of ovarian responsiveness, as they are very predictive of your clinical response to fertility treatment. They help our physician team to choose a treatment protocol and medication dosing that is appropriate for you. This avoids cycle cancellation and optimizes opportunities for success. In instances where ovarian reserve is decreased, our physician team might suggest that treatment is not in your best interest. We consider it unethical to offer treatment, particularly at great expense, where the chance of pregnancy is very small. However, that does not mean that you will never become pregnant. It simply means that our ability to boost your fertility with medications does not justify the cost and risk of treatment.
If your ovarian reserve is markedly diminished, we still have treatment options for you. These include holistic treatments such as acupuncture and traditional Chinese medicine, or more advanced treatments such as egg donation. Whatever the case, we will continue to work with you towards your goal of building a family.
Current tests of ovarian reserve include day three FSH, antral follicle count, and AMH level.
10. How is the sperm analyzed?
If you have not had this test performed already, we will obtain a routine semen analysis from a community laboratory. We use outside laboratories as these tests are covered by OHIP. Information available includes the count (in millions), the percent motility, the volume, and a brief description about the morphology (shape). We are most interested in the total motile count, a number that includes most of these parameters in a clinically useful assessment. If the total motile count is less than 40 million, we will likely suggest some form of advanced treatment on the basis of decreased sperm count.
If the sperm count is significantly decreased, we will usually obtain an advanced semen analysis through London Health Sciences Center. This test is not covered by OHIP and costs $300. The sperm is put through dynamic testing in a laboratory setting, with a strict assessment of morphology and function. After the testing is complete, the lab will issue a report as to what sort of fertility treatment they feel is required. An advanced semen analysis is always required if we are considering intrauterine insemination, in vitro fertilization, or intracytoplasmic sperm injection.
11. How are the fallopian tubes assessed?
All patients need to have their fallopian tubes assessed in order to make sure that we are choosing the right treatment for you. There are two ways to perform this task, either by saline sonohystogram or by hysterosalpingogram (HSG).
The saline sonohystogram is performed in our office under ultrasound guidance. It is a screening procedure, and not as accurate as a hysterosalpingogram. However, it is generally more comfortable and does not involve ionizing radiation. If your fallopian tubes appear normal on a saline sonohystogram, there is no need for an HSG. If your fallopian tubes appear blocked on saline sonohystogram, we will confirm that suspicion with an HSG, as this is the only test that OHIP will accept to consider funded IVF.
The hysterosalpingogram or HSG is performed by one of our physicians at either University Hospital or Westminster Campus, usually first thing in the morning. It is a fluoroscopic assessment, meaning that x-ray images of the fallopian tubes and uterus are obtained. We usually recommend an antibiotic the night before having an HSG done.
12. Should I start Clomiphene?
Clomiphene citrate is an oral medication used to enhance ovulation, and the most commonly prescribed fertility medication in the world. It competes with estrogen in your system, and makes the brain think that the estrogen levels are low. The brain’s response to this is to release more follicle-stimulating hormone (FSH), which usually will result in ovulation in patients who do not regularly ovulate.
Clomiphene works best in patients with poly cystic ovarian syndrome. It is an excellent medication for people who do not ovulate. However, if you already have regular ovulatory cycles, the benefit of clomiphene to your overall pregnancy rate will be small. If we have documented regular ovulation, we prefer to skip ovulation induction with clomiphene citrate in favor of more effective treatment.
Treatment with clomiphene citrate is usually for five days at the start of your cycle. We usually recommend 3 to 6 cycles of treatment. Side effects of clomiphene are available on the product monograph. One of the most important side effects is a 5-8 percent risk of twinning that you should be aware of prior to starting the medication. It is important to document ovulation with a progesterone level to ensure that you are responding to clomiphene. If a pregnancy has not been achieved within six months, we will usually suggest progressing to more advanced treatment.
13. What is endometriosis?
Endometriosis is an inflammatory condition of the pelvis that is often associated with infertility. Approximately 50% of patients with infertility will have endometriosis. there are several theories as to why endometriosis develops, but the simplest to understand is retrograde menstruation. In this theory, the lining of the uterus that bleeds every month is pushed backwards through the fallopian tube and deposits in the pelvis. The glands of the lining are still hormonally active, and responsive to estrogen. They grow in response to ovarian hormones. As they grow and shrink, they produce a tremendous inflammatory response that has been implicated in every aspect of the fertility process, including egg quality, ovulation, fertilization,fallopian tube transport, and implantation.
Symptoms of endometriosis include pelvic pain, pain with periods, pain with intercourse, abdominal discomfort, and infertility. Screening tests include CA-125 levels and high fidelity ultrasound. Unfortunately, a firm diagnosis of endometriosis can only be obtained by a surgical procedure called a laparoscopy.
14. Is there treatment for endometriosis?
As mentioned previously, definitive diagnosis of endometriosis requires a surgical procedure called a laparoscopy. Laparoscopy also provides an opportunity for treatment. Potential benefits of laparoscopy are twofold. The first is diagnosis and staging. Staging of endometriosis is related to potential for fertility. Endometriosis is staged from 1 to 4, with stages 1-2 being mild to moderate and stage 3 to 4 being severe. Again, staging relates to fertility potential and does not correlate well with the amount of pelvic pain a woman is having.
The second potential benefit of laparoscopy is an increase in fertility potential. This only applies to stage 1-2 endometriosis. In mild to moderate endometriosis, ablation of the deposits of endometriosis by laparoscopic surgery has been shown to increase fertility potential over a six-month period. Unfortunately, these findings do not hold true for severe endometriosis. There is little available evidence to suggest that surgical management of severe endometriosis increases pregnancy rates. These cases are much better handled using medical therapy.
