D&C (Dilation and Curettage) or D&E (Dilation and Evacuation) After a Pregnancy Loss
by Tina

I just wanted to say, before getting into the details of D&C or D&E, I am sorry for your loss and that you even need to be reading this area. I have miscarried three different ways (detailed further in the text), so I hope my experiences can help you to make a decision on how you handle yours.

There is no right or wrong way to manage your miscarriage, as long as it is not life-threatening to you. Sometimes you do not have an option in how you manage your miscarriage–it just begins without warning and you miscarry naturally. Other times, you have choices and time to make those decisions, and your choices should be made based on your own personal wants and needs to honor the baby to whom you are saying goodbye.

Why You Would Opt For a D&C or a D&E?

As background, D&C (which stands for Dilation and Curettage) is a procedure done in the uterus by scraping of the lining of the uterus (the endometrium). Another, less invasive, version of a D&C is the D&E (which stands for Dilation and Evacuation). In a D&E, instead of scraping, the lining of the uterus is suctioned out.

The following are the main health reasons a woman may have a D&C or a D&E done:

• for a woman who knows she is going to miscarry and opts not to have a natural miscarriage at home;
• for a woman who a recently miscarried naturally, or who previously had a D&C/D&E done and retained tissue remains in the womb;
• for a woman who is experiencing heavy or irregular periods, or vaginal bleeding after the menopause.

Opting for a D&C/D&E when a miscarriage is detected and has not begun is a personal choice, which has its own set of pros and cons – and there is no right or wrong choice in opting for a D&C/D&E, as long as it is the right choice for you.

Choosing to have a D&C/D&E depends upon several personal factors you need to consider:

• how far along the pregnancy might have been or what bleeding has already occurred;
• how long you have known about the impending miscarriage and the emotional toll already taken on you because of it;
• strong emotional feelings over the impending pregnancy loss;
• emotional preferences on how one feels the pregnancy should be allowed to end;
• family issues, such as care of other children in the home;
• preference for medical testing on the fetal tissue from the miscarriage, especially in recurrent miscarriage;
• work issues, such as project management and duties, and time off for the miscarriage.
  

What to Expect

A D&C/D&E is considered minor surgery, therefore, it is performed in a hospital or ambulatory surgery center or clinic.

In most cases, you would be given general anesthesia, which would require someone to drive you to/from the location of the procedure. You should not eat/drink anything 12 hours prior to the procedure. Sometimes, women will request local anesthesia instead – that is something that would have to be discussed with the gynecologist performing the procedure.

In the actual procedure, a speculum is inserted into the vagina to open the walls to view the cervix. A clamp-like instrument holds the cervix in place as the cervix is dilated with a series of tapered rods of increasing widths, which are inserted into the cervical opening.

If a D&C is performed, the ob/gyn will insert a specialized scraping scalpel (called a curette) to scrap the retained tissue from the uterus;

If a D&E is performed, the ob/gyn insert a hollow tube through the cervix and suction is applied to remove the retained tissue.

The procedure usually takes anywhere from five to twenty minutes to finish, depending upon how far along the pregnancy was or if the procedure is specifically to clear out retained tissue from a natural miscarriage or previous D&C/D&E.

It is normal to experience light, irregular bleeding in the days following the D&C/D&E, along with mild cramping. Naproxen or ibuprofen is usually given for relief from cramping. You may also be given a prescription for a medication to stop a hemorrhage (just as a precaution should you begin to hemorrhage after the procedure).

Most women are told to take the day of the procedure and the following day off from work (if you work), and to rest as much as possible for those two days. But, generally, physical recovery is fairly quick.

After a D&C/D&E, you should get a list of instructions with the following instructions:

• Avoid intercourse for 2 weeks. Bacteria can easily get into your uterus and cause infection until your cervix returns to normal after the dilation;
• Use only sanitary pads for bleeding. Avoid tampons for at least 2 weeks. Do not use douches;
• Be sure to return for your follow-up visit, usually 2 weeks after the procedure. Your ob/gyn should discuss all lab reports on your tissue sa
  mples, if testing of the fetal tissue is ordered. Your ob/gyn will also examine you for any signs of infection and to make sure your cervix/uterus have returned to normal size.

