By Hannah Saunders, co-founder at The Fertility Circle. Hannah underwent five rounds of IVF at three different hospitals/clinics (including one in Hong Kong). You can read her story in her Path to Parenthood, here
Your first consultation with a fertility clinic can feel a little daunting. All the unfamiliar terms, worries about whether they can fix you, if you can even afford it, and, well, just the pure medicalness of it all.
And whether you’ve a limited choice of clinic (e.g. if your treatment is going to be NHS-funded at a hospital near your home), or you’re working your way through a hefty shortlist of private clinics, there are some bits of info you’ll need before you commit.
But don’t worry, we’ve done some of the heavy-lifting for you.
Below is a handy checklist: it’s the ten key questions to ask your consultant at your first meeting.
Q1: Am I eligible for treatment at your clinic?
Before you get too far down the line, double check the clinic is willing to treat you. A few clinics have certain criteria you need to meet and won’t treat you if, for example:
-Your BMI (Body Mass Index) is above 30
-You are over 37
-Test results (such as your FSH score) aren't in line with the clinic's requirements
Many clinics have relaxed their criteria in recent years though and some now even trade on their open-arms approach (e.g. with an over-40s programme) but do ask the question up front to be sure.
Q2: Which treatment would you recommend, and why?
If you’ve been trying to get pregnant for some time, it's possible you may have already undergone some tests (usually via your GP or hospital referral), and might know what your particular fertility issue is.
However, according to recent HFEA data, up to 33% of patients undergoing fertility treatment are suffering from what is usually described as ‘unexplained infertility’, i.e. the root cause is unknown.
If this is the case, it’s possible your consultant might recommend a further course of tests, first, to see if they can pinpoint any specific issues (These tests might include things like sperm count and sperm motility testing; blood tests to check your hormone levels and other fertility markers; ultrasounds and genetic testing, among other things).
If you’ve been through most of the tests already and/or are just keen to crack on with treatment, then your doctor will map out a suggested treatment plan for you.
At your first meeting, ask them to explain exactly what they’re recommending, and why.
Use this opportunity to sense-check your understanding of the difference between many of the acronyms you’ll hear bandied about: IVF, ICSI, IUI... and what's involved in each.
For example, if you’re needing IVF, will you need ICSI too (if there’s potentially an issue with sperm count or motility)? Or should you start off with IUI and see how that goes before moving to IVF later, if required?
Doctors sometimes forget that all of this stuff is brand new to most of us – all the FSH, AMH, IUIs and ICSIs – and it can take a while to get your head around it. Don’t let them rush through their explanation just because they’ve outlined the process to 1,000 other couples before you. Ask them to walk you through, step-by-step, and use diagrams to explain things, especially if you’re more visual than verbal!
Also request a written summary of your treatment plan if possible, but if your consultant is pressed for time (and they usually are of course), make sure you take notes yourself.
TOP TIP: read your notes BACK to your consultant by way of summary before you leave to make sure you’ve not missed anything or have inadvertently invented new names for things…it’s a well-known phenomenon that fertility treatment plans are crystal clear when you’re with the consultant but everything they’ve said mysteriously evaporates into the ether as soon as you close the door behind you.
Finally, ask your consultant to sketch out the likely timings of your treatment. For example, there are several steps in an IVF cycle, including the stimulation or injection phase, egg collection and embryo transfer. The length of time it takes to complete the cycle depends on whether you’re doing a long or short protocol so it’s good to understand the approximate number of days/weeks in each phase of your treatment. And seeing the big picture before you start also helps remove some of that fear of the unknown.
Q3: What are my chances of success with this treatment at your clinic?
Success rates can vary significantly between clinics so you need to understand their figures.
Try to tease out:
-When were your figures reported? Are they current or is the clinic still using stats from three years ago?
-What’s the live birth rate for my treatment at your clinic? (this is a more important marker than the number of pregnancies or embryos transferred)
-What’s the percentage of live births in my own age group?