Ideal medical therapy of severe endometriosis involves using a class of medications known as GnRH agonists. We usually follow this up with a cycle of in vitro fertilization. Pretreatment with a GnRH agonist has been shown to increase pregnancy rates fourfold amongst patients who have severe endometriosis, when used in conjunction with an IVF protocol. At Fertility Ontario, we have special protocol specifically designed for patients with severe endometriosis.
When you have completed your childbearing or pregnancy is no longer an option, we have multiple medical treatments available for the pelvic pain associated with endometriosis.
15. What is PCOS?
Poly cystic ovarian syndrome, or PCOS, is the most common hormonal abnormality in women of reproductive age and a very common cause of sub fertility. Women with PCOS have decreased ovulation, and once pregnant, often have an increased risk of miscarriage.
PCOS is diagnosed by history, physical examination, blood tests, and ultrasound. The key findings in PCOS are lack of ovulation, evidence of increased androgen in the system ( either on physical examination or blood work) and ultrasound evidence of poly cystic ovaries.
It is important to note that poly cystic ovaries on ultrasound can be a normal finding in up to 10% of patients.
The word poly cystic is actually a misnomer, as the “cysts” that are seen on ultrasound are actually multiple small follicles, or parts of the ovaries that contain eggs. In PCOS, rather than one follicle or egg being selected out on a monthly basis, multiple follicles grow at the same time, but none of them mature enough to produce ovulation. The process tends to build up over time.
Treatment of PCOS is centered around enhancing ovulation. Medications for enhancing ovulation include clomiphene, metformin, and letrazole.
16. What is insulin resistance?
Insulin resistance is a hormonal abnormality with a strong genetic component. It is found in 25% of the general North American population, and up to 50% of the population defined as obese ( BMI > 30). It is a common feature in PCOS, but the presence of insulin resistance is not diagnostic of PCOS. Most patients with insulin resistance have normal blood sugar levels. It is highly prevalent in North America due to our highly processed diet and genetic predisposition.
Insulin resistance is often suspected in patients with a strong family history of type 2 diabetes, a personal history of obesity, or physical signs consistent with insulin resistance.
Diagnosing insulin resistance amongst the fertility population is important. Treatment with the insulin sensitizing drug metformin has been shown to enhance ovulation and decrease miscarriage in fertility patients with documented insulin resistance. In addition, lifestyle changes such as healthy diet and exercise will have a long-term impact on both insulin resistance and fertility.
17. What is intrauterine insemination?
Intrauterine insemination, or IUI, is a relatively low cost approach to advanced fertility treatment. It is reserved for patients who have a reasonably good prognosis for pregnancy. There are three components to our IUI program: stimulation with fertility medication, cycle monitoring with blood work and ultrasound, and the actual insemination procedure. Using all of these components, we report a 20% pregnancy rate per cycle any cumulative pregnancy rate of 40% after three cycles.
If you have not achieved a pregnancy after three cycles of IUI,we generally do not recommend additional treatment. This is because our extensive database of thousands of patients shows little benefit to more than three cycles of IUI. The pregnancy rate is 9% in IUI cycles four and five, and approaches zero at IUI cycle six. Although the procedure is covered by OHIP, we cannot ethically suggest a fertility treatment that is no more effective than spontaneous intercourse.
Patients are considered good candidates for IUI based on the results of their advanced semen analysis. If the event semen analysis shows a significant male factor (decreased sperm count), our laboratory usually recommends either IVF or ICSI rather than intrauterine insemination.
Medications for IUI usually involve low-dose injectable FSH. Monitoring involves approximately 3 visits to the clinic for blood work and ultrasound. When the ovarian follicles that contain eggs are considered mature enough for ovulation, the insemination procedure is scheduled. Insemination procedures are done at our local hospital, which is accredited on a regular basis.
18. What is IVF?
IVF, or in vitro fertilization, is the most effective form of fertility treatment currently available. It involves using injectable medications to stimulate the development of multiple ovarian follicles at one time, with the hope of retrieving as many eggs as possible. These eggs are then fertilized in a laboratory setting using your partner’s sperm or donor sperm. The fertilized embryos are allowed to develop over a three-day period, at which time our laboratory will determine which embryos are of the highest quality. Based on your age and prognosis, we will determine together how many embryos are to be transferred back into your uterus.
There are many different protocols for in vitro fertilization. Presently, our most commonly used protocol is a GnRH antagonist or “short protocol”. This takes approximately 2 1/2 weeks to complete from start to finish, and has excellent pregnancy rates associated with it. It is often referred to as the “patient centered protocol”, as it requires the least number of visits and is often viewed as the least stressful form of IVF.
Other protocols in use involve the use of GnRH agonists ( long protocol) or micro does Lupron (flare protocol). These are used less frequency but still have a clinical indication in certain instances.
19. What is ICSI?
ICSI, or intracytoplasmic sperm injection, is a process that is very similar to IVF but involves a different method of fertilization. Rather than letting the sperm and egg come together over a 24-hour period, a single sperm cell is injected directly into an egg within hours of the eggs being retrieved. ICSI is usually reserved for significant male factor where the lab is uncertain that successful fertilization will occur if the sperm is not placed directly inside the egg. There is an additional cost of $1500 for ICSI, so it is not recommended unless our laboratory staff feel that it is necessary. Other than the final step of fertilization, the process is very similar to IVF. We use the same protocols and the same medications.