What to Expect at Your First Fertility Appointment

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For the past year, I’ve tried to get pregnant through what was, for me, a totally foreign method: by having sex.

I already have a 3-year-old, Hazel, who was conceived via an anonymous sperm donor when I was 37. To have her, I ordered sperm from California Cryobank and became a patient of Dr. James Grifo’s at NYU. After two IUIs (intrauterine insemination), Grifo and his team got me pregnant.

When Hazel was a few months old, I met my partner, a man who I love deeply and has become Hazel’s father. After two years together, he and I decided to try for another baby. Though I was 40 when we started trying, I never imagined that getting pregnant through real-life insemination would be so much harder than getting pregnant through artificial insemination. Alas, for me, it has been. Last spring, I had a chemical pregnancy, then I had a $7,000 miscarriage (thank you to my former health insurance company, which shares a name with a famous grouch), then many months of nothing.

Once I hit the year mark, I wanted to know more about what was going on with my fertility and asked an OB/GYN friend for recommendations of doctors. At her suggestion, I arranged to see Dr. Luk at Generation Next Fertility. I also booked a consult with Dr. Zaher Merhi at New Hope Fertility Center, since another knowledgeable friend swore by him (and specifically, New Hope’s approach to “mini-IVF” — a gentler, less medicated, less needle-heavy method of growing and maturing the eggs for retrieval).

And then I spent a long, angsty week wondering what to expect.

To find out, I talked to several experts, eventually gaining my own experiences over the course of those two appointments. I’ve written from the perspective of someone with fertility concerns like mine, but much of what’s below can apply if you’re seeking a fertility clinic for genetic reasons, egg freezing, or interest in an egg or sperm donor. Here’s what I learned.

What should you do before the appointment?

Technically, nothing — all you have to do is show up. Still, there is some legwork you might want to take care of beforehand, depending on your needs and how your clinic works. It’s definitely a good idea to ask when you’re making an appointment what, if anything, you can or should do ahead of time.

You could have your anti-Müllerian hormone levels tested (to evaluate your ovarian reserve — though there’s some debate about AMH’s predictive ability) and be prepared to discuss results at that first appointment. Some patients also might want to have their partner’s or known donor’s semen analysis — to assess sperm count and motility — done early. Others may want to do STD testing or genetic screenings (to see whether you carry genetic mutations that can cause disease or an increased risk for certain cancers) in advance. But again, none of this is expected — and some clinics require tests to be done in-house anyway.  

“I don’t expect the patient to do any work before they see me,” said Zaher Merhi at New Hope Fertility Clinic, when I met him for my consult. “It’s stressful enough just making the appointment.”

What can you definitely do? My best suggestion is to bring a big, nerdy calendar (this is mine), so you can carefully track the timing of your last and future cycles and a potential timeline for treatment. You’ll probably also want a notebook to jot down information. A notebook also comes in handy for writing down your and your family’s health history in advance, making it less likely you’ll accidentally leave something out the day of your appointment.

What happens when you get there?

The waiting room of a fertility clinic can be a strange place. In my experience, no one really makes eye contact, and the collective vulnerability feels thick and present.

At NYU, it’s basically like a big, fancy waiting room, with wall-to-wall carpeting, glossy women’s magazines, and well-dressed singles and couples who all look like lawyers. At Generation Next, the set-up kind of looks like an intimate spa — it’s cozy and well-lit and everyone sits side-by-side on one long banquette. At New Hope, the room is large, bright, and futuristic, with coffee and coffee cake on offer. At some fertility clinics, babies and kids are unofficially (sometimes officially) not allowed, as their presence is considered insensitive to other patients.

After checking in, you do a lot of paperwork — insurance, consent signatures (if your partner isn’t with you, he or she will have to come in and sign them in person, or with a notary), and an overall health and pregnancy history. Eventually, your name is called and you see the doctor.

What will the doctor want to know about me?

When I asked Grifo what doctors normally want to know at your first infertility appointment — “I prefer ‘fertility,’” Grifo corrected me — he said you should be prepared for a long and in-depth conversation about your health history, and, if you have one, your partner’s. “We ask a lot of questions,” he said, recommending that patients come armed with as much information as possible.

Over at New Hope, Merhi says it’s also the doctor’s job to do a lot of explaining in that first meeting. “We actually try to go through education on how babies are made through intercourse. You’d be surprised how many people don’t understand how ‘normal’ pregnancy happens! We go through that. Then we explain the benefit of IUI over intercourse. We explain all about washing the sperm, taking the best quality sperm, bypassing the vagina, going right to uterus, and getting the sperm closer to the egg. And then we explain IVF …”

Right, how exactly does IVF work?

