Fertility FILE

Could I be pregnant?

One of the most common questions women ask themselves when they are trying to conceive is "Could I be pregnant?" It's very normal and common to become a little obsessed with this without your even realizing it. This question usually pops into your mind during the time between when you have ovulated and the time when you expect your next period to come (or hopefully, NOT to come). For those of you undergoing fertility treatment, it is especially strong and starts to occur after your insemination or your embryo transfer.

Bear in mind that during the times in your life when you were NOT yet trying to conceive, you have had different feelings on different days. Some days, you might be more tired than others. Some days, you might get a headache or momentarily feel a rumbling in your stomach. You might have soreness in your breasts on occasion. All these things go unnoticed. However, when you are focused on conceiving, it is normal for you to pay meticulous attention to each little change. Your mind will start to play tricks on you and you will associate every little change with the possiblity of pregnancy. "Does the fact that my back aches mean that I'm feeling implantation?" "Does the increase in my appetite despite my feeling a little bloated mean I'm pregnant?" "I can't describe it but something just feels a little different these past few days, maybe it means I'm pregnant?"

When my patients undergo fertility treatment and come in on the big day when they get their blood drawn to see if they're pregnant or not, I often get to inquire how they're feeling. They are a little nervous that day, of course. Sometimes, however, they will share some additional information about some new thing they're feeling, such as being very tired or very hungry or a little nauseous or urinating a lot or noticing breast swelling or feeling like their face is glowing or having strange cramping. They often volunteer a guess as to whether their test will come back positive or not. I always tell them that we'll have their result back in an hour once we run their blood through our machine and only then can we know for sure.

From years of this, I am convinced that very few women are truly able to predict with 100% accuracy if they're pregnant or not. There was this one patient who has three babies with us in her life. She required a total of seven insemination treatments to have her three successes. The first two cycles were unsuccessful, while the third resulted in her first son. A year later, the fourth cycle resulted in her second son. A few years later, she came back and failed cycles #5 and #6 before getting pregnant on cycle #7 with her third child, a daughter. Each time, when getting her blood drawn she would either look dejected and say, "I know I'm not pregnant" OR she would beam with joy and say "I know it worked this time". Each of the seven times, she was correct! My staff would marvel at her uncanny ability and we joked that we shouldn't even bother doing her tests.

However, there have been other times when patients came in for their blood test with shining optimism that they knew they were pregnant, but when the results came off the machine, it turned out they weren't. More commonly, there are patients who come in and sadly share that they have already had a little bleeding and they feel that their period is coming, so why even bother testing. Many many times, the tests are positive and the patients go on to have a healthy baby! My point is that pregnancy tests are the best way to accurately know if someone is pregnant or not. All the little symptoms you notice may or may not mean something.

By the way, when I questioned that one patient what symptoms enabled her to predict so accurately all the times she was pregnant, she burst out laughing and confessed, "Doctor, I cheated! I always do a home pregnancy test in the morning before I come in for my blood test."

Letting Your Fertility Go Up in Smoke

When you spend money to do infertility treatment, you trade your hard-earned resources to get a boost towards getting pregnant sooner. How would you feel about spending money to LOWER your chances? This is exactly what happens when you or your partner smokes.

I usually start off by telling my smoker patients that cigarette smoke, whether actively inhaled or even breathed passively, can harm the ability to conceive. Consider the fact that the tars, ammonia, hydrogen cyanide, fomaldehyde and carbon monoxide found in smoke are toxins that can cause short-term damage to eggs and sperm as well as accelerate the aging process so as to cause long-term damage in females. Toxins are concentrated in the cervical mucus of the female, rendering a hazardous barrier to the sperm as they try and swim past.

