When to refer to a reproductive endocrinologist and how to ensure a seamless handoff

Bat-Sheva Maslow, MD

While most women will have an established and likely longstanding relationship with an ob-gyn who will provide routine gynecologic and obstetric care, they likely won’t ever see a reproductive endocrinologist and infertility specialist (REI) unless there’s a problem.

Fertility topics are widely discussed on social media and in pop culture, so some patients may seek out reproductive endocrinology and infertility treatment directly, but most will rely on their trusted ob-gyn to advise if/ when they should meet with one, and to facilitate a smooth handoff if necessary. Ob-gyns therefore not only need to know when to refer, but which tests to run, how to pick the right reproductive endocrinology partner, and how to ensure an effective handoff so their patients have a seamless experience.

Knowing when to refer

Knowing when to refer starts with asking patients key questions that might go beyond the scope of routine well-woman exams. Are you considering building a family? What might that look like for you? How long have you been trying to get pregnant or build your family? How long have you been unsuccessful?

Given that female fertility starts to drop off significantly with age, patients younger than 35 who haven’t gotten pregnant after 12 months of unprotected intercourse, or patients over 35 who haven’t gotten pregnant after 6 months of unprotected intercourse, should be referred to an REI immediately.

If you are not actively trying, what have you been using for contraception? Couples who are engaging in routine unprotected intercourse or using ineffective methods of contraception (like withdrawal) for an extended period of time and have not conceived still have an infertility diagnosis, even if they have not been “trying”. An early referral to an REