PLANNING A COST-EFFECTIVE WORKUP FOR INFERTILITY

In this chapter we will discuss numerous tests to rule out various problems that may be preventing you from getting pregnant. But not all tests need to be done to arrive at a proper diagnosis and develop an effective treatment plan. What is needed is a cost-effective workup. Fortunately Dr. Annette Lee, a reproductive endocrinologist, has developed a strategy for a cost-effective workup. Here is what Dr. Lee suggests.

You want to make sure that, if you have insurance that will cover treatment and/or diagnosis, you are doing what you need to do and avoiding any missteps that will disqualify you from receiving benefits. To do this properly:

· Call the insurance company to verify what benefits you are entitled to. State specifically that you wish to verify what, if any, infertility benefits you have.

· Document this contact and the determine whether you will need any preauthorization.

Step 2: Participate in a Directed History and Physical With Your Physician

The physician will do a physical exam and take your medical history and your partner's history. The information that you have gathered with the medical history forms in this chapter will be very useful. Make sure to bring them to this meeting. In taking the history the physician will ask about such things as your cycle length, how regular the cycle is, whether you have PMS, mittleschmirz (pain around the time of ovulation) and dysmenhorrhea (painful menstrual periods). The physician will inquire about coital frequency, timing, and your use of lubricants. Believe it or not, some lubricants such as petroleum jelly, can reduce your chances of getting pregnant. He or she will ask your partner whether he has ever created a pregnancy, about any exposure to health hazards at work, and lifestyle factors that may have a bearing on his fertility. In your physical, the physician will be looking for hirsutism (hairiness) that may suggest polycystic ovary syndrome, fat distribution, and estrogen status. The physician will also conduct a breast and pelvic exam.

Physicians and insurance companies use different approaches to determine how to conduct a workup. While physicians typically use an approach based on their experience diagnosing a large number of patients sharing common characteristics, insurance companies turn to a computerized analysis of statistical predictions of treatment outcomes. This difference in approach may explain why sometimes your insurance company will refuse to pay for diagnostic procedures your doctor has ordered.

If you want to get pregnant, you must release eggs. You need to know whether you are ovulating. According to the latest available CDC National Statistics approximately 12% of the women who did Assisted Reproductive Technology (ART) procedures had a primary diagnosis of ovulatory dysfunction. Of all the infertile woman who have failed to conceive after engaging in unprotected intercourse for 12 months, 40% are diagnosed with an ovulatory disorder. So it is important that you rule out this possibility. The inexpensive way to do this is to use a Basal Body Temperature thermometer for three months at a cost of about $7. A more expensive way to diagnose this problem is by measuring your blood progesterone level during the luteal phase of your cycle. This will cost about $75.

Approximately 35% of couples who have not conceived after one year of trying on their own are diagnosed with a male factor problem (25% who are trying ART have this diagnosis.) The diagnosis requires collecting a semen sample from the male partner and conducting an analysis using the Kruger Strict Criteria system. Ideally, your partner should abstain from ejaculating for 2-5 days before producing the sample to be used for the analysis. The cost of the analysis and report is about $125.

3. Evaluate the status of the fallopian tubes and the uterine cavity ($250 physician fee and about $1,000 for radiology fee)

More than 30% of the patients doing ART are diagnosed with either a tubal or a uterine problem. You can get information about your tubes and uterine cavity by having either a hysterosalpingogram (HSG) which is an X-ray procedure or a sonohysterogram, which is an ultrasound procedure.

Fewer than 10% of infertile women have a cervical problem. You can diagnose this problem using a Post Coital Test (PCT) that is timed using an ovulation predictor kit. ^[i]

The importance of this evaluation increases as you get older. Dr. Lee estimates that less than 10% of women under age 30 who experience unexplained infertility have an inadequate ovarian reserve. For women between age 30 and 35 perhaps as many as 30% may have diminished ovarian reserve. This figure increases to 40% in women between the ages of 35 and 40 and rises to 50% for women who are over the age of 40.

Dr. Lee suggests that there are certain tests you should avoid. She believes that you don't need to have a routine TSH and Prolactin screening (saving you $100), if you have very regular cycles. You can also avoid a routine endometrial biopsy which costs about $300, unless you have symptoms suggesting that you have a luteal phase disorder. She also cautions you to avoid having several cycles of Clomid therapy without any other monitoring if you already know that you are ovulating and making a sufficient number of follicles. Finally, if you do not have insurance that covers a diagnostic laparoscopy, you may decide to pursue treatment for 3-6 months before undergoing a diagnostic laparoscopy, unless there is a strong suspicion that you have endometriosis or your HSG shows that you have tubal disease. On the other hand, if your insurance carrier will cover a laparoscopy for a patient with your diagnosis, you may decide to have a laparoscopy before beginning treatment.

[i] Be aware that several studies have found that the Post Coital Test does not correlate with pregnancy. The problem may be the result of poor timing. Reproductive Endocrinologist Samuel Thatcher suggests not including this testing in your routine fertility workup.

Planning A Cost-Effective Workup