Smoking may not just hurt your chance to conceive naturally. It can also lower your odds of success with IUI or IVF, requiring more cycles and more time to achieve the pregnancy you want. Smoking during pregnancy can cause an increase in obstetric complications and even affect the child after birth, including a higher risk of sudden infant death syndrome

BUT, as much as I look negatively on the effects of smoking, I am not in favor of demanding government bans on smoking. I believe in the principle of individual freedom, which includes the rights of smokers to harm their own health as long as the rights of non-smokers are not infringed upon. These include the right not to be exposed to second-hand smoke and the right not to be financially burdened to care for the excess health problems brought on by smoking. In any case, I continue to do my part to offer education to others to help them make their own decisions.

Please remember that the decisions that you make will affect how long it takes before you have a healthy baby.

How Old are my Ovaries?

Diego and Susy Golberg are a couple in Argentina who began a yearly ritual in 1976. Every June 17th, they took portraits of themselves and their eventual family of three sons, producing a vivid photographic reminder of the reality of aging.

Age plays a very important role in reproduction, especially biological age. Chronological age is determined by what it says on your driver's license. Biological age is different, and arguably more significant. Do you know any athletic women in their late-30's who have the "body of a 20-year-old"? Have you ever seen a 35-year-old alcoholic smoker who looks like he's 50? When it comes to a woman's reproductive capability, it's important to consider her ovarian age in addition to just her chronological age.

Near one extreme, you can have a 43-year-old woman with enough quality eggs remaining that she conceives twins on her own. Or you can have a 19-year-old girl who goes into premature menopause. But for most women, their ovarian age stays fairly faithful to their chronological age with a gradual decline in fertility throughout their life until they reach their 30's at which point the decline accelerates. Then by age 40, the decline becomes very sharp.

It's not possible to tell someone's ovarian age with a single test. You can't tell based solely on how healthy and young she looks. There are a variety of clues about a woman's biological age provided by various methods, some of which are more important than others.

CHRONOLOGICAL AGE: Not surprisingly, the biggest predictor of ovarian function is someone's true chronological age. There is no getting around the fact that if you are 46, you still have poor reproductive outlook, even if you are in the biologically youngest 1% of all the 46-year-olds in the world.

FSH LEVELS: There is a blood test that is typically done on day 3 of your cycle. A high FSH (over 10 IU/l) is suggestive of advanced reproductive aging. A value over 15 IU/L is significantly worse. Consistent values over 25 IU/L indicate that you are likely menopausal. A bad test result is bad news. Unfortunately a GOOD FSH result (under ~9 IU/L) is not necessarily good news. If you are 46 and have a FSH of 5 IU/L, that still does not mean you have the fertility of a 26-year-old. Another warning about interpreting FSH levels involves the possibility that FSH results can look much better than they actually are if your estradiol levels are high on the day of the FSH test. This is why reproductive endocrinologists always know to test an estradiol level at the same time as the FSH level. For example, a day 3 FSH level of 6 IU/L with an estradiol of 53 pg/ml is more favorable than a FSH level of 5 IU/L and an estradiol level of 119 pg/ml. The final point to make about FSH levels is that they are a MARKER of ovarian aging and they are not the CAUSE of ovarian aging. Many patients when told they have a high FSH level often ask what they can do to make the FSH level lower. Making it look lower doesn't change the message that the ovaries are old. This is similar to having a red "engine warning" light come on in your car and inquiring what you can do to cut the wire so the light goes out. It still doesn't change the fact that there is a problem with the engine.

OVARIAN VOLUME: In general, younger women have large plump ovaries, because there are more stored eggs left in them. Menopausal women have tiny ovaries that are sometimes so small as to not be visible on ultrasound.

ANTRAL FOLLICLE COUNT: Every cycle, before a woman begins developing her eggs, the number of tiny pre-ovulatory follicles is higher in women with young responsive ovaries as compared to in women with older resistant ovaries.

RESPONSE TO CLOMIPHENE CHALLENGE TESTING: An old way of testing ovarian reserve or ovarian age involves giving Clomid pills and testing FSH levels before and after. Elevated FSH levels pre or post Clomid are signs of ovarian aging.