Let me try to break down IVF for you, based on what Merhi told me, because it’s a beast to understand. You take medications for approximately two weeks in order for your eggs to grow and mature. Then the eggs get collected — vaginally with a very small needle — while you’re under local anesthesia or full sedation. Then sperm is added to the eggs and, hopefully, embryos form.

After 24 hours, an embryologist will contact you to let you know how many of your eggs were mature and how many have fertilized. The embryologist will continue to monitor your embryos over the course of the next three to five days, and depending on your protocol, and how many embryos you have in the running, the doctor will recommend either a fresh or frozen transfer.

A fresh transfer means the doctor will transfer the embryo into your uterus about a week after the retrieval. Will the embryo be any healthier than an embryo made through sex? Not necessarily. “IVF doesn’t create super babies,” says Dr. Aimee, a San Francisco doctor and fertility expert, known as the “Egg Whisperer.” “What IVF can do is speed up the time it takes to get pregnant, and decrease your risk for miscarriage and in some families, prevent the inheritance of debilitating and deadly diseases (through genetic testing).”

What can you tell me about genetic testing and IVF?

For these answers, I turned again to Grifo. “There are two things that we test embryos for,” he said. “PGT-M [also known as preimplantation genetic diagnosis, or PGD] is used when both parents, or the sperm and egg source, are known carriers of a genetic disease, like Sickle Cell or Tay-Sachs. The other test, PGT-A [also known as preimplantation genetic screening, or PGS], is more widely used and checks for chromosomal abnormality or aneuploidy, which affects a large percentage of embryos.”

But just how large a percentage, and what’s the significance of aneuploidy? “Aneuploid embryos account for the majority of miscarriages and IVF failure — and are incrementally more common as women age. It’s the reason for declining fertility rates as well as the increase risk for miscarriage and Down syndrome.”

So, the reason to test an embryo is to identify and transfer a healthy embryo — but does it really lower a miscarriage rate? Aren’t there other factors?

“The embryo that is found to have a normal number of chromosomes (euploid) has the highest chance of making a pregnancy and the lowest chance of miscarriage. This is proven with data, and not a debate,” said Grifo.

With this in mind, does he insist his patients do genetic testing? “We offer it to everyone and most choose it once they see the data.”

Okay, back to the appointment itself. So … will there be a transvaginal ultrasound, and is that exactly what it sounds like?

Most likely, and yes. After talking to the doctor, you’ll be escorted into an exam room and probably told to disrobe from the waist down. Sometimes the doctors do the ultrasound, sometimes it’s a nurse or a technician.

A long, wandlike tool is inserted inside of you (sometimes you can insert it yourself). It is lubricated and slightly uncomfortable, but most women say it does not hurt.

Once the wand is inserted, the doctor can get a good look at your uterus, ovaries, fallopian tubes, cervix, and general pelvic area through images projected on a screen. There’s usually a larger screen, too, which you can look at.

At this first fertility appointment, a doctor is usually looking at the number of follicles. When I asked Merhi to explain follicles to me he said, “Imagine a balloon, and as you blow on the balloon, it fills and it pops — and then the egg comes out.” Based on the number of follicles you have, the doctor might be able to gain information about your ovarian reserve. When Merhi looked for mine, I had about ten total, which is “normal” for my age.

They’ll also let you know if they see fibroids (generally non-cancerous, non-dangerous growths of the uterus that can interfere with getting or staying pregnant; I have many and they were a non-issue with my first pregnancy) or anything else concerning. Usually, this process takes about five to ten minutes.

Will I have to give blood?

Almost certainly. At the very least, you’ll probably need your hormones tested. You might do STD screenings and any of the remaining genetic tests you need. This all depends on what, if anything, you’ve already had done.

What if I’m afraid of needles?

If you do begin fertility treatments, you’ll most likely be giving blood frequently — this is how your doctor can measure your progress, your reaction to the meds, and the timeline of your cycle.

If you opt for IVF, you’ll also have to administer your own medication via shots for at least five nights in a row, usually more. Some clinics will do the shots for you, but those services cost extra. There are also nurse-run services that come to your house, like this one, which is based in the Bay Area.

Again, some clinics like New Hope do offer (relatively) needle-free IVF, also known as mini-IVF.  The difference between traditional IVF and mini IVF is the dose of medications given, the types of medications, and the way the medication is administered. With traditional IVF, there are usually two to three injectables a day; with mini IVF, you’re taking pills, nasal sprays, and a smaller dose of injectables (one per day).

If you’re needle-phobic, or don’t love the idea of being on so many meds, you might want to ask if your doctor offers mini IVF.

Will I cry?

