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Are you over 35 and still trying to conceive after trying for a year or more?

You've been diligently following your Ob/Gyn's instructions and advice for what seems ages
now. Yet, despite all the ovulation predictor kits, testing and other suggestions by your
Ob/Gyn, you're still making no progress. You're beginning to wonder whether your search
for a biological family may be in vain. At this stage, it's time to get some more specific
information about your own biology and that of your partner. You're probably asking yourself questions like:

Why am I not getting pregnant?
What kinds of tests do I have to go through and are they painful?
How much will it cost?
What if I can't seem to get pregnant even if my work-up seems to be OK--- what are my options?
Where can I go to get more information?

Click on the questions above to reach some answers.


Why am I not getting pregnant?

If after a year of consistently trying to get pregnant, without success, a basic infertility
evaluation may be in order. If the female partner is over 30 or has a past history of irregular periods, previous pelvic infections, surgery, pregnancy losses, DES exposure, an infertility work-up should be started earlier. You can start with your regular Ob/Gyn or you may go to a clinic who specializes in infertility. To find a good infertility clinic, ask for a referral from your regular doctor, ask friends and neighbors (remember one in six people experience infertility in some sort), or call several offices listed in your yellow pages and interview them before you make an appointment.

Timing
A complete evaluation of the female generally takes three or four menstrual cycles and
generally follows a specific sequence. The male evaluation generally is much shorter.
One thing to keep in mind as you begin is that this process has to take priority, at least
short-term, in your daily life. Why? Because it follows a specific sequence, there are
specific days on which you must have intercourse. You may have to report to your Doctor's
office within a specific number of hours after intercourse. Lovemaking may lose some of its
spontaneity. And other areas of our lives take a lower priority. Some may find it difficult to take the time off work needed for testing. And further, for some, it may be a difficult thing to talk about or share with friends and relatives.

Stress
Because of all of these things, and the fact that infertility by its nature can be stressful for
some, it has the potential to put a dent in your relationships with friends, family, co-workers,
and spouses. If you are aware of this from the beginning, you may be able to take action
before you get stressed, so that you and your spouse can more easily deal with some of the
emotional hurdles together. Talking about what each of you is going through both emotionally and physically together from the beginning, can be strengthening, in itself. And planning for ways to relieve stress as you get further into the process will make the whole experience much easier.

Steps you can take
Start by planning to go together to as many Doctors appointments as you can manage. Use whatever resources you can find to educate yourself and your spouse, so you are both working from the same information. Decision-making is a lot easier if you both have the
same knowledge. Decide together, how best to engage family members if you choose to tell them. They will be curious and anxious (which may sometimes come across as intrusive), but try to remember they are only asking out of love for you and your spouse. One of the ways you may be able to help them is to give them a copy of "Coping with Infertility: How Family and Friends Can Help" which is RESOLVE Fact Sheet # 6.

What kinds of tests are done for the female infertility work-up?

Ovulation Detection
A doctor may request Basal Body Temperature (BBT) charts to determine when and if the patient is ovulating. Other testing may scheduled based on special times during her cycle.
Perhaps a better way to predict the time of ovulation is with an ovulation predictor kit that
tests with urine, similar to a pregnancy test. A plasma progesterone blood test can be taken
midway between ovulation and menstruation to document ovulation. A series of ultrasounds may be taken to monitor growth of follicles and ovarian response to Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH).

Evaluation of the Uterine Lining
An endometrial biopsy is used to evaluate how uterine tissue is building up and thickening
after ovulation. It is usually done after day 21 of the cycle. A tiny sample of the uterine lining is taken. It is uncomfortable because it is necessary to dilate the cervix, which causes moderate to strong cramping. Your doctor can recommend ways to alleviate discomfort.

Hormonal Evaluation
This evaluation is usually done through a series of blood tests to check levels of follicle
stimulating hormone (FSH) and luteinizing hormone (LH). Blood tests to check the level of
prolactin should also be done. Testosterone and androgen level (male hormone) will also be
checked if the patients has irregular cycles. Also a blood test for thyroid dysfunction should
be done by measuring levels of TSH and free T4 in the blood.

Fallopian Tube Evaluation
Hysterosalphingogram (HSG) is an x-ray used to determine if the fallopian tubes are open. A
dye is inserted through the dilated cervix, x-rays are taken as the dye flows up and out of the tubes. The procedure usually takes 20-30 minutes. Follow-up x-rays may be taken as well. This test has a reputation for being uncomfortable for some (and absolutely no problem for others) because of cramping due to the cervix being dilated and the dye flowing into the
cavity, much like menstrual cramps. Some women also experience shoulder pain afterward. This test can be therapeutic in that the dye flowing through the tubes my remove tiny mucus
plugs, thereby increasing the chances of pregnancy.

Sonohysterography (saline infusion sonography) uses saline to inflate the uterus to view the
uterine cavity with ultrasound. Either a CAT (computerized axial tonography) scan or MRI (Magnetic Resonance imaging) may be done if the hysterosalpingogram shows a pelvic mass such as a fibroid. These tests are not routinely done as part of a routine infertility evaluation. These tests are painless but expensive.