INHIBIN B: In contrast to FSH testing, higher levels of inhibin B are good and lower levels are bad.

ANTI-MULLERIAN HORMONE: The usage of this hormone to predict ovarian response is a fairly new concept. Again, as with inhibin, higher levels are good. Lower levels are bad.

ACTUAL PERFORMANCE: All of the previous mentioned tests and methods are just predictors of how the ovary MIGHT function. None of them beat actual performance in terms of importance. Even if your age, FSH level and all other testing predict bad news, if you undergo infertility treatment, make a surprisingly large number of good eggs and get pregnant, then you won't really care what the testing predicted. One patient who comes to mind is a woman with small ovaries and a documented day #3 FSH level of 22 IU/L, who came to me for fertility treatment. After I informed her that her chances of success would be low, she polite acknowledged my warnings and then wound up defying the odds, getting pregnant and delivering a perfectly healthy girl at age 41 with her own eggs!

Before asking your doctor to order this whole slew of tests, bear in mind the principle that tests are only of value if they can help us make better decision choices. Knowing that you might have a better or worse outcome may not necessarily change what you decide to do. For example, if you are applying to law school and your LSAT scores tell you that you have a 80% chance of being accepted, but your GPA suggests you have a 55% chance of being accepted, and you are going to go through with the application process anyway despite of which is more accurate, then knowing this additional information doesn't really change your actions. Think about it. I will share more on this very important concept of decision-centered thinking in future posts.

Photos by Bobby Neel Adams.

Everything is normal. So why am I not getting pregnant!?

Kristen is an ambitious 33-year-old half-Asian half-European graduate student. After seven happy years of marriage with regular sex twice weekly and no birth control, she and her husband have only one pregnancy together, an early miscarriage six years ago, which resulted in a D&C.  Since then, there have been no more pregnancies and despite their busy career schedules this year, they really want a baby now. So they decided to take action and seek help from a Reproductive Endocrinologist. She was referred to see me by the recommendation of her sister, who coincidentally, is a RE herself on the East Coast.

Previously, Kristen had been working closely with her OB/Gyn who started some basic testing. Her husband’s sperm was normal (84 million/cc, 90% motility), even though he was still smoking a half pack per day and she reported that some basic hormonal testing done on herself came back all normal, although I don’t have information regarding what exactly was tested. She reported that her periods were regular, but they were a little prolonged in that they came every 35 days or so. Her frustration stemmed from the fact that nothing was wrong with her and her husband. It was compounded by the fact that she had gotten pregnant in the past without a problem. In addition, she had spent several hundreds of dollars already on fertility monitors and test strips. I told her that we had several options at this point. We could do an HSG (hysterosalpingogram), which is an X-Ray test to see if her tubes are open or blocked. We could also give her Clomid to see if it helps the quantity and quality of her ovulation. Or she could keep trying to get pregnant on her own. I advised against choosing this last option. She and her husband discussed it and decided not to be too aggressive yet, so they opted for three cycles of Clomid, without ultrasound monitoring. She did self monitoring with temperature and urine tests and had a positive ovulation test each month.  After three months of Clomid, she was still not pregnant, and as we agreed beforehand, we now proceeded to do the HSG.

The HSG revealed two things. Her tubes were clear. Her uterus was normal. This is an example of the classic diagnosis of UNEXPLAINED INFERTILITY. The sperm, ovulation, tubes and uterus show no major problems, yet pregnancy is still not happening. This is the point where many patients are told by their doctors “There is nothing wrong. Keep trying. Goodbye.”, leaving the patient completely frustrated. The proper approach to unexplained infertility is to offer options. Yes, one choice is to keep trying naturally, but for a patient who has already been doing that for seven years, that’s not the best option. Another choice is to help the couple “cheat” to get the odds in their favor. I usually explain it like this.
- A normally fertile couple has a 25% chance of getting pregnant each month.
- A couple with unexplained infertility has about a 2% chance of getting pregnant each month on their own.
- By doing simple intrauterine insemination (IUI) in conjunction with fertility medications, we might be able to bring that up from 2% to 10-20%, depending on how many mature eggs are grown.
- By doing IVF, we can in a single month bring the odds from 2% to about a 40-60% chance of pregnancy.