Problems That May Arise and Ways to Troubleshoot

Although I personally have not had any problems after either my D&E nor my D&C, there are several problems that can arise from the procedures:

• If your ob/gyn is too cautious in the procedure (especially with a D&C, since it involved a real scraping scalpel), retained tissue can remain. This tissue is usually passed without complication afterwards, although in some instances, the possible need for another procedure may arise. Sometimes, like a natural miscarriage, tissue is missed;
• Rarely, an ob/gyn can accidentally puncture the uterine wall while performing either a D&C/D&E;
• Hemorrhage is rare, but it can occur if an instrument injures the walls of your uterus. It also can occur if an undetected fibroid is cut during procedure;
• You can end up with an infection because your natural uterine environment is being invaded to do the procedure. Some ob/gyns’ prescribe antibiotics up-front to prevent it from happening – some, like my ob/gyn, do not;
• Asherman’s Syndrome, although rare, can develop later on. This syndrome involves the formation of scar tissue in the uterus, caused by aggressive scraping, repeat D&C/D&E’s, or abnormal reaction to the scraping. Thick scars can result, which can fill up the uterus completely. Abnormal bleeding/loss of periods and heavy cramping are signs of the syndrome. A sonohystogram can detect this scarring, which can be corrected surgically if diagnosed correctly.

Call your doctor immediately if you develop any of the following symptoms:

• Fever/chills;
• Severe persistent pain or cramps not relieved by ibuprofen or naproxen;
• Prolonged or heavy bleeding (more than 6 hours, or requiring a change of sanitary pads several times in 1 hour);
• A foul-smelling discharge from your vagina.

Personal Tips

I have personally experienced three miscarriages: One natural miscarriage at 4 wks 1 day (9/04), a blighted ovum which required a D&E since the miscarriage would not start on its own (11/05) and a missed miscarriage when the baby stopped growing at 6 wks 4 days, which I opted to have a D&C immediately (3/06).

Through these experiences, I have several tips that I hope can help anyone that has to go through this experience:

1. Do not let an ob/gyn pressure you into an immediate choice of a D&C/D&E. You need to take into account how you feel you need to manage this decision, and make sure the diagnosis of miscarriage is confirmed.

2. Make sure your miscarriage is confirmed by blood work AND ultrasound before you consider a D&C/D&E. My ob/gyn is very experienced, but he told me that even he has made mistakes in diagnosing a miscarriage – on rare occasions, blood work and repeat ultrasound can detect an incorrect diagnosis and the pregnancy is viable. So, having repeat betas and ultrasounds to confirm the miscarriage is crucial. With my 11/05 miscarriage, I had three beta draws and three ultrasounds to confirm the miscarriage.

3. Discuss the procedure thoroughly with your ob/gyn so you understand how the procedure is done and any questions you have are answered. Be clear on what kind of anesthesia you want – and what is allowed in the surgery center where you are having the procedure. This can be a very emotional procedure, and you need to have your concerns and questions answered before hand.

4. If you experience nausea/vomiting as a morning sickness sign like I did with my 3/06 miscarriage, even though you are miscarrying, you can ask for meds to be injected into your IV line so that, when you wake up from the procedure, the nausea subsides for you.

5. When you wake up from the procedure, be prepared for the reality that the pregnancy is now completely over. When I woke up from my D&E in 11/05, I was crying as I realized the procedure was done. Luckily for me, the nurse was very sweet and gave me tissues and allowed me to cry while she stood there holding my hand.

6. Make sure your ob/gyn leaves instructions on what you should do when you go home and if you see any problems arise after the procedure. Better yet, ask that your ob/gyn stops in to see you after the procedure is done. My ob/gyn stopped in to see me after both my D&C and D&E to make sure I was physically okay.

