So you’ve been trying to get pregnant and it’s taking longer than you think it should. Now what? Sounds simple, you probably have a local gynecologist who you have been seeing for your checkups. Why not start there?
This may not be a bad idea at all. A general gynecologist could quite possibly be a very good fertility start. She has your history and may be conveniently located. But how can you tell she is good?
It boils down to 2 things: diagnosis and treatment.
Let’s start with diagnosis. If you have been trying 6-12 months, and you doctor says relax and try for 6-12 more months, relax your relationship with him. Of course he will occasionally be right and some people will be successful by just hanging in there, but most following his advice will still not be pregnant, and will be that much older.
Even if you want to wait, you should strongly consider at least having some basic simple testing. You can keep trying on your own as the testing proceeds, but at least you will acquire some important information. Once you get some answers, you will have the power to decide how to proceed.
Now what tests are we talking about? The gold standards are the HSG (hysterosalpingogram), semen analysis, and day 2 or 3 blood testing for FSH and estradiol (estrogen). All of these tests can be finished within a few weeks, and within that time you will have your bundle of information. Now some of this is a little simplistic because many of you have very complicated problems, but most people just starting out do not. And if the testing is systematic and is done quickly, you will all be on the right track.
You do need someone good to read your HSG. Many doctors will not look at your films; they will just read the report. This becomes less material when the report is normal, but much more significant when the report is abnormal. If you are told its normal, odds are it is. However, if you are told it’s abnormal, then you may need to take things one step further, usually by getting a second opinion, preferably with an RE. If you are told it’s normal and you continue without conceiving, you should have someone else have a look at it.
That’s the basic testing, sounds simple and it is.
What about the treatment side? For example, let’s say the HSG really is abnormal and you are told you need surgery on your uterus or tubes? Who should do your surgery? Your GYN or an RE? Many generalists are excellent surgeons, and some REs are terrible.
How do you know where to go for quality surgery? And let’s extend the question to “How do you find any good doctor?” Whether it’s a generalist or Reproductive Endocrinologist, how do you know who is good?
This is one of the most difficult questions in medicine. I would start by doing some of your own investigation.
What about those best doctors lists? This could be a good place to start because many doctors on those lists are good. However if you show a list to a good doctor who is very familiar with the people listed he will really wonder how some of them made it on. And I don’t know too many fertility doctors that are not on the “Best Doctors in America” list. That’s not a list of the super-best doctors in America, it’s a complication of all if the doctors who are on the best local doctors lists. So there is no cut to make the America list. Most of those lists give a high priority to chairmen and division directors, again most of whom are good, but holding one of those positions is not an automatic for quality. Some lists are assembled through other doctors voting, and some of that could be politically biased.
You may have local infertility organizations that could make suggestions. This is tough because although I think these groups do an excellent job, I have been involved with at least one group who referred to their biggest supporters. But it might be good to at least find out which doctors are on their list.
What if the doctor is in all the medical societies? Medical societies are very important organizations that provide education and networking, but unless you have a criminal record, almost all societies allow members in. So you will see most doctors with impressive lists of their fancily named societies, but membership is usually about paying your dues and getting your certificate. There are usually no entrance criteria that represent quality control.
What about board certification? There is no excuse not to be boarded in OBGYN. Most of us are. What if you are going to a specialist, does he need to be boarded in Reproductive Endocrinology? This is usually important but there are some excellent physicians who have good reasons for not being boarded in RE. Maybe they are young and are waiting to become eligible. Maybe they are a little older and trained before getting certified was the thing to do. I would say that if your doctor is not, you need to carefully evaluate other criteria.
Does it matter where she did her training? Again hard to say, but better programs are more likely to turn out better physicians. Some of this may have to do with recruitment. The places with the best training reputations can more easily recruit the smartest and most caring people. So just by getting the best, they will turn out the best. The problem for you is knowing which training programs are the best. There are many renowned institutions that just have bad programs. It’s not uncommon to have a hospital with a great program in one specialty and a very bad program in another. And sometimes things change quickly within a program, so the training can become worse before the reputation changes. Magazines do publish the lists of top hospitals, and I don’t think there are many bad places that make those lists. However, there are many excellent places that don’t get the nod.
Nurses can be a good referral source because they see the doctors work every day. But a referral from a nurse may not be a slam dunk. I have seen nurses refer to their better friends, or to the doctor who is popular because he frequently brings in pizza. Nurses know who operates the most, but not about their daily functioning and this brings us to the next point.
Is a doctor who operates at high volume the best surgeon for you? Maybe. A doctor who operates frequently may be really wonderful and have a massive referral base that keeps him in the OR frequently. They can be more experienced and confident and have fewer complications. However, some busy surgeons are busy because, for whatever reason, they over-operate. And some of these doctors have not gained from their experiences and maintain a higher complication rate. They may feel their procedures are indicated, but others may not. Getting back to the nurse, he sees what’s happening in the OR but he does not know about how the patients have been worked up and how they are followed after surgery.
There is one good trick that only works in a teaching hospital: ask a resident. No one knows the skills and limitations of your doctor better than a resident. The resident is in the hospital all day long and is involved with the workups, surgeries and recoveries. They are constantly communicating with your doctor. And believe me the residents have very strong opinions about each of the doctors they work with. Now it is hard to get hold of a resident, but ask around, may be a friend of a friend knows one. Plus, many hospitals have departmental web sites that list the residents, and some may list contact information. Because they are young, tired and stressed, sometimes the residents are a little too opinionated, and they may know about some of the doctor’s personal issues that don’t affect you. If you have a doctor and want their opinion, you don’t need to hear the doctor is the best of the best. You do want to hear that she is solid, not that she is below average or worse.
What if your only source is your friend who became pregnant after seeing the doctor she recommends to you? This is not enough at all. Many questionable doctors get some of their patients pregnant. It doesn’t mean that they are good. Just like there are some of the best doctors who just can’t be successful with everyone. This is probably one of the most common ways couples find fertility doctors, but it is the least reliable. So if you are told about a doctor, use other sources to validate the person.
Check the available medical misconduct sources in your state. Your doctor should not be listed there. There is also the National Practitioner Database. This is different than misconduct; it lists the cases where your doctor was sued. Even the most excellent doctor can have a few things listed; it’s the nature of the beast, the way of the world. Most doctors are non-malicious hard workers who can run into a bad outcome, but this should happen only very occasionally, and if they have any cases listed the list should be very short. Some of the doctors who take care of the most complicated cases are more likely to be sued. That being said you must avoid the frequent fliers.
And then there’s the internet. Have you ever stayed at a nice hotel and enjoyed the experience? Go to the internet and check the reviews, you would be surprised by all the negative comments. But, the average of the reviews would at least be close. So yes, the internet chats are some of the best places to find doctors, especially if you repeatedly read similar concrete reasons why a doctor is good or bad. I have heard of administrators going undercover on the sites to steer business to their doctor, so watch for that.