So rather than patiently accepting a 2% chance each month, Kristen and her husband opted to do a cycle of IUI treatment. She started by taking five days of Clomid followed by two days of injectable gonadotropins. When she returned for her ultrasound, she had two mature follicles growing on her left ovary. She took a shot of hCG to trigger ovulation and insemination was performed two days later. A blood test twelve days later showed an hCG value of 60 IU/L, meaning she was pregnant! She is currently in her second trimester and is due to deliver early next year.

KEY POINTS TO CONSIDER:
- Unexplained infertility is a common diagnosis for infertile couples. It basically means that there is nothing wrong (that we could find).
- There are many good options for dealing with unexplained infertility, including fertility medications, IUI and IVF.
- Had she chosen not to do any treatment, there was still better than a 40% chance that she would be pregnant on her own within the next 5 years.
- It is OK to be proactive and take measures to improve your odds of pregnancy, even when there is nothing wrong found on testing.

By the way, my farewell words to her and her husband when they joyfully graduated from our office at 12 weeks of pregnancy with a single healthy-looking baby was this advice. After the baby is born, she should  breast-feed as long as she wanted. THEN, they could try on their own again for six months to a year. If they still weren’t pregnant by then, they could always return for another treatment cycle to get their second baby.

Charting Basal Body Temperature: The Good and the Bad

Last week was an especially busy one for me with ten new infertility patients seen. I love how all their stories are uniquely different. One patient in particular had been infertile for almost three years and brought a neat stack of color-coded temperature charts to show me! This follows a trend I've been noticing lately with more and more patients turning to the internet for fertility information, often going to special websites that provide tools for charting ones cycles, either for free or for a small fee. Overall, there is more benefit than harm to doing this if used correctly, but in this patient's case, it was harmful in that she wound up doing it TOO long before getting professional help, thereby wasting several of her potentially fertile years.

The first thing that needs clarification is this. How exactly does ones body temperature have anything to do with fertility? It all has to do with a hormone we discussed previously known as PROGESTERONE. When a egg is ready to be released, the cells surrounding the egg produce progesterone. Over 95% of the time, this is accompanied by actual physical release of the egg. There are some unusual instances when there is a rise in progesterone, but no actual ovulation, but this is rare.

Elevated progesterone levels lead to elevated temperature. However, other factors also affect body temperature. Some of these include activity level and environmental temperature. This is why, in an attempt to standardize conditions, basal body temperatures are intentionally measured first thing in the morning after complete rest (sleep). Normal body temperature is 98.6 degrees Fahrenheit (37 degrees Celsius). Basal body temperature, on the other hand, is a little cooler, about 98F or 36.6C. This makes sense because when at rest, you don't burn as many calories. The levels of progesterone that are present after ovulation will make ones BBT rise about half a degree F. So a normal BBT chart should consist of a range of lower temperatures before ovulation and a range of higher temperatures after ovulation.

Now, here are what I consider to be the PROS and CONS of charting ones BASAL BODY TEMPERATURE.

GOOD: It can bring some peace of mind, giving you "something active to do" while you are trying on your own. Remember that for most couples who want to have a baby, unless they already have some suspicion of an existing infertility factor, their best strategy is try on their own just having sex every 1-3 days. This should continue for six months to a year to give things an adequate chance. However, some of us have good proactive tendencies and like the feeling of taking action. Charting ones temperature is a good safe way of channeling these energies.