7. If you have children at home, ask someone to care for them for a little while as you sleep off the anesthesia and you are sure your bleeding after the procedure is within the normal range. To recover well, you need to rest.

8. Remember: After a D&C/D&E, you have now had a complete miscarriage. Your hormones usually “dump” quickly, which can potentially make you an emotional basketcase. I cried through Thanksgiving dinner in 11/05 since my D&E was done two days prior and my hormone levels were going down quickly. So, if you are having a hard time with the loss right after the procedure, it is completely normal and to be expected.

9. If you are not prepared to go back to work (if you work) after the two days home, don’t. My D&E in 11/05 was done two days before Thanksgiving, so despite the holiday, I had several days to begin to sort through the emotions. But, after my D&C was done in 3/06, I returned to work after the two days – and it was just not enough time to begin to the grief process.

10. Insist on that follow-up visit in two weeks. Some ob/gyns try to skate around it – you really need the follow up to make sure you are physically recovered and to ask questions you may have.

11. Ask for repeat betas afterwards to make sure your HCG levels are going back down to zero. For some women, it takes a few days – for others, it can take a few weeks. If you want to TTC right away, you need to make sure your HCG levels are down to zero again.

12. You are usually very fertile after a D&C/D&E – the lining is almost always cleaned out and fresh. So, if you do chose to TTC after the procedure, your odds are usually a little better for conception.

13. And, lastly, be comfortable with the decision in how to handle your miscarriage. Waiting to miscarry sometimes is not an option and you miscarry quickly. Other times, like for my 11/05 miscarriage, you are waiting for weeks for it to begin. A part of the emotional healing process is to be comfortable with how you chose to manage your miscarriage…there is no right or wrong way to do that. It just has to be right for you.

Testing for Recurrent Pregnancy Loss
by Amy

A starting list of tests for your doctor to run if you are experiencing recurrent pregnancy loss (RPL). This post is simply a starting point to help you start the conversation, though your care should be guided by your doctor.

Anti Phospholipid Antibodies (APA)- cardiolipins are proteins found in your body that work against your body. Cardiolipins help regulate blood flow throughout the body. However, when your body looks at the cardiolipins as an invader, it will attack them. The three main groups are: IgG, IgM, IgA.

• Normal Results: IgG is below 23 ug/mL, while normal IgM and IgA is below 11 ug/mL. This indicates typical levels of cardiolipin antibodies in your blood.

• Abnormal Results: levels between 25ug/mL and 70 ug/mL. However, these levels may interfere with your ability to become pregnant or carry a pregnancy to term.

Other anticoagulant tests that fall under APA are the following:

Anti Cardiolipin Antibodies (ACA)- cells that attack the nuclei of other cells in your body. This is a mistake made by the body, thinking the good guys are the bad guys. Low levels should cause no problems.

• Normal results: levels are typically under 1:20, though 1:40 is also acceptable.

• Abnormal Results: levels above 1:40 indicate a high presence of anti nuclear antibodies in your blood.

Anti Nuclear Antibodies (ANA)- Again this is your body mistaking the good for the bad. Only this time it attacks the nuclei of the cell(s).

• Normal and abnormal levels are the same here as they were for the APA.

• Typical treatment for abnormal results is the use of the medication prednisone.

Lupus Anti Coagluant (LAC)- this is a protein in your blood that causes it to clot in your bloodstream and veins differently than it normally would. To test for this there are actually several tests compiled and then looked at as a whole. These tests are the Activated Partial Thromboplastin Time (aPTT), the Modified Russel Viper Venom Time (VPTT), the Platelet Neutralization Procedure (PNP), and the Kaolin Clotting Time (KCT).

The typical treatment for this is baby aspirin, prednisone, and heparin/lovenox.

