The First Consultation – what to expect

Hi, Cape Fertility family. We thought we would use this opportunity during the lockdown to reach out to some of our patients, answer a few questions and see if we can explain a few things more clearly for you. Some of the questions we received via Facebook and Instagram involved what happens when I want to come and see the doctor? How do I go about this? And what can I expect? So, first of all, we need to make an appointment. We are not a walk-in clinic because we have a lot of time procedures. So, you can check out our Facebook page or our website. I will drop in links for those below as well as our Instagram page for some information, how to find us.

Yes, we are only based in Claremont in Cape Town. We don’t have any other branches anywhere else. You can ring us and we’re always happy to help. We are also happy to reach out via email and you can get ahold of us at, see the links below.

So, let’s start with the first question on what to expect when you come to see us. When you come to see the doctor at the clinic, we will take a medical history. This is very individualized, even though we send out the questionnaire as every single patient will have a different underlying issue that’s stopping you from falling pregnant. We can’t treat a 25-year-old, the same as a 45-year-old. Some patients might have an issue with the sperm and that’s why they’re not falling pregnant. There might be issues with the tubes, there might be underlying endometriosis. There might be a problem with eggs. So, we need to try and identify where the problem might be and individualize your management, according to this.

Other patients might’ve fallen pregnant once before, might have suffered from miscarriages whether one or many. And we need to know about these so we can try and understand where the problem might be. Some of the questions that we will ask are about medical treatments, so are you on any treatments? Do you have any allergies? Why? Some medication can interfere with you falling pregnant and some medication needs to be changed before you are pregnant so that it is healthy and safe for the baby. Also, some medical problems such as blood pressure can be an extra stressor during pregnancy and put you at risk of complications in pregnancy. So, we would want to know if there is an underlying medical problem, is it controlled so that your pregnancy will be safe, and you will be safe.

We also want to ask about surgeries you might’ve had; some women have had cysts removed or they’ve had tubes removed or pregnancies in the tubes, or even a burst appendix. We need to know about all of that as it can affect what’s happening inside of the pelvis and your chances of falling pregnant. We’re going to ask about your family history, any illnesses that your mother, brothers, sisters, father, grandparents might have. Why? Influences pregnancy and there might be something underlying and genetic that we need to be aware of in your medical history.
We’re also going to ask about your social history. We want to know what work are you doing, what kind of stresses do you have in your life. We want to know about drinking, smoking, recreational drug use. All of this can influence falling, pregnant, your general state of health and the health of the pregnancy. We then go through the same history for the male partner to try and understand if there’s anything we should be aware of from that side; medical problems, surgeries, injuries to the testicles, perhaps bad infections, STDS, that kind of thing. Many men like to tell their partner, oh I’ve had a child before, there’s nothing wrong with me. It doesn’t mean that they can’t be a new sperm problem. So, it is important that in every single patient, we check that the sperm is okay.

We asked the male partner to come in and complete the medical questionnaire. And the next step is an examination. So, lot like your normal gynecological examination, except we do look for a few extra things. One of the things we do look for is sign of an endocrine disease, such as dark marks around the neck. Perhaps acne, perhaps problems with excess body hair that you don’t like. These might seem like irritations to you, but there can be a key in helping us understand what might be the problem with you falling pregnant.

We check you from head to toe. So, we check your thyroid gland, which the breast examination, we check the tummy, including for any scars. If you’ve had previous surgery, these scars help us understand what kind of surgery was done. We then do your typical gynae examination; we do a pap smear if you haven’t recently had one. Why? It’s important to check on your cervical health, we always screening for cervical cancer and we don’t want to run into an issue during pregnancy. If there’s an issue we want to know about it before you’re pregnant, so we can deal with it effectively and not be a problem in the long run.

We do an internal examination because sometimes the uterus can be a little bit big and we like to feel and see if the uterus enlarged, why is it enlarged? It gives us a bit of insight as to what we’ll find on the ultrasound exam. We like to feel each ovary, sometimes there can be enlarged as well, and see if we can fill any little nodules that might be significant for endometriosis. Sometimes, if there’s a lot of scarring inside of the pelvis, everything is fixed and doesn’t really move, and we could pick this up on the examination as well. Then we move on to the internal ultrasound where we have a good look at the uterus and the ovaries and any other signs of pathology.

So, we always start with the lining, which is the inner most part of the uterus. So, the lining, if I can just show you, is this little inner bit of the uterus where pregnancy implants. We want to check that it is thick enough, I want to check that it’s not too thick and no sign of scar tissue and no signs of polyps. Polyps are a little fleshy growths inside of the uterus. And just to give you an example, those are little polyps sitting in there, we like to remove those. We also have a look in the actual muscle of the uterus for fibroids. These are little muscular growths that you can see inside of the actual muscle of the uterus. They’re not dangerous, they’re not generally cancerous. They can cause irritations with the period, but we want to know if they are there how big are, they? Where are they? And how many are there because sometimes we need to remove them.