GOOD: It can alert you early if you are not ovulating, so that you will know to get help sooner. If your temperatures don't rise in the second half of the cycle, this is a tip-off that you are likely not ovulating. This early warning can help you know to get help right away rather than wait a year. One possible reason for not ovulating is if you suffer from PCOS.

GOOD: It can play a part in a nurturing supportive environment, which lowers stress and therefore helps conception. Many of these websites allow women to copy or even email their charts and share them with friends. Again, this fosters an atmosphere of supportive community which has many positive effects.

BAD: Temperature charting can NOT be used to signal the best time to have intercourse. By the time you see the temperature rises, it is already too late. Therefore charting temperatures more tells you when your fertile period has already passed and gone rather than telling you when it is about to come.

BAD: Temperature charting does NOT help increase the chances of conceiving for couples who already have sex regularly. As I mentioned in an earlier post, the best way to get pregnant naturally is to have sex every 1-3 days. It's only when sex is very scarce that you can benefit from meticulous timing.

BAD: For some people, obsession with temperature charting leads to INCREASED stress which in itself, could lower their chances of conceiving. I've encountered many patients for whom this was the case. They actually reported starting to feel worse (much more tense) from the time they first began charting.

BAD: For some people, obsession with temperature charting leads to DECREASED frequency of sex, thereby lowering their chances of conceiving. I've seen patients who were inaccurately predicting their peak fertility time. It was actually later than they thought. But since they thought it had already passed, they stopped having sex that month, ironically missing the most favorable times.

Overall, charting ones BBT can be done in the context of a grander strategy that takes care to have a backup plan for seeking professional help when too much time has passed with no pregnancy still.

The Mechanics of Making a Baby

The universal way to create things is to start with the right components and then to assemble them properly. When cooking, the quality of the finished dish depends on the ingredients you use as well as how you put them together. Building a car involves using the right parts and then performing proper assembly.

The same applies to the making of a baby. In a previous post, we learned about the components that are used in making a baby, specifically the maternal DNA packaged into an egg and the paternal DNA packaged into a sperm. The joining together of sperm and egg take place in the woman's body, usually in the Fallopian tubes. If the sperm and egg are both perfect enough to create a perfect embryo and if that embryo properly migrates into the a hospitable uterus, then you will have a perfect baby.

So in order to make a baby, you basically need sperm and egg to come together and for that sperm and that egg to be perfect enough to create a surviving embryo. This leads into the generation of many ideas on how we can improve the odds of pregnancy for infertile couples.

1. You can improve the quality of your sperm and eggs by overall getting healthier. Some ways include getting to the optimal body weight, avoiding tobacco, avoiding environmental toxins, avoiding excess stress, treating any existing medical problems.
2. You can improve the chances of the egg and sperm physically coming together. Some ways include intrauterine insemination and IVF.
3. You can improve the QUANTITY (and sometimes the quality) of eggs. This is done with ovulation medications.
4. You can substitute better sperm and eggs from somebody else, if necessary. This is done with donor sperm or donor eggs.
5. You can optimize the final implantation site for the embryos inside the uterus. Some ways include surgically cleaning out any abnormal uterine lesions, hormonally preparing an optimal lining and eliminating any immunological problems.

Looking at things systematically and logically can help us understand the rationale behind the various fertility treatments available.

The Truth about Meticulous Timing of Intercourse

It’s human nature that when things are not happening the way we want, we try to take actions in an attempt to change things. Some of these actions make an actual difference. But the truth is that many actions may not significantly help us achieve our goals, but do serve a purpose of calming us by allowing us to pretend it’s making a difference.

For example, a man who is depressed because he hates his low-paying job might regain a sense of hope by sending out resumes and going on interviews. Alternatively, he might instead seek hope by purchasing a lottery ticket each week and fantasize about how winning might rescue him from his current situation. The first approach is likely to make a difference eventually. The second approach is almost impossible to make a difference.