Anti Thyroglobulin Antibodies (ATA)- Thyroglobulin is the protein that connects with the thyroid, which produces different types of hormones. Antithyroglobulin is usually found with antimicrosomal antibody in the bloodstream. These two antibodies together, a.k.a antithyroid antibodies, attack the thyroid gland.

• Normal/ Negative Results: levels less than 1:72

• Borderline Results: levels between 1:72 and 1:300.

• Abnormal/ Positive Results: levels higher than 1:300

Further testing is usually required to rule out other issues and is then treated with prednisone and dexamethasone.

Parental Chromosome/ Karyotype- when blood samples are taken from both partners and tested for extra chromosomes, missing chromosomes, deletions or additions to the data within each chromosome, and translocations of chromosomes (in which all chromosomes are present but rearranged.

Embryo Toxic Factory (ETF) Panel- this when your immune system looks at your new embryo and says, “invader!” So it attacks the embryo because your body is producing too many white blood cells. This test occurs in two steps

First, your blood is taken and the cells (lymphocytes) are isolated and placed ina special solution

Second, is the embryo culture. This is when the lyphocytes are combined with a two-cell embryo from a mouse. After several days, the mouse embryos are looked at again to see if toxic substance is being produced. If the mouse embryo has stopped developing or died, it is and indication of ETF. If it’s still developing then there is no toxic substance being produced.

Anti-Mullerian Hormone (AMH)- this appears to a relatively new test. However, it is expensive and still not covered by insurance companies. It is projected that it is accurate 70% of the time.

This test measures the hormone, Anti-Mullerian, which is produced by the ovaries. This hormone does not fluctuate through out the month and is considered to be an indicator of a women’s ovarian function. The manufacture believes this test to be a more reliable test than testing a women’s oestrogen. If it turns out that this is true it could be a predictor in how successful a women will be when undergoing IVF and a diagnostic test to help indicate if a women has PCOS. Women with PCOS have higher levels of AMH than their peers.

NK Cell Test/ Natural Killer Cell Activity Levels- this test measures the bodies immune system and it’s natural production of natural killer cells. Natural killer cells are made by the body to attack cancer cells. Once the NK cell binds with the cancer cell it emits a toxic chemical to kill the cell. However, during pregnancy the natural killer cell mistakes the embryo for a cancer cell and begins attacking. This is why women with multiple miscarriages, or Recurrent Pregnancy Loss, have a tendency to have high levels of NK Cells.

In the lab after mixing the NK cells and embryonic cancer cells and dying ech with a different solution they are cultured. After two hours, another solution is added that absorbs only the dead cells. Finally, the remaining cells are placed under a laser and counted by a computer. The number of cells left indicate a positive or negative result.

The treatment for a positive NK is IVIg. This is where blood products are gathered and used in an infusion. This infusion helps suppress the immune system and success rates are as high as 80%. Treatment lengths vary and can start as early as 2-3 weeks before conception and as late as 35 weeks. Also, an individual treatment of IVIg can cost anywhere from $3,000- $5,000.

However, it should be noted that many in the field of reproductive medicine consider this treatment and test controversial as there has been difficulty duplicating studies. If you are interested though, to get started you can check out SIRM (Sher Institute of Reproductive Medicine) at haveababy.com. There are several clinics throughout the country and if travel is not an option for you perhaps you can look at their chat rooms/ message boards and get some ideas of where to begin in your area.

Leukocyte Antibodies Detection (LAD)- Leukocytes are white blood cells. During a pregnancy your body can recognize your baby as an invader and attack it. In response to this your body produces leukocyte antibodies. These antibodies are found in pregnant women, those receiving blood transfusions, and donated organs.

• Lower- than normal levels of these antibodies have been liked to those with miscarriage, still births, and recurrent pregnancy loss.

• Normal Levels/ Negative Results: above 50%

• Borderline Level Results: between 30% and 50%

• Abnormal Levels/ Positive Result
  s: less than 30%

Treatment is Leukocyte Immunization Therapy (LIT) and consists of an injection of white blood cells either given by your partner or donated.