This is the most helpful stat to get your head around. While IVF has an average success rate across all age groups in the UK of 22% per embryo transfer (Source: HFEA Fertility Treatment 2017: Trends & Figures report), and 29% for women under 35, if you’re aged 40-42 that figure dips to 11% because of the natural decline in egg quantity and quality after the age of 35.
You need to ask your consultant to be totally open and honest about your chances with, say, IVF. No one wants to leave the consulting room feeling dejected but you have to be pragmatic about success rates based on your age/medical issue. Treatment costs can quickly mount up so you need to be in full possession of the facts and spend your budget on the treatment which will offer the best chance of success for you. For example, if you're already over 40 is it better to go straight to IVF or try ICSI first and work up to IVF? Your consultant should help you work through these big and important decisions.
-Is there anything else I can do to help improve my chance of success?
For example, some clinics might suggest PGS (Pre-implantation Genetic Screening) to check the DNA of embryos created during IVF for genetic abnormalities (this might be recommended if you’ve suffered several miscarriages and your consultant thinks egg quality could be a factor).
Are there any lifestyle changes your clinic would recommend?
And given the rising number of studies showing the benefits of holistic treatments on fertility patients, are there any complementary therapies they would recommend (e.g. acupuncture), and does the clinic offer this, or work with a recommended provider?
Q4: Does your clinic favour single or multiple embryo transfers?
Medical best practice is now for elective single embryo transfer (eSET), as only 1-2% of eSETs result in multiple pregnancies, thereby reducing potential risks to mother and child (see below).
Generally, if you’ve two good quality embryos on embryo transfer day, and one is good enough to freeze, most clinics will suggest you put one back and freeze the other for a later frozen embryo transfer (if required).
However, the decision is not always clear-cut and there are certain circumstances when a clinic might advise putting two embryos back – for example if you only have a couple of embryos of below average quality and therefore nothing to freeze. The best advice is to be clear on the risks of multiple embryo transfers and to discuss the options carefully with your consultant. Ultimately the decision is 100% yours though, and you have to be comfortable with the outcome, whatever it is.
Q5: What are the risks and side effects?
Once you are clear on the treatment plan your consultant is recommending, it’s important to ask about the drugs they’re proposing and any associated risks or side effects. OHSS (Ovarian Hyperstimulation Syndrome) – where your ovaries react to the hormone injections and produce too many follicles – is a fairly rare condition but can be quite serious so it’s important to know what symptoms to look out for.
One of the biggest risks from fertility treatment is multiple pregnancy, which can have physical ramifications for both mother and baby, such as premature or preterm birth, or more rarely, birth defects. Conditions during pregnancy are also more likely if you’re carrying multiple babies, such as high blood pressure and gestational diabetes.
Of course it’s easy to scare yourself silly so get the facts and try to keep perspective. Risks and side effects do happen and you need to be aware but they are relatively rare.
Q6: Is all treatment done onsite?
In the long list of questions to ask, this one somehow seems like a minor detail when you’re facing up the fertility treatment mountain, but it’s definitely worth knowing upfront whether the laboratory is there onsite or not.
Some hospitals and smaller clinics will use other clinics’ laboratories for embryo culture and embryo transfer. Which means while you might have been enjoying a short trip to and from the hospital for your blood tests, consultant appointments and ultrasounds during the initial phases of treatment, you could suddenly find yourself trekking halfway across the city for your embryo transfer.
While we’re talking laboratories, it’s also good to ask about embryo development and transfer: does the clinic do a 3 or a 5 day transfer?
Most clinics will tend to favour pushing to 5 days or blastocyst stage if they can, but there is then a risk that you could end up with only a few, or even no embryos to transfer. Talk to your consultant about their laboratory processes and the embryology team as an experienced team can really make all the difference.
Q7: How much will my treatment cost?
There’s no escaping it: fertility treatment can be extremely expensive if you’re having to pay for it yourself.