When I first met with Grifo to explore my pregnancy options, he said something like, “Congratulations, you’re in the game.” That made me weep happy tears. All I ever wanted was to be in the game. My mother was with me, and we still tear up talking about that moment.

This time around, I have not cried. But my fertility struggles are different now: I have a child and I know I’ll be okay if I never have another. Trying to start a family without any forward motion, on the other hand, can be a living nightmare — too many of my friends are going through it right now.

“I’d say 20 percent of patients cry at the first appointment,” said Merhi. “Many times it’s because they’re traumatized by something another doctor said; maybe a doctor said they’d never get pregnant.” He added, “Egg freezing patients are usually the most anxious. They usually don’t have a partner. Their mom sent them, or their friend made them go. They’re typically scared and don’t really know what’s happening.”

Does therapy come with the appointment?

At many clinics, there is an in-house fertility therapist available for extra charge. At NYU, I had to pass a psych test (which I also had to pay for) before moving forward with my single-mom-by-choice aspiration.

Should I do acupuncture?

If you can afford it, why not? Clinical research has shown that acupuncture used in conjunction with IVF can improve the procedure’s success rate.

“Acupuncture and Chinese medicine can help promote blood circulation to the pelvis, improve ovarian function, promote follicle development, enhance uterine blood flow — which improves uterine lining thickness, decrease uterine contractions after embryo transfer, and improve semen count, motility, and morphology,” says Jill Blakeway, founder of Yinova Center in New York, a fertility acupuncture center.

Will my doctor propose a plan before I leave?

“I like for my patient to have a plan in her head before she leaves, yes,” said Merhi. “And then I call her the next day, after she’s processed everything. There are always more questions.”

If you’re really decisive, and you understand everything, and your bloodwork is done, you might even leave that first appointment with a timeline for treatments and some prescriptions to fill. Then you’re really “in the game.” But once you turn this exciting corner, prepare to stay close to home for the next few weeks, scheduling as few commitments as possible, since you’ll be going in several times a week for monitoring.

As for me, after meeting with both Luk and Merhi, I was not quite ready to make a decision between IUI and IVF. Mostly because I wasn’t sure what my partner and I could afford.

Will I find out how much this is all going to cost?

The last portion of the appointment will most likely be with someone from the billing department. A designated staffer will give you a financial breakdown of what’s to come, with or without insurance. Some billing folks are extremely proactive, others are not (and obviously, that’s extremely frustrating). In the end, only you can really sort it out with your insurance, and do your own fighting.

Assuming you’re out of pocket, an IUI in NYC currently costs between $800 and $1600, which doesn’t include medications. IVF is going to be $7,500 to $15,000 or more per cycle (this essentially means each “try”). On top of that, the meds for IVF can be hundreds of dollars, but there are discounted pharmacies. For example, CVS quoted a friend $680 for the same shot she got from Medcal — a fertility pharmacy — for $80.

You can also talk to your doctor about the cost of treatments. “If you have a good relationship with your doctor, he or she might offer you a discounted rate (especially if things are not working out how you planned and you need to pay for another cycle)  — but that might only work in a small clinic. In a bigger clinic, you can try negotiating with the billing department — but I could barely get them on the phone, so good luck with that,” says Amy Klein, former fertility diary columnist at the New York Times. Klein, who had four IUIs, nine rounds of IVF, and four miscarriages before giving birth to a healthy baby girl, is writing a prescriptive book (The Trying Game, forthcoming from Ballantine in 2020) about infertility in the hopes of helping people avoid some of what she went through.

What happens when it’s over?

When I left my first appointment at Generation Next, my mind was not just full but overflowing. I felt like a zombie. And then I felt like a zombie who forgot to ask a bunch of things: I forgot to ask if I should take progesterone suppositories. I forgot to ask if I need to stop drinking coffee, or worse, wine. I forgot to ask about the damn acupuncture.

I called Amy Klein. (I believe every woman doing fertility treatments needs her Amy Klein. Find yours! It’s too scary and confusing to go it alone.) She could sense my exasperation: “Sometimes you feel like you’re in a factory.”

I told her about all the things I forgot to ask about, which she sympathized with. “At my first appointments,” she said, “I wish I had known that I was hiring them to help me, and had not felt too intimidated to ask thorough questions.”

Luckily, Generation Next was great about calling me right back and answering all the things I’d forgotten to ask about. And the next day on the online patient portal, Luk said my blood work showed I was about to ovulate. So, without any medicine or treatments yet, she prescribed the following: Sex tomorrow. Sex Wednesday. Sex Thursday.

That made me laugh, and finally, relax just a little.

What to Expect at Your First Fertility Appointment