**** It is important that you have the traditional IF work up done in conjunction with these tests as well if you are suffering from Recurrent Pregnancy Loss*****

Diagnosis: Infertility Caused By Endometriosis
by Royalyne

What Endometriosis Means and Its Impact on Fertility

Endometriosis is a condition in which endometrial tissue (the tissue that lines your uterus during your cycle and is shed during menstruation) occurs outside of the uterus. It can be found pretty much anywhere inside your pelvic cavity: fallopian tubes, ovaries, bladder, bowel, etc. The adhesions can cause varying levels of pain during menstruation or intercourse, from no pain at all to debilitating pain. As the adhesions grow they can impact thetissues they are on. Endometrial adhesions on the ovaries can cause endometrial cysts (called endometrioma). Adhesions on the bladder or bowel can infiltrate and obstruct. Adhesions on the fallopian tubes can infiltrate or constrict and result in scar tissue forming. In addition, scar tissue on the fallopian tube can prevent eggs from passing into the uterus to implant (which can lead to an ectopic pregnancy). Endometrioma can affect ovulation and scar tissue on the uterus can prevent implantation or lead to miscarriage and premature labor.

There are varying levels of endometriosis, from level 1 which usually causes no symptoms to level 4 which can seriously impede fertility.

Diagnostic Process

Endometriosis cannot be seen on ultrasound or diagnosed with blood testsor pap smears. The only way to diagnose endometriosis is to undergo laparoscopic surgery. During the surgery, a small incision is made in the abdomen for a tiny camera and a second incision is made to facilitate a tube used to pump air into the abdomen. Inflating the abdomen allows more space and a better view of tissues. During surgery the adhesions can be removed.

Treatment Options

Many doctors will also recommend Lupron injections. Lupron basically “kills” the adhesions by halting the growth for 6 months. Endometriosis is also controlled with birth control pills. Birth control pills can be used to treat symptoms or to prevent/control a reoccurrence after surgery.

Personal Experience

My endometriosis was level 4, affecting one ovary with a large endometrioma. The endometrioma pulled that ovary down and behind my uterus and twisted the fallopian tube. There was also a small adhesion to my bladder. I had debilitating pain during menstruation–it was so bad that I couldn’t walk and often vomited from the extreme pain which was not reduced by any OTC or prescription painkiller. My laparoscopic surgery lasted over 3 hours (I was scheduled for 1 hour of OR time) to remove all the adhesions and re-anchor my ovary where it belonged. I had spent 5 years on triphasic birth control pills, which kept me symptom-free for the duration. I chose against Lupron because I didn’t feel the side effects were worth it for me.

Natural Miscarriage
by Lisa Blogger

First of all, if you’re reading this for advice, I am very sorry that you’re going through this. I’ve had two natural miscarriages, one at 8 weeks with a blighted ovum and one at 9 weeks with an embryo measuring only 6 weeks. I am not an expert on this by any means, and I do realize that every experience is different, but hopefully this will be of some help.

Pregnancy losses that occur prior to 20 weeks are called a miscarriage. While some pregnancy losses necessitate the use of a D & C, other pregnancies end without medical intervention or assistance. This write up is for a natural miscarriage.

Why You May Have a Natural Miscarriage (rather than using medical intervention)

Some doctors will take a “wait and see” approach once there is an indication of a potentially failing pregnancy, particularly if it is a first pregnancy. Other doctors are inclined to suggest natural miscarriage rather than a D&C due to the potential for post-D&C complications (scarring, for example, or if you are not good with anesthesia). If there is a possibility that you are off on your ovulation calculations, many doctors will not suggest a D&C until a second ultrasound a week later confirms that the pregnancy is not just progressing slower than expected.