Clinics’ pricing information tends towards the ambiguous. Many clinics quote a figure on their website, for IVF, say, but it will likely exclude many of the essentials you’ll need, such as medication, and sometimes blood tests and ultrasounds, too.
This can make it not only hard to set a clear upfront budget and know exactly what you’re in for financially, but also to compare clinics.
At your first clinic appointment, drill down into every aspect of your treatment plan and ask for itemised costs for each element.
Also ask whether your prospective clinic offers any kind of financial packages for your treatment.
Some offer ‘multi-cycle IVF’ or ‘Refund IVF’, which means you pay an upfront fixed fee for your treatment package for say, 3 cycles of IVF, and if you don’t get pregnant with that clinic after the three cycles, you are refunded part or even all of your initial payment.
The downside is you end up paying slightly over the odds if you’re lucky enough to get pregnant with your first cycle (but hey, at that point you won’t care about the money you spent – you’re pregnant). And given some recent studies suggest the average couple take 2.7 IVF cycles before getting pregnant, it could be worth considering, particularly if you’re the type of person who likes to have a plan in place and keep a tight rein on your finances.
Q8: Tell me about appointments and communication
Some clinics can get extremely busy, especially in cities, or if they have consistently high success rates. The amount of contact time you’ll need, for blood tests and scans, will vary between clinics too. It’s useful to ask the following:
-How often will I need to come into the clinic?
-I’m working full-time – do you have flexible appointment times e.g early mornings/later evenings and weekends for blood tests?
-How often will I see a consultant?
-Will you be overseeing my treatment personally?
-How often will I be updated during treatment and how/by whom?
-When can I start treatment?
This last one is important. Your preferred clinic might not be able to treat you immediately and you might be put on a waiting list. Ask how long the wait is going to be and if it’s several months and time is of the essence, you might want to consider going with one of your other shortlisted clinics, especially if their success rates are similar.
Q9: How long has the team been together?
This might seem an odd question to ask, but several studies have shown that teams – particularly in the medical, airline and military fields - who have worked together for a long time tend to get better results (it’s known as the ‘familiarity effect’. We’re going a bit off topic but this Harvard Business Review article explains things in case you’re interested https://hbr.org/2013/12/the-hidden-benefits-of-keeping-teams-intact).
As well as asking the question straight up at your first appointment, there’s usually a ‘meet the team’ section on clinics’ own sites; and you can find some candid feedback from past patients on a variety of fertility forums. And here at The Fertility Circle, you can read other members’ reviews and ratings of each of the clinics listed in our database.
Q10: What happens if my treatment doesn’t work? What next?
It’s always good to have a back-up plan. You might start with IUI, but if you’ve not had success after a few rounds, move onto IVF (depending on your age and fertility issue).
So before choosing your clinic, it’s good to know:
-Does your clinic offer the full spectrum of fertility treatments?
-Do you offer counselling if my treatment fails and I need some support?
-Do you offer egg donor/sperm donor treatment, if I might need to consider it in future?
A few final tips:
Don’t forget the paperwork
Remember to take any paperwork you have with you to your appointment. Blood test results; any investigative procedure results; relevant medical history for you and your partner. This is all essential background info for your consultant to help them determine the best protocol (treatment type) for you.
Write it down
If, like me, you’ve a memory like a sieve, take as many notes as you can during your consultation. You’ll be unintentionally bombarded with rapid-fire stats and drug-names and you’ll probably leave the room with your head swimming, thinking ‘what is it we’re supposed to do next?’. Better still, give this task to your partner or friend, if you've someone accompanying you on your appointment. It’ll not only make them feel a really useful part of the process (because let’s face it, there can be times along the fertility journey when they can feel like a casual bystander), but allow you to focus your full attention on your checklist.
Be a good listener
There’s an awful lot of info to digest at your first appointment and naturally you’ll be bursting to ask your questions. Just make sure you give your consultant a chance to get a word in edgeways, too!