Fertility clinics, like all doctor’s offices, can feel unfamiliar and intimidating when you start seeking answers about your health. That's why it’s important to remember just how much help is out there for you. From ovulation tracking and fertility hormone testing to egg freezing, there’s a whole spectrum of ways to get information about your reproductive health and pursue different paths to parenthood.
In a recent conversation with Dr. Rashmi Kudesia, MD, MSc, a reproductive endocrinologist and infertility specialist (REI) at CCRM Fertility in Houston, we discussed everything you need to know about assisted reproductive technology (ART). The more access you have to information about these kinds of treatments, the better you can plan to do what’s best for your reproductive health.
The basics of ART
The American Society for Reproductive Medicine (ASRM) defines ART as “all treatments which include the handling of eggs and sperm and/or embryos.” Ordinarily, you won’t undergo ART until you’ve already attempted techniques like timed intercourse or less elaborate fertility treatments like oral medication (which we cover later) — unless you’re trying to get pregnant with a partner who has ovaries or on your own. Doctors who practice ART (like Dr. Kudesia) are called reproductive endocrinologists (REIs), and they treat infertility by handling both the egg and sperm to create an environment where egg fertilization can more easily occur. You’ll hear a lot of these acronyms when discussing ART treatments: REI, IVF, IUI, ICSI, and more. Keep reading to learn what each of these procedures actually entails.
“The next step” on your road to conception
Choosing to pursue medical assistance on your fertility journey is often thought of as “the next step” on your road to conception. Different circumstances will motivate you to take this next step, an action Dr. Kudesia describes as “preemptively talking to someone about your concerns — maybe starting with your gynecologist or primary care doctor but then working up to a reproductive endocrinologist.” You may be experiencing one of the following when you start this process:
- Hormone test results: If your fertility testing results from a panel like the Modern Fertility Hormone Test reveal out-of-range hormone levels and you want help understanding what that could mean for your fertility.
- Age: If you’re under 35 and have been trying to conceive with a partner who has sperm for a year. If you’re 35 and older and have been trying to conceive with a partner who has sperm for six months.
- Pregnancy loss: If you’ve experienced two or more miscarriages, referred to as recurrent miscarriages, ART can help you understand what’s causing pregnancy loss and potentially help you overcome it — especially in vitro fertilization (IVF) combined with genetic testing of embryos, Dr. Kudesia says. (We’ll dive further into the details of that procedure in a later section.)
- Pre-existing reproductive health conditions: If you have any pre-existing medical conditions related to your reproductive health, such as polycystic ovary syndrome (PCOS), endometriosis, ovarian cysts, or fibroids, you may already know that getting pregnant on your own may be difficult and choose to seek medical guidance.
- Interest in fertility preservation: People with ovaries are born with all the eggs we’ll ever have, and as we age, our number of eggs decreases and the quality of those eggs decreases, too (meaning they may be more likely to have genetic abnormalities). Fertility preservation, or egg freezing, gives you the opportunity to preserve younger, healthier eggs that remain safely stored at a laboratory until you want to use them to create embryos at a later date. (We’ll explain how that works in a later section.)
- Conception with donor sperm: If you require donor sperm to conceive because you’re single, in a relationship with someone who has ovaries, or in a relationship with someone experiencing male factor infertility, then you will need help from assisted reproductive technology.
What may happen before ART
When you begin your fertility treatment journey, your REI may take you on a gradual process that Dr. Kudesia describes as going from “the most basic treatment and working our way up” to ART. Below, we’ll break down these different treatment steps.
Ultrasound and/or blood panels
Before your REI prescribes you any medication, you might undergo ultrasounds and/or blood -work panels to better understand the status of your ovarian follicles (fluid-filled sacs in your ovaries that house your eggs).
“Are you actually growing a follicle? Is one of those follicles becoming bigger, suggesting that the egg is maturing and going to ovulate on its own?” These are the kinds of questions your REI will want to explore before deciding the best route of treatment, Dr. Kudesia explains.
