"I can't get pregnant. What happens now?" So many readers have asked me this question. If you've been trying to get pregnant for a year without success — or for six months if you're over 35 — it's time to get help. If you've had two or more consecutive miscarriages, it's also time to seek help. But how can you get that help? And what does "help" look like? What can you expect?
While not every couple's journey will look the same, here's a general guide of what to do and expect next.
Step 1: Make an Appointment with Your OB/GYN
Your first stop should be at your regular gynecologist. While not necessarily required at this moment, your partner may also want to see a urologist. You don't need to go straight to a fertility clinic, and in fact, most clinics prefer you have a referral from your primary gynecologist or physician.
You could discuss your concerns when you get your next pap smear, or you can make a separate appointment to discuss your fertility concerns. No matter what you decide, be sure to mention to the secretary that you need time to discuss an important issue with the doctor. This way, he can schedule enough time for the appointment.
While you're waiting for your appointment, gather important health information together with your partner and write down your questions. This will help your doctor help you. Information you should collect or write down includes:
- The dates of your last six periods: Even if they are regular, bring the dates. If you've been keeping a fertility calendar or body basal temperature charting, bring the last six months' information. It can be a huge help to your doctor.
- A list of all the regular medications you and your partner take: Some drugs can interfere with your fertility, and some antidepressants and even over-the-counter allergy drugs lead to trouble conceiving.
- A list of any infertility symptoms or risk factors you have.
- Any questions you have. If you write them down, you're more likely to ask them.
More on talking to your doctor:
- Talking to Your Doctor About Getting Pregnant
- When Should You Seek Help for Getting Pregnant?
- Is Your Period Normal?
- Quiz: Do I Have Infertility Symptoms?
- Take a Fertility Quiz
Step 2: Begin Basic Fertility Testing
The next step is some basic fertility testing. Typically, this includes blood work for the woman and a semen analysis for the man. (Make sure your partner has the semen analysis before you start treatment! Clomid can't help you if there are male factors involved.) Depending on your symptoms, testing may also include an HSG, vaginal ultrasound, or diagnostic laparoscopy. Your doctor will also likely preform a basic pelvic exam, pap smear, and some STD testing.
How much testing your doctor orders will depend on your symptoms and possibly also on your insurance coverage. (You can pay for fertility tests out of pocket, but many gynecologists prefer to refer you to a fertility clinic in those cases.)
More on testing:
- What to Expect During Fertility Testing
- Coping with Fertility Test Anxiety
- Performance Anxiety During Male Fertility Testing and Treatment
- Causes of Infertility
Step 3: (Maybe) Begin Basic Fertility Treatment
Depending on the results of your fertility tests, your gynecologist may recommend treatment, which may involve treating an underlying cause of infertility, or may include very basic fertility treatment, like with the drug clomid. If there are structural abnormalities or endometriosis, your doctor may suggest surgical treatment.
It's also possible that your doctor will refer you directly to a fertility specialist or reproductive surgeon, or you may choose not to try basic treatments with your gynecologist and instead proceed straight to a specialist. If male infertility is a factor, your partner may be referred to an andrologist, or a male fertility doctor.
If your gynecologist can't find a cause for the infertility — also known as unexplained infertility — she may suggest trying on your own for a little longer. (One study looked at 7,000 women with unexplained infertility, ages 28 to 36. Of those who did not pursue treatment, just over 40% eventually went on to conceive spontaneously.) Other options your doctor may offer include referral to a fertility specialist, or giving a fertility drug like clomid a try.
More on basic fertility treating:
Step 4: Graduate to a Fertility Clinic
If basic fertility treatment isn't successful, or if your test results suggest treatments that go beyond your gynecologist's purview, you may be referred to a fertility specialist. This usually means finding and choosing a fertility clinic.
In most of the United States, and in some countries, fertility treatment is not covered by insurance. Finding the best fertility clinic for you will require you to not only find a good practice, but also to find something affordable. Be sure when calling fertility clinics to be clear on how much the initial consultation costs, and discuss the fees ahead of time for any recommended tests or treatments.
More on finding a fertility clinic:
- Fertility Specialists: Who They Are and How They Can Help You
- Finding the Best Fertility Clinic for You
Step 5: More Fertility Tests
Often (but not always) your fertility clinic will want to do more testing or even rerun some tests you've already done. For example, your gynecologist may have checked your FSH levels, while the fertility clinic will decide to also do an antral follicle count. If you experienced a miscarriage, your gynecologist may have sent the tissue from the miscarriage for analysis, while the fertility clinic may suggest karyotyping.
Be sure to discuss with your fertility clinic the costs for all recommended tests, as they may not be covered by your insurance.