Endoscopy
"Endoscopy" allows a doctor to inspect the internal pelvic organs. There are several varieties
of endoscopy. They include:
Laparoscopy - the most frequently used technique to evaluate the outside of the uterus, the
tubes and the ovaries. Used to check for endometriosis. The woman is put under general
anesthesia and is in the hospital. A laparoscope is inserted through a small incision near the
bellybutton and/or near the groin area. Pain is minimal and many women return to full
activity within 1-2 days.
Culdoscopy - a slim telescope is inserted into the abdominal cavity via a small incision in
the vaginal wall. Local anesthetic is usually used.
Hysteroscopy - used to see the internal cavity of the uterus. Involves inserting a small
telescope-like device through the cervix into the uterus. General or local anesthetic is
required.

MALE - FEMALE INTERACTION EVALUATION
The main test used to check for sperm survival in the cervical mucus is the post-coital
test (after intercourse). It is used to evaluate how a man's sperm and a woman's mucus
interact. It is done during ovulation. After intercourse, you are instructed to go to your doctor's office, where they take a swab of cervical mucus to look for sperm activity and quality and viscosity of the mucus.

How much will it cost?
Average cost for an infertility work-up can be as high as $5000 including laparoscopy.

What if I can't seem to get pregnant even if my work-up seems to be OK---what are
my options?

For those who can't get pregnant on their own after getting a clean bill of health from the
infertility evaluation of both partners, there are several options. Here are just a few that may
be done separately in or some combination recommended by your physician.

DRUG TREATMENT
Medication to induce and regulate ovulation --- Clomiphene citrate (Clomid™).
(The American Society for Reproductive Medicine recommends a maximum treatment of six
cycles of clomiphene.) Generally in pill form.
Medication to produce a higher level of LH to trigger the release of the mature egg.
hCG (human chorionic gonadotropin) is a natural hormone secreted by the placenta. It is given by intramuscular injection usually in combination with clomiphene.
Medication to decrease the level of DHEAS (adrenal hormones)
that can inhibit the action of clomiphene --- Dexamethasone or prednisone will allow the
clomiphene to trigger ovulation.
Medication to induce ovulation in various fertility treatments.
hMG (human Menopausal Gonadotropin) Humegon™, Pergonal™ , or Repronex™. Available
as an injectable medication.
Medication to stimulate the growth and development of the follicles
FSH (follicle stimulating hormone) brand named Gonal F™, Fertinex™, and Follistim™ and
given by injection.
Medication to increase progesterone levels after ovulation.
Progesterone, a naturally occurring hormone is administered by intramuscular injection,
orally, or intravaginally.

PROCEDURES
Inseminations
Used for about 10% if couples with a male infertility problem such as low count or low
motility. There are several types of inseminations that include placing the partners sperm
near the cervix, near the uterus, near the fallopian tubes, etc. There are also donor inseminations where the sperm of the male partner is unable to be used due to genetic factors, motility factors, etc. A donor is chosen through a sperm bank or other resource, the donor is then tested for certain infections that can be transmitted via semen to the woman, such as HIV, syphilis, hepatitis, etc. The American Society for Reproductive Medicines (ASRM) recommends that physicians use only frozen semen and that the specimen be frozen and stored at least 180 days, then tested again for HIV. The woman is inseminated as close to ovulation as possible.

Where can I go to get more information?
There are several places on this website that you can use to help you take the next steps.
You can call our help line, leave a message and one of our volunteers will give you a call within 48 hours. There are several sources of written information too. Refer to the list of RESOLVE Fact Sheets at the foot of this page.

This is a very stressful time and many of us find talking with someone who has gone through
what we're experiencing is a great place to get information. Most of our members have
experienced infertility in some form and by joining RESOLVE, you can bring those people
within reach and take comfort from the large proportion of them who have found a way to
create the family they sought so fiercely and have resolved their infertility issues.

For further information, see the following Fact Sheets from RESOLVE National

#6
Family and Friends - how they can help
#10
Meditation and Infertility
#15
Stress of Infertility / How to Cope
#16
Selecting an Infertility Physician
#19
Bromocriptine (Parlodel): Prolactin problems
#20
Clomiphene Citrate
#21
DES: Its impact on Infertility
#23
Superovulatory Drugs
#23a
Overview of Drugs
#26
Endometriosis
#30
Infections: role in Infertility and Pregnancy Loss
#35
Luteal Phase Defects
#36
"Husband" [sic] Insemination
#43a
Donor Insemination: Medical and Emotional Aspects
#47
An Overview of the Infertility Work-up and the Tests Used.
#48
Ovulation Pinpointing
#49
Polycystic Ovarian Disease
#50
Premature ovarian failure (early menopause)
#52
Laparoscopy and Hysteroscopy
#54
Microsurgical & Laser techniques for Tubal Repair
#58
Uterine Factors in Infertility
#59
Unexplained infertility
#60
Ovarian Cyst



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