What You Can Expect

While both of my natural miscarriages were different, there were also similarities. Both times, spotting was my indication that something was wrong, followed in both cases by an ultrasound that confirmed we were likely going to lose the pregnancy. After the ultrasound, things moved rather quickly the first time (I miscarried that evening), but more slowly the second (it took three days to complete).

In most cases, bleeding will begin to increase first. Cramps will begin, often mild but will intensify as the miscarriage progresses. My first miscarriage felt almost like what I’ve heard labor pains feel like, in that there was a rhythmic pattern to them and they were very intense at the end. When I was in the midst of one, it helped immensely to have a microwavable heating pad wrapped around my lower abdomen, and it was almost necessary that I was up and walking — sitting still seemed to make the cramps worse. Also — and this may sound odd — but I somehow knew when I was going to pass a clot or tissue, because I had the urge to go sit on the toilet. As a result I did not bleed as much on a pad as some people might.

The cramps will be the worst while you are passing tissue or large clots. After this occurs, the cramping will subside and the bleeding will begin to taper off, although this may still take a day or so. Your doctor will likely want to schedule a series of betas to make sure that your levels are dropping to zero (some doctors will only test to <5). Problems That May Arise and Ways to Troubleshoot

If you are bleeding so much that you are soaking a pad in an hour or less, you should go to the emergency room, as this could indicate hemorraging or other problems. Have someone drive you — rapid blood loss could cause you to faint or pass out. It is possible that you will still need to have a D&C if there is retained tissue; a sign of this may be that you are still bleeding heavily after most of the tissue has passed. Your doctor will most likely want to do an ultrasound or at least a repeat beta to see whether your levels are not dropping off.

Personal Tips

If you have seen your doctor for an ultrasound or other diagnosis prior to the miscarriage, try to remember to ask your doctor what their recommendations are and for a script for pain medicine if you think you’ll need it. I know that it’s an emotional time, but try to make sure you are looking out for your body as well. I was distraught the day of our ultrasound and was given no advice on what would be considered an emergency, when to call the doctor, or whether it was safe to take Advil or something stronger. Luckily I had online friends and resources that could tell me some of the things I describe here. When I was still reading loss message boards, I’ve seen many people ask whether they should try to get a tissue sample to their doctor for chromosomal testing. There are a few problems with that with a natural miscarriage, mainly that by the time you would be able to get the sample to your doctor it would likely be unusable, not to mention collection/storage and the emotional aspect of doing this.

I was extremely calm during my miscarriages, but extremely emotional afterwards. Be sure that you take some time for yourself if at all possible and just allow yourself to feel whatever you feel. It will help with the grieving process if you do not try to resume “normal” life immediately.

Questions When Choosing a Reproductive Endocrinologist (RE)
by Cara

The best type of patient is a prepared patient! I was both excited and anxious for my first appointment with my RE. I find I function best when I know what to expect and I stay calm if I am organized. In order to help you through this potentially nerve-wracking first experience, I have prepared a list of tips, questions and expectations for your first appointment with your RE. If you are not satisfied with the answers from the first RE and clinic that you visit, I urge you to keep looking for one that is a better fit.

Tips for your first appointment:

• Bring your list of questions with you
• If possible, have someone accompany you to the appointment–2 sets of ears are better than one
• Take notes during the consultation
• Bring relevant medical records: surgeries, recent pap test, list of medications
• Bring copies of any fertility work up you or your partner have had completed with the OB
• Bring list of concerns/observations about your cycle. If you have a month or two before your first appointment, try charting your basal body temperature
• Do not leave your appointment until all your questions are answered to your satisfaction!

Questions, Questions and more Questions!

About the Clinic

• How long has this clinic been in business?
• What are your office hours?
• What procedures are performed on the weekend?
• Are the Clinic and Lab open 365 days a year?
• How much work should I expect to miss?
• Do you provide pre-natal care? If not when will I be released to an OB?

About Communication

• Who is the case manager?
• Who is available if I call with questions?
• Can I leave a message for my RE? Can I email my RE directly?
• How long will I wait to receive a return call/email?
• Is there a number for off-hours problems?

