By Anthony Dobson, M.D., Ph.D.

Between 10 and 15 percent of all reproductive-age couples in the United States are subfertile, which means the chance you may have trouble starting a family is fairly high. It is therefore useful to discuss how you and your partner will react to the possibility of diminished fertility before trying to conceive. Getting the right information and treatment can provide hope and peace of mind if you end up having difficulty conceiving.

Before starting a family, it is a good idea to have a consultation with your gynecologist or primary care physician. He or she will make sure that your Pap is up to date, your blood count is okay and you are aware of your immunity to diseases such as chicken pox and rubella, and that you are vaccinated for the flu. Your doctor will also ensure that you are taking prenatal vitamins, leading a healthy lifestyle with proper nutrition and exercise, and avoiding tobacco, alcohol and illegal drugs.

Your doctor will also review your medical history to make sure it is safe for you to carry a pregnancy, and ensure that you are not on medications or have medical conditions that could pose risks to the pregnancy or your unborn child. He or she will also help to identify medical conditions that could make it difficult for you to conceive, such as a history of pelvic inflammatory disease or endometriosis.

Finally, your gynecologist or primary care doctor can provide advice on selecting an ovulation predictor kit. These kits can be purchased without a prescription at pharmacies and can help women predict ovulation and time intercourse appropriately. Your doctor can also order some basic tests if he or she suspects that subfertility may be an issue for you and your partner. For men, these tests include a sperm count. For women, doctors test the reproductive hormones and check to make sure the fallopian tubes are open. (A closed fallopian tube will prevent an egg from reaching the womb.) Finally, your doctor can refer you to a fertility specialist if needed.

• How do I know when it is time to consult a specialist in fertility and reproductive endocrinology?
• Since fertility treatments can be expensive, is there one method that has the best success rate?
• My partner and I wanted to start a family, but with the recession, we've decided to wait. How long is it safe to do so?

How do I know when it is time to consult a specialist in fertility and reproductive endocrinology?

Referral to a fertility specialist is warranted if you:

• Have been trying to conceive for more than a year without success and are less than 35 years of age;
  
• Have been trying for six months or less and are 35 to 37 years of age;
  
• Are 38 years of age and older; or
  
• Have medical or reproductive issues that compromise your fertility, such as irregular menstrual cycles, blocked fallopian tubes, diminished ovarian reserve or male factor infertility.

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Since fertility treatments can be expensive, is there one method that has the best success rate?

The types of medical treatments necessary to conceive really are as individual as the patients who need them. Depending on test results and your age and health factors, your reproductive medicine specialist may recommend ovulation induction with oral or injection medications, artificial insemination or in-vitro fertilization (IVF). For some women, the recommended treatment may involve surgery to fix a problem such as fibroids or endometriosis.

In California, state law requires insurers to offer group plans that include coverage for infertility diagnosis and treatment. However, the law does not require employers to purchase these plans for their employees and the law specifically exempts IVF procedures. As a result, many patients must pay for infertility treatments themselves.

If this is your situation, don't be embarrassed about discussing your financial concerns with your doctor. He or she can give you the most accurate picture possible of your chance of conceiving using various fertility treatments. Once you know the various treatment strategies and your individual fertility potential, you will be better prepared to decide which approach to starting a family is right for you.
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My partner and I wanted to start a family, but with the recession, we've decided to wait. How long is it safe to do so?

Because every woman is an individual, there is no set date when it will become hard to conceive. However, in general, it becomes more difficult to conceive around the ages of 35 to 37 years.

We live at a time when advances in reproductive medicine can help some women to conceive at the end of their reproductive potential (early 40s, for most women). However, the majority of women who try to conceive this late in life either fail to realize their dream of a child, or choose to conceive using eggs donated by another woman. The use of donor eggs allows couples to expand the window of opportunity and start a family later in life.

The best advice I can give is to understand and be comfortable with your options. Get evaluated by a physician in order to have an idea of your fertility potential. And if you are in a relationship in which you will eventually want to start a family, don't delay too long. Waiting until you are at the end of your window of opportunity for starting a family could leave you with without good options.

Anthony Dobson, M.D., Ph.D., specializes in reproductive endocrinology (fertility) medicine and treats patients at the Palo Alto Medical Foundation's Dublin Center and Fremont Center. His professional interests include working with women with ovarian causes of infertility, such as diminished ovarian reserve and polycystic ovarian syndrome, and researching the role of the human egg in infertility. Dr. Dobson is also the father of four sons.

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