There are many things infertile couples can do to help themselves get pregnant. Some couples only need be patient and wait for pregnancy to eventually happen. Others will require medical assistance. For couples who do not yet wish to take advantage of modern medical advancements, the most popular way for them to take action is to meticulously obsess about the timing of intercourse to try and coincide with supposed peak fertility times. But is this the best strategy?

Actually, for most couples, it’s NOT. For them, compulsively timing intercourse with the help of calendars, basal body temperature, cervical mucus awareness or ovulation detection kits serves more to placate them psychologically than to actually make a difference between pregnancy and no pregnancy. In some cases, being so obsessed about strict timing can even LOWER some couples' chances of conceiving by adding extra stress and decreasing their frequency of intercourse. Why is this true? The secret is as follows: Because your odds of conceiving on your peak day are not much different from your odds of conceiving on the day before that. I will elaborate on this more in future posts. Meanwhile, keep in mind the best strategy for most couples is to randomly get together every 1-3 days.

Autism Incidence DECREASED in Babies born from Fertility Treatment

I was catching up on reading the July 2007 issue of the journal HUMAN REPRODUCTION during lunch and I found an interesting study out of Denmark that looked at the possibility of an increase in autism among babies born from fertility treatment. To the researchers' surprise, they discovered an actual DECREASE of autism risk in babies born from different fertility treatments (including hormonal treatment and technical treatment) as compared to babies conceived naturally.

To better understand the implications of these findings, let's look at how this data was obtained. The researchers started by reviewing the medical records of 461 babies born in Denmark between 1990-1999 who were later officially diagnosed with infantile autism. Next, they found 461 other non-autistic babies who matched the autistic ones in terms of gender, year of birth and county of birth. They then compared these two groups to look for any differences in the number of children who had been conceived from fertility treatment.

Of the babies in the autistic group 2.3% of them had been born from fertility treatment. Of the babies in the non-autistic group, 5.4% where born from fertility treatment. This was statistically significant and showed a lower risk of autism in the children who were conceived with some type of fertility treatment in comparison to those conceived naturally.

There could be some interesting factors that affect this. For example, one can imagine that women who are undergoing infertility treatment tend to be watched more closely by doctors and may also tend to be better about taking vitamins. Either of these alone could be the possible reason that the fertility babies did better in terms of avoiding autism. This initial study is promising and future research will serve to investigate this further.

Fertility FILE 101: FERTILITY DRUGS

Fertility drugs are given to help women who don't ovulate perfectly on their own. They are also given to women who already ovulate to help them super-ovulate, meaning increase the number of eggs released (better quantity) and to improve the chances that the eggs will successfully become a baby (better quality).

The two main classes of ovulation medications work on the principle of improving FSH activity. FSH (Follicle-Stimulating Hormone) is a natural substance produced in the brain (actually, from the pituitary gland) which communicates with the ovaries to persuade the ovaries to develop and mature an egg or many eggs.

With the goal being to increase the strength of FSH that is talking to the ovaries, there are two ways to do it. We can either help people make more FSH on their own or to actually give them FSH. This is like helping someone who doesn't have enough money by either giving them tips on how to make more money or by just giving them a large amount of money. One way is gentler and easier, the other way is more direct and much more powerful.

CLOMIPHENE CITRATE: Taken by mouth in pill form. This is a gentler medication that can help a woman produce more FSH on her own. Brand names in the US include Clomid and Serophene.

INJECTABLE GONADOTROPINS: These are actual injectable forms of purified FSH. Brand names in the US include Bravelle, Follistim, Gonal-F, Menopur, Pergonal and Repronex.

hCG: hCG comes in an injectable form. While the above two classes of drugs work to help the eggs develop and grow, hCG does something entirely different. It works to trigger the follicles to burst (ovulate) and release their eggs. So the sequence is take clomphene citrate or injectable gonadotropins first. And then when they have done their job, take hCG to finish the ovulation process.

Watch for more detailed information regarding these drugs in future posts.