We have a look at the ovary, and we want to have a look at the follicles, which are the potential eggs sitting in the ovaries. So, where you measured the amount of potential eggs on each side and that gives us an idea not only of the number of eggs that you have but how active the ovaries are. We can also use this to diagnose polycystic ovaries. Just to give you an idea, these are little potential eggs that we can see inside of this ovary. We check how freely, everything moves. You wants to know that the uterus and the ovary can move, there’s no scar tissue that’s holding them down. We don’t want to see big sick swollen tubes, but it’s important to note just because we don’t see them on ultrasound doesn’t mean you don’t have a damaged tube. Tubes can be blocked, tubes can be swollen, but you can’t see them on the scan. And that’s where we would need to do a different kind of test. If we are suspicious about tubal pathology. That’s called an HSG and we will chat about that a bit later in the series.

We also need to look for signs of endometriosis. You can’t always see it, but some of the signs that we can see on ultrasound is if you have a big cyst full of endometriosis on the ovary, it’s got a very characteristic appearance, and we can tell when we see that. The other thing we can look for is a little nodules that we can sometimes see at the back of the uterus, so we have a look for these as well. After the ultrasound and examination, we will request blood tests, blood tests come in two different categories. So, the first test or the tests you need to do for pregnancy. So, any woman who is pregnant will always have an HIV Syphilis test. We’d like to screen for Hepatitis, German Measles immunity status and your blood group.

So, these tests are done in anticipation of pregnancy. Why? If there’s any issue with any of these blood tests, we need to correct them. If you are HIV positive, we need to make sure that you’re on treatment and your viral load is suppressed. If you have syphilis, we need to treat that, if your blood group has shown us that you’ve got immune issues, we need to be aware of that before you conceive. If you are not immune to German measles, we need to vaccinate you. So, these are just some of the reasons we do those tests. Then we have the hormone tests, which we tend to check your egg reserve, which is a blood test called an AMH. It tells us about egg number, not egg quality, so it doesn’t tell me how good the egg is. It just tells me how many eggs we have left.

Now this test doesn’t tell me you have 2,422 eggs left or 14 months of trying to fall pregnant. What it does tell me is give me a number and tell me how you would respond if we did IVF treatments. And we use this to gauge how many eggs we think you have left, or how we think you would respond and how aggressive we need to be, or how relaxed we can be with treatment options. It can be reassuring, or it can tell us we need to get a bit more active. Some of the other tests we do we check your thyroid gland, which sits over here to make sure it’s not over or under active. If we have a concern, we check prolactin levels, which come from a little gland inside of the brain, which can sometimes present with a bit of milk leaking from the breasts. It can also present with you losing your period. So, we’d like to check that one.

We might do a few other hormone tests such as your estrogen levels or your progesterone levels. If you want to check if you have ovulated and where you might pick up one or two extra things, depending on whether we think you might have polycystic ovaries. So, we might want to test testosterone. We might want to test a couple of other of the testosterone linked hormones. We might want to check your sugar levels, your insulin levels, your cholesterol levels, but they will all be covered in the polycystic ovary video.

The next step was to do the sperm test. Now, a lot of men are very intimidated at the thought of doing the sperm test. The sample is produced with masturbation. We have two options, number one, you’re welcome to produce the sample at home. We provide containers that are clean. Men can go home in the comfort of the home produce the sample and drop it off at the clinic. We do need it to be here early in the morning, and ideally not older than about an hour, maximum hour, and a half between producing the sample and arriving at the clinic.

Our lab can then test the sample, we do this onsite and the difference between us and a different laboratory is our embryologist and our andrologist work with sperm every single day. This is not just some tests that they’ve been asked to do. This is something that they actually have hands on experience, and they know exactly what they’re doing and what they’re looking for when they do the semen analysis. The second option is you’re welcome to use our facilities at the clinic. Now it’s not like Hollywood, it’s not like the movies. I’m afraid. It is just a private room towards the back of the clinic. So, it’s not a public bathroom, you don’t have to worry about people barging in it. There’s a big space, it is clean. And you’re welcome to make use of this as well, that will be easier because of travel constraints.

The next step is to put all the information together. So, we take the medical history, physical examination, your ultrasound, sperm tests, the blood tests. We put all this information together, based on that we make a decision where we think the issues may be. Do we need to do further testing, for example, do we need to do some male blood hormone tests if we’re worried about the sperm. Do we need to check the tubes? Is there anything else we are worried about? We can make a plan going forward from there for those tests. Alternatively, it might be clear cut where the problem is and the treatment options, we can discuss all of these with you.

One of the questions we often get is how much will it cost to have treatment? And the difficulty with answering that is sometimes it costs this much for this treatment, that much for that treatment. We don’t know which treatment you need. And it’s not simply a case of I want this treatment, or I want that, it depends which treatment is actually going to benefit you. We will run through some of the different types of treatments, but our job as the doctors to make sure you understand why we recommend specific forms of treatment. And while we think that would be more beneficial. Sometimes it’s not that clear cut and we can’t always find a clear answer for why you’re having difficulty falling pregnant. And if that is the case, then we might start off with some lower level treatments. Give that a try, see if we can successfully get you pregnant. And if not, we might upscale treatment later.