More on diagnosis and causes of infertility:
- Causes of Infertility
- Anovulation and Irregular Ovulation
- PCOS Symptoms and Treatment
- Endometriosis Symptoms and Treatment
- Pelvic Inflammatory Disease (PID)
- Getting Pregnant After 35
- Male Infertility Symptoms and Treatment
- Blocked Fallopian Tubes: Symptoms and Treatments
Step 6: Create a Plan of Action with Your Partner and Your Doctor
After you received the results of your fertility tests, you will likely meet with your doctor to discuss her recommended treatment plan. Be sure to ask about your chances for success, your doctor's experience with this kind of treatment, and the potential risks. Your doctor may also recommend lifestyle and diet changes, which may improve your chances for treatment success.
After speaking to the doctor, you'll likely speak with the clinic's financial advisor to discuss payment fees and options.
Your doctor should give you and your partner time to consider the proposed treatments (you don't need to decide on the spot if you want to go ahead with the proposed plan). You will also likely need time to figure out what you can afford. If you need to save up money to afford the treatment, be sure to discuss this with your doctor.
You may also decide to forgo treatment for a number of reasons. In this case, you may decide to pursue other family building options (like adoption), decide to continue to try without treatment, or decide to remain child-free.
More on considering treatment risks and cost:
- Fertility Drug Risks
- How Much Does IVF Cost?
- What Are Your Chances of Having Multiples?
- Twin Pregnancy Risks
- Ovarian Hyperstimulation Syndrome
Step 7: Begin Fertility Treatment Plans
Once you, your partner, and your doctor decide on a treatment plan, you'll begin whatever that treatment entails. The process for starting treatment may be relatively simple, or it may be complicated and involved.
Your treatment plan may involve separate stages. For example, if you have endometriosis, your doctor may perform surgery to remove endometrial deposits first. Then, after you have time to recover, you may start IVF or even try on your own for awhile.
Fertility treatment can be overwhelming. Be sure to ask your doctor and nurses questions as needed, and to get emotional support from friends, a support group, or a therapist.
More on fertility treatment:
- What Are Gonadotropins?
- What Is IUI?
- What Is Mini-IVF?
- IVF Procedures, Risks, Costs, and Success Rates
- IVF Treatment Step by Step
- Becoming Parents with Surrogacy
- Fertility Treatment Stress: How to Survive Your IVF, IUI, or Other Fertility Treatment Cycle
Step 8: Reevaluate Treatment Plans When Unsuccessful
Fertility treatment is less of a pinpoint solution and more of a try-this-then-that kind of process. You may conceive on your very first treatment cycle, but it's more likely you'll need a few cycles before you succeed. (Of course, every treatment has different per-cycle success rates, which you should speak to your doctor about.)
Keep in mind that one failed cycle isn't a sign that treatments will never work, and remember that even couples without fertility problems need three to six months to conceive.
A good doctor will help you understand when it's good to stick with the current treatment plan for a little longer, and when it's time to make big or small changes. There are also suggested limits on treatments. For example, you shouldn't take clomid for more than six cycles.
If your treatment plans are unsuccessful for an extended amount of time, or you are very unhappy with the treatment you're receiving, you may want to consider switching doctors.
More on success and failure:
- When the Pregnancy Test Is Negative
- Taking a Break from Treatment
- Clomid Success Rate
- IVF Success Rates
- IUI Success Rates
Step 9-A: When Successful, Plan for a Healthy Pregnancy
If treatments are successful, congratulations! Your fertility clinic will likely monitor you for the first several weeks of the pregnancy, and you may need to continue some hormonal treatments or injections.
Depending on the cause of your infertility, and whether you conceive multiples, you may need closer monitoring during your pregnancy. Also, like any couple who gets pregnant, you should try your best to have a healthy pregnancy by making healthier lifestyle choices.
More on pregnancy after infertility:
- Making a Pregnancy Announcement After Infertility
- What to Expect During Early Pregnancy After IVF
- I'm Pregnant! Now What?
- How to Have a Healthy Pregnancy After Infertility
- Positive Thoughts on Twins and Multiple Pregnancies
- Pregnancy Success Stories
- Due Date Calculator
Step 9-B: Deciding to Move On From Fertility Treatment
Sadly, not all infertile couples will conceive. You may end up here after many failed treatments, or you may find yourself at this step early on if you can't afford the treatments you need, or decide not to pursue them.
This can be a heartbreaking experience, but one that you can heal from with time and support. Be sure to seek counseling to help you and your partner grieve. Once you have regained your emotional bearings, you may want to consider alternative family building options, like adoption or foster care. Or you may decide to live child-free.
More on moving on:
- Reader Stories: Deciding to Stop Treatment
- Reasons to See a Counselor
- Before You Decide to Adopt
- RESOLVE: Deciding to Live Childfree
- 5 Ways to Be an Awesome Auntie
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Danielle L. Herbert, Jayne C. Lucke, Annette J. Dobson. "Birth outcomes after spontaneous or assisted conception among infertile Australian women aged 28 to 36 years: a prospective, population-based study." Fertility and Sterility. March 2012 (Vol. 97, Issue 3, Pages 630-638, DOI: 10.1016/j.fertnstert.2011.12.033)