Ovulation-induction oral medications
If monitoring and testing reveals irregular cycles, unexplained infertility, a diminished ovarian reserve, or another obstacle in your way of conceiving, then your REI might suggest adding oral medication to your treatment plan to induce ovulation. You will likely be prescribed one of the two medications: clomiphene citrate (aka Clomid) or letrozole (aka Femara).
While these medications do not work identically, they have similar instructions and results. You take either Clomid or Letrozole for five days at the beginning of your cycle, Dr. Kudesia explains, and the medication changes how your brain communicates with your ovary. By interfering with this communication, your brain provides increased stimulation to your ovary, helping it produce one or more follicles which can then house one or more mature eggs.
These injectable medicines are the next step if oral medications are not enough to help you conceive, and they’re known as the “IVF medications,” Dr. Kudesia says. You do hormone injections — usually a combination of follicle-stimulating hormone (FSH), and/or luteinizing hormone (LH) — for 8-10 days, followed by human chorionic gonadotropin (hCG) and/or leuprolide acetate (Lupron) on the last day to trigger the ovulation process and prepare for egg retrieval.
“Those hormones are the same hormones your brain is making every month to get your ovary to grow one egg,” Dr. Kudesia says, “so when we're doing IVF and using these medications, we're basically giving your ovary extra food so it can grow a whole bunch of eggs for you at the same time.”
The three treatments above can be paired with timed intercourse or with a procedure called intrauterine insemination (IUI). In the case of timed intercourse, your doctor can help you track your ovulation to determine your fertile window (most fertile days of your cycle: 5 days leading up to and the one day of ovulation). Then, you can plan for intercourse when your egg is already most likely to be waiting for sperm.
Intrauterine insemination (IUI)
Intrauterine insemination (IUI) is a treatment in which sperm (either from a partner or a donor) is inserted directly into the uterus with the use of a speculum and a small catheter. This is typically a quick office procedure that can be completed with fresh or frozen sperm, and it’s used by people with partners who have sperm as well as people who are conceiving on their own or have partners with ovaries. According to one study which analyzed over 4,000 insemination cycles, pregnancy rates per cycle averaged between 5% and 15 %.
CCRM adds that the sperm inserted via catheter “are washed in a special solution that supports their health and facilitates the separation of the fast-moving sperm from the sluggish or non-moving sperm.”
Dr. Kudesia says that, while not the most statistically effective treatment, IUI does slightly increase pregnancy rates “because it helps more ‘good’ sperm get closer to where they need to be.” IUI also does not require as many additional medications and appointments or as many invasive follow-up procedures as other treatments like IVF. (That means it’s less expensive, too.)
The different types of assisted reproductive technology
If the above methods (combined or on their own) don’t make conception possible, using ART can help ensure sperm reaches your egg.
In vitro fertilization (IVF)
In vitro fertilization (IVF) is a fertility treatment that initially happens outside of your body, when an REI recreates the steps of fertilization in a laboratory using your own eggs or donor eggs and a partner’s sperm or donor sperm. The embryos resulting from these fertilized eggs are then transferred back into the uterus or frozen for later use.
According to SART, the IVF success rate in the US for women of all ages is around 30% — but this varies depending on many factors. Dr. Kudesia clarifies that when taking into account your age, whether you’re using your own eggs or donor eggs, infertility diagnoses, and the laboratory you’re using, this success rate can range from <5% all the way up to nearly 80%.
“We use those injectable medications [to stimulate ovulation] for about 8-10 days, during which time we watch you very closely to see how your follicles are growing,” Dr. Kudesia says. “Then we do a procedure called egg retrieval under IV sedation with the guidance of an ultrasound — you’re deeply asleep and don’t feel any discomfort.” When your eggs are removed, they’re either frozen for later use or taken to a laboratory to be fertilized by sperm.
Intracytoplasmic sperm injection (ICSI)
Intracytoplasmic sperm injection (ICSI) is a procedure that often accompanies IVF, especially when a couple is experiencing male factor infertility. During ICSI, your doctor injects a single sperm into the egg in hopes of creating an embryo. This direct contact between the egg and one sperm can help counter low sperm quality by making fertilization easier.
Preimplantation genetic testing (PGT)
Preimplantation genetic testing (PGT) is another procedure to help make IVF more successful. When embryos are created in a laboratory, your doctor has the ability to perform genetic testing on them before they’re implanted into your uterus. That way, you can use the highest quality embryos to increase your chances of a healthy pregnancy and birth.
One of the most common types of genetic testing, Dr. Kudesia says, is aneuploidy testing. Aneuploidy testing screens for abnormal chromosome numbers (more likely to occur when we try to conceive at an older age), and these abnormalities can put you at risk of miscarriage or other pregnancy complications. Through genetic testing, your REI can be sure to use your most viable embryos so that your IVF is successful.
Cost of fertility treatments
In the United States, SART reports that IUI can cost anywhere from a few hundred dollars up to $2,000 per cycle, based on the fertility clinic, the type of medication used, the blood work, and follow-up that’s required. They explain that the average cost of IVF is around $11,000 to $12,000, but again this doesn’t include the cost of medication, which can add thousands of dollars to your medical bill. If your treatment requires donor eggs or a gestational surrogate, then the costs go up again.
“Increasingly, insurance companies are covering part or all of it,” Dr. Kudesia says. “But it depends on the state you live in and a variety of other factors. Your medical team will help you brainstorm how to get affordable treatment.”
Your first appointment will likely also include a meeting with a financial consultant who can explain your benefits coverage and each impending cost.
How to find a fertility clinic
Dr. Kudesia knows that finding the right clinic to begin ART can be daunting, but there are ways to make sure you end up with a supportive medical team and a clinic with high success rates:
- Research clinic success rates: Whether or not you expect to need ART like in vitro fertilization (IVF), Dr. Kudesia stresses the importance of looking at prospective clinics’ IVF success rates. These statistics are public information that get submitted to the Centers for Disease Control (CDC) and the Society for Assisted Reproductive Technologies (SART), and not all fertility clinics are equally successful at helping patients conceive. Since it’s impossible to predict whether or not you’ll need an IVF lab’s assistance at the start of your fertility treatment, it can be helpful to be at a clinic that can assist you should IVF become part of your fertility journey. Moreover, Dr. Kudesia says it’s a “red flag” if any clinic does not readily supply this information.
- Get personal recommendations: Recommendations from a doctor you already trust or from friends and family who have experienced similar reproductive needs can help you find the right fit. If you’re conceiving with a partner who has ovaries, these recs can help you find LGBTQ+-affirming clinics (since that’s not something you can easily search for on websites like SART’s).
- Consider online reviews: Dr. Kudesia suggests researching doctors’ online reviews as well, but to remember to take them with a grain of salt. Take note of any recurring patterns from patients’ comments, but don’t let one random bad review stop you from learning more about a doctor who interests you.
Keep in mind that it’s important for your REI to hear your needs and take them seriously, and for you to have convenient access to nurses and doctors throughout the process. Once you find a clinic or doctor you think you like, you can set up a consultation to make sure it’s the right place for you.
ART is often not an expected part of fertility journeys, and difficult emotions can follow these appointments.
“I think a lot of us are the ‘go-getter’ type, and we may have planned so many aspects of our lives,” Dr. Kudesia says. “Patients tell me, ‘I was going to get pregnant at this time and I was going to deliver my baby at this time — but then they experience difficulty or haven’t found a partner. And I think there’s a bit of an identity crisis.”
But Dr. Kudesia stresses that there is nothing “wrong” with you for needing ART, so there is no reason to “blame” yourself. Choosing when to start exploring ART options is a wholly personal decision, and you deserve a strong support system as you navigate your ART journey. And that’s what the Modern Community — and Modern Fertility — is here for.
Watch our full convo with Dr. Rashmi Kudesia below, and stay tuned for more information on reproductive health from this discussion and from all of our experts.