Ok so I thought I could cover all the details of our fertility journey in two parts, but to be honest it is quite draining to sit down and relive all we went through in the past year. I also hope these posts will be somewhat informational for folks who aren’t quite sure where to start, and so wanted to share some helpful info we learned in the process. This post is continued from Pt. 1, which detailed our time trying to conceive naturally.

The journey continues – the male assessment

After the chemical pregnancy in May 2020, we decided to find a new OB/GYN and discuss what our options would be. He confirmed the pregnancy was not viable, and asked if we had ever gotten any fertility testing done (we had not). He directed Burjis to get a semen analysis done as the immediate next step before we even began discussing any testing on me. Fertility testing on females can be much more invasive than fertility testing on males, which is quite literally just giving a sample in a cup. And now for one of the biggest assurances/false hope moments that almost every infertile couple will hear at least once on their journey – he told us that the good news is we got pregnant at all, which means that it is possible and probable that it will happen again (but when? naturally or through assisted reproduction? will the next be viable or also go away?).

I’ve mentioned before about wasting valuable time during the TTC journey, and well, this next bit was it for us. Despite being ordered to do the semen analysis, we didn’t actually get it done until October 2020. A little thing called the iPhone was coming out, and we both were super wrapped up in making that magic happen. And besides – my cyst was removed and I was on the mend, and we had been given the assurance that the chemical pregnancy meant it could happen again. So we thought it may just happen on its own anyway.

The doctor scheduled a video call to discuss the results of the test. A semen analysis measures three parameters – sperm concentration, morphology (shape) and motility. The numbers came back low on all three counts. Not tragically low that we couldn’t get pregnant naturally, but low enough that he recommended IVF (in vitro fertilization) right away (vs. trying naturally for an indeterminate amount of time).* He recommended a reproductive endocrinologist (RE, aka fertility specialist) that he often works with, and assured us that the cost was high, but with my age and health we would probably be “one and done” – one egg retrieval to cover enough embryos for both future children.

One of the biggest travesties in the US is that fertility treatments are extremely woman-centric. However, there ARE things men can do to improve the chances of success, even naturally, which are never talked about and were never even brought up to us by our OB/GYN or our RE. The best thing to do is to go to see a male urologist who specializes in this sort of thing. They have additional assessments that can be done and if you are patient, can help to improve semen analysis results and sort out any physical blockages (if they exist).

*Note: Many couples will try IUI (intrauterine insemination, aka “turkey baster method”) first as it is cheaper and less aggressive on the body, albeit with lower success rates, but we skipped this step due to our semen analysis results.

The female assessment

We booked our appointment with the RE, which was almost two months out since these docs are in high demand and tried to learn as much as we could about what was to come. There’s a lot of crappy info on the interweb, but luckily our company provided access to a website called fertilityIQ.com in which world renowned specialists give video lessons on every possible fertility topic you could imagine. We went into our appointment in December 2020 feeling educated and prepared to ask the tough questions.

For women, the obvious first step of the fertility workup is to look at your menstruation cycle history. If it’s not regular, you are likely not ovulating every month. This is also where they start to harp on your age…being 30 at the time I was a prime candidate for successful outcomes, but after 35 women experience a pretty steep decline in fertility which results in reduced outcomes. Everyone talks about “the biological clock” in passing (and usually offensively if you are not married yet), but the statistics are real on this, which is something I wish more people were educated about earlier on. For the younger crowd in their 20s – egg freezing is a great way to harvest your eggs when they are at their highest quantity and best quality, to “buy yourself more time”.

The next step in the workup is measuring your AMH (anti-mullerian hormone – done via blood test) and AFC (antral follicle count – done via vaginal ultrasound). When coupled together, these two tests are the best indicator of your ovarian reserve, how well your ovaries will respond to stimulation, and what your chances of success in either IUI or IVF will be. We also did a saline ultrasound called SIS (saline infusion sonohysterogram), which is used to detect any abnormalities inside the uterus. Due to my surgery in Singapore, we also had great laparoscopic images of the exterior of my uterus. Since we weren’t doing IUI we did skip one test, HSG or hysterosalpingogram, which entails injecting die into the womb to flow into the tubes and ensure they are not blocked.

We passed all these tests with flying colors, which gave us and the doctor confidence that we would have pretty successful outcomes. We would soon realize this was one of the many lies told in the IVF world. You can have the best odds, pay all the money, do all the things right, and still end up with no baby.

A note on choosing an RE

If like us, you find yourself needing to explore IUI or IVF, there are some factors that should be considered in choosing an RE and fertility clinic. The first one of course is if they are in-network for your insurance (and while you are at it, check if your insurance covers fertility treatments at all, and how much is covered). A lot of folks will chase the top doctors in the US, waiting six months or even a year for the first consultation, and often moving to or traveling to other cities for weeks at a time to do treatments. Others will go abroad to do treatments, which is often cheaper than the US and may give you the added benefit of a doctor that specializes in fertility for your specific ethnicity.

For us, we knew that we have very hectic schedules, which was the top factor. We wanted a doctor that was recommended to us and decided we needed a doctor pretty close by (within 30 minute drive) since during peak treatment you could be going into the office 3-4x a week. Major fertility clinics often consist of a group of doctors, and you may not see the same person every time, which we had read was one of the great annoyances of treatment (great for getting quick appointments, bad for getting personal care). For this reason, we made sure to choose a private RE where he was the only doctor at his practice, to ensure we saw the same person every time. We have not once regretted this decision – he always remembered every detail of our case, as did the nurses and front reception team.

One other callout to consider is that the fertility lab that the clinic uses MUST be top notch. If you only have three embryos frozen, you don’t want to lose one in the de-thawing process because the lab is not skilled enough. There are a number of parameters here that I won’t go into detail on but should be looked at and can be found on the SART website for any clinic:

• fertilization rate
• blastocyst conversion rate
• PGS biopsy rate
• blastocyst cryosurvival rate
• implantation rate

What to expect in Pt. 3

Pt. 3 of our journey will go into our experience with the actual IVF process, including the egg retrieval, genetic testing of embryos, unfortunately multiple embryo transfers, and all of the in between. I also plan to share my thoughts on what to expect after you are finally successful and how we felt through it all.

Takeaways

• Get a fertility workup as soon as you can, even just to rule out any issues when TTC
  • Male: semen analysis
  • Female:
    • Menstruation cycle history and your age
    • AMH via blood test
    • AFC via vaginal ultrasound
    • SIS via saline injection and vaginal ultrasound
    • HSG via die injection and X-ray
• Book an appointment with a urologist (male factor infertility) or a RE (male or female factor, or unexplained infertility)
• Choose an RE based on your specific lifestyle factors and the kind of care you value, as well as their lab success rates
• Do all the research you can! Chat with people who have gone or are going through it. Some resources I found helpful:
  • fertilityIQ.com
  • “It Starts With The Egg”, by Rebecca Fett
  • SART data on fertility clinics
  • Instagram infertility accounts like @fertility.rescripted, @fertilityrally, @cofertility, @drlorashahine, @lucky.sekhon and many others