Choosing a Doctor: The Ob/Gyn vs. RE Debate

After you have finally decided to conceive on your own, the difficult aspect about picking a doctor to help you do it is that you don't usually know whether you have fertility issues. Unlike married couples, who go to fertility specialists after a long period of unprotected sex, the single woman is generally trying to conceive without having tried to get pregnant before.

Some women are able to safely make the assumption that everything is working well. Many women into their early 40s are able to conceive without medical intervention. But that assumption might not hold, especially for women older than 35, as we've been discussing.

So it becomes a gamble: Spend money upfront for a specialist and fertility tests, or try it for a few cycles and see what happens at the lower cost?

Ticking time...purchasing sperm...grief about not conceiving "naturally"...deciding whether to use the friendly neighborhood gynecologist or proceed immediately to a specialist. It all places pressure on those of us who simply want to be a mom.

Fellow Choice Moms will differ significantly in their advice to women just beginning this journey. Many who felt they waited too long to conceive the first time - or those who had fertility challenges to confront - urge women to visit a specialist right away, especially if they eventually want more than one child. Others who conceived easily are optimistic that trial-and-error can be worthwhile. Doctors, too, will vary in their philosophies.

Q: Should I use my ob/gyn or go to a reproductive endocrinologist?

There are reasons for both. Understanding the pros and cons of each is key.

Obstetricians/gynecologists (ob/gyns) are sometimes more likely to be covered by health care plans, making them the preferred first choice by women who have no obvious fertility challenges. Their overall costs may be lower, too. Often they are someone we've been seeing for Pap smears and annual exams, and that existing relationship can make the process less overwhelming.

One doctor pointed out, however, that in his city, the ob/gyns in outlying areas seem almost more well-rounded in addressing fertility issues. He believed that the city ob/gyns who tended to be connected to HMO programs were often not as effective in helping women pinpoint issues early enough.

Reproductive endocrinologists (REs) in the U.S. must complete a fellowship, tend to have more experience with inseminations, and have the equipment to provide more fertility-related follow-up. Many are available seven days per week for inseminations, which is important.

A subset of U.S. REs are board-certified, which means they passed a demanding post-fellowship test that a typical RE did not. There are fewer than 1,000 board-certified REs in the U.S. (Long-time REs will typically not be board certified because it was not an option years ago; new physicians also may not be board certified because the process requires several years.)

Here's a sample of what our panel of doctors (most of them REs) have said about this debate.

Licciardi: Why do women wait to see the fertility doctor? It's hard to make the initial call because some women are afraid. Afraid that they will be told there is an insurmountable problem. They are also afraid the doctor will make them feel guilty or stupid for not getting there sooner. They may also worry that the cost of treatment may be just too much. If you get to your doctor, whenever it is, you are smarter than the other women who are still not getting help. If your doctor is a good one, you will be made to feel comfortable and you will not be blamed for your lack of fertility. Yes, some treatments are expensive (IVFs are usually more than $6,000), but you don't yet know what you really need. Just get checked. The tests are basic and can be done quickly.

Singleton, an RE, tells her patients that it's fine to start with their ob/gyn as long as he or she is comfortable handling fertility issues. "Many ob/gyns are very cognizant of the tests that need to be performed to evaluate fertility. Those who are not will generally refer you to a reproductive endocrinologist. Ask your ob/gyn what they are comfortable handling."

Ashby cautions against starting with your ob/gyn if there is any chance you have fertility issues. She and others describe patients who have wasted many months and thousands of dollars sticking with an ob/gyn too long. "For the younger patient in her 20s with no obvious fertility issues, who has an ob/gyn who is comfortable with it, that's fine. But the 41-year-old with high follicle stimulating hormone (FSH) should consult right away with an RE."

Wisot: What you don't want is an ob/gyn who gives you a six-month prescription for Clomid and says 'go out and get pregnant.' Initially, your physician should take a full medical history, do a physical exam and hopefully an ultrasound to see the anatomy of your pelvis. He or she should then offer you some basic finding regarding what your fertility options are and should then sit down and talk with you about those options.

Q: Once you've decided between ob/gyn and RE, how do you pick one?

There generally are two categories of doctors: 1) those with good "bedside manner" who can walk a patient through the process, and 2) those who might not be warm and fuzzy but know some of the best ways to get people pregnant. You'll find doctors who can do both. But many times a woman needs to choose which is most important to her at that stage of her life.

Wisot: There are two key issues in evaluating and selecting a physician to work with you. First, choose a doctor who has the right skills and a strong track record. Ask a friend in the medical community. Even the SART.org success rate cannot tell you everything, partly because there are differences in patient populations (one center may start IVF when patients have not had all the conservative measures, whereas another might recommend IVF only after all conservative measures have been exhausted). Yet others might reject certain patients to boost their rates. A few years ago I recommended a friend to a center with excellent success rates in another part of the country. I realized after they rejected her as a patient, because her FSH was slightly above 10, that a great part of their success was selecting only high prognosis patients.

When you look at the SART report, perhaps one of the most important columns is the average number of embryos transferred. A lower number is better and that shows that the center has confidence in their embryo lab. Ask how long the team has worked together, both doctors and embryologists; a long history is good. Check the qualifications of the program's director and the long-term reputation of the center in the medical community.

Second, call the physician's front desk and directly ask if the physician is supportive of single women having babies.

Wahl: As far as clinic choice, don't be swayed by marketing and slick advertising. Visit the offices, meet the staff and doctor(s) then go with your gut.

Q: What should I know about schedules? Is it ok to have a nurse do my IUI?

Kim: Most reproductive endocrinology practices cannot guarantee that a patient's own physician will be available for all her procedures. But there are doctors on call so that even if your doctor is not on call, there should be a covering physician. I would look for a practice that performs IUIs seven days a week. Some practices will not perform IUIs on weekends. This is important to find out, because you may ovulate on a weekend. The egg only lives for approximately one day after ovulation. If the ovulation test is positive on Friday, waiting until Monday will be too late.

In general, it is okay for nurses to do IUIs. The goal is to place the sperm through the cervix into the uterine cavity. In the some cases, women have tricky cavities to enter and physicians may have more experience entering the uterine cavity, since they do other procedures that also involve entering the uterine cavity.

Licciardi: An experienced nurse is an expert at IUI.