About the Reproductive Endocrinologist (RE)

• Where did you earn you degree?
• What is your training in infertility? Are you board certified as a reproductive endocrinologist?
• What hospital are you affiliated with?
• Will I always get to see you?
• If not, how many REs are part of the group?
• Will I always see the same nurse?
• Will all my treatment and procedures be performed by you?
• How often will I get to meet with you face to face?
• How open are you to discussing information that I have learned about from other sources?
• Do you recommend counseling?
• Do you have a counselor on staff? If not, can you refer me to one?
• What books do you recommend reading?
• What is your view on alternative treatments (acupuncture, TCM, vitamins)?

About Initial Evaluation

• What tests do you perform to evaluate me/us?
• How long will it take to diagnose my/our problem?
• What specific tests would you recommend to diagnose my infertility?
• How long will you wait from the time of diagnosis to starting treatment?
• What do you see as our first step in treatment?
• If that fails to produce a positive, where do you see us moving next?

About Treatment and Procedures

• Will my treatment be individualized or will you follow set protocols?
• What procedures do you perform at your clinic?
• Which do you perform on-site? Which in a hospital?
• How will you proceed if we have unexplained infertility?
• Do you monitor while on Clomid?
• What kind of monitoring should I expect for other types of medicated cycles?
• During a treatment cycle, how often will I have to come into the clinic?
• What are your office hours for different procedures (ie: Blood tests, ultrasounds)
• If we go to IUI or IVF, can I bring in sperm sample or does it have to be produced in the clinic?
• How long do you stick with a particular treatment before moving forward?

About the Lab

• Do you have a Donor Egg and Donor Sperm programme?
• Do you do Blastocyst transfers?
• Do you do Assisted Hatching?
• Do you do Intracytoplasmic Sperm Injections (ICSI)?
• Do you do Pre-implantation Genetic Diagnosis (PGD)?
• How long do blood tests and other results take to receive? What is the procedure for getting the results?

About Expenses

• Do you have a price list? Can you run through it with me?
• Do your fees include the medications? Injection Instruction?
• Is it possible to set up payment plans?
• Will my insurance pay for the testing and/or treatments?
• Will your clinic help me determine what my insurance will cover?

About Success

• May I contact any of your patients who have had similar treatments?
• What are your statistics for couples with our diagnosis?
• What are your live birth statistics for different procedures?
• How do your statistics stack up against national averages?
• What would account for these differences?

What you might expect from your first RE appointment:
You can expect your first appointment to last from an hour to two hours. You will meet with the RE and your primary care nurse. The RE will ask you about your medical history as well as your sexual history. Check your embarrassment at the door! The more honest you are with your doctor, the quicker he may be able to arrive at a diagnosis and treatment plan. Whenever I feel myself getting embarrassed about something, I think: no matter how weird/abnormal this seems to me, the doctor has certainly seen worse!

At your first appointment your RE will probably order blood tests to check for the following diseases: Rubella (female only), Chlamydia (female only), HIV antibody, Hepatitis B surface antigen, Hepatitis C antibody, RPR (syphilis).

Depending on where a woman is in her cycle, your RE may also take blood to check the following: Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH), Estradiol, Progesterone, Prolactin, Free T3, Free Thyroxine (T4), Total Testosterone, DHEAS, Androstenedione.

For women, the RE may also wish to perform a vaginal ultrasound to look for any abnormalities, measure ovarian volume and look at antral follicles. The RE will probably order a Hysterosalpingogram (HSG) to be done between days 7 and 10 of the next cycle.

Men may also do a semen analysis, even if they have done one or two before. Be prepared: abstain from sex 3-5 days before your appointment! If the man has had previous semen analyses with abnormal results, the RE may refer him to a urologist. The urologist will order blood work to look at hormone levels, and he may recommend a testicular ultrasound.