Seven Signs of a Good Initial Infertility Consultation

When a husband and wife make the decision to actively get professional help in their quest for a baby, the first step is the initial consultation.  This is much more than just an evaluation visit. It is the all-important first encounter between patient and doctor and it is sets the tone for the professional relationship.

Many of my new patients have already had some infertility treatment elsewhere. Based on their stories, here are some are some common things that they sometimes felt were missing.

Ask yourself if the following criteria have been met in your own first visit:

YOU SHOULD HAVE GAINED AN OVERALL UNDERSTANDING OF YOUR SITUATION. A good first consultation is not a one-way interaction in which the doctor asks all the questions. It should also be an educational session where you are educated and your questions are answered. Ideally, your doctor should be able to give you an overall idea of how serious your condition is and how favorable your chances of getting pregnant are, based on the information available so far.

YOU SHOULD HAVE BEEN GIVEN A CLEAR IMMEDIATE PLAN AND SOME IDEA OF THE LONG TERM CONTINGENCY PLANS. At the end of your consultation, you should know what the next step is, whether it be to get some tests or to choose a particular treatment. If there is only one test planned, you might even get an idea of where to go from there after the tests are back. For example, if this test result is A, then we will do this. If B, then we will do this. If there are multiple tests, then it is best to wait until the results are back and then formulating the next step, rather than try to go through all the permutations of possible results.

YOU SHOULD FEEL CONFIDENT THAT YOUR DOCTOR IS KNOWLEDGEABLE. If you have an uneasy feeling about your doctor's level of expertise, it is your right to ask for further clarification on their thought process in the recommendations they have made for you. It is also reasonable to ask your doctors regarding their training and career experience. No matter how many diplomas, years of practice and board certifications they have, you are still the ultimate judge of whether or not your feel comfortable with this person as your doctor.

YOU SHOULD FEEL CONFIDENT THAT YOUR DOCTOR HAS YOUR BEST INTERESTS AT HEART. One common feedback from patients is that their previous doctors seemed very pushy about selling them on IVF and deflected any questions about other options. There is a difference between a recommendation of IVF because it is the best option for a given couple's particular situation vs a universal push towards IVF in order to boost the practice's IVF volume. You are entitled to an all-important discussion of all your options as well as the pluses and minuses of each choice. Once again, you are the ultimate judge of whether you feel comfortable trusting the doctor's recommendations or not.

YOU SHOULD HAVE HAD THE CHANCE TO SHARE ALL THE INFORMATION THAT YOU FEEL MIGHT BE RELEVANT. Your should be satisfied that your doctor made a thorough attempt to investigate the things in your life that might have an effect on your fertility, including the factors that contribute to your stress level. Any questions, even minor ones, such as how much soda you drink or how much you sleep, are permissible to discuss if you are concerned about their relevance.

YOU SHOULD FEEL SATISFIED WITH THE TIME AND PACE OF THE VISIT AND YOU SHOULD HAVE FELT UNRUSHED. Ideally, all your visits will be satisfying and unrushed. However, in reality, for some of your follow-up visits, when you are just having an ultrasound or blood tests done, it won't be feasible to have an in-depth discussion with your doctor each time. The initial consultation visit is different. I don't think it is unreasonable to spend one to one and a half hours during the first visit. From time to time, it might be necessary to have reconsultation visits.

YOU SHOULD HAVE GAINED CONFIDENCE ABOUT THE OFFICE TEAM. Don't forget to pay attention to the level of service and care given to you by the rest of the office staff and medical team. The doctor is not going to single-handedly conduct all your interactions. Even before you see the doctor, you will have a chance to form your own opinion on how promptly and courteously you were treated so far, both on the phone and in person.

If you care that one of the above points is missing from your interaction with your doctor, it's not too late to fix it. Next time, bring up the topic, so your doctor can have a chance to make things right. Your time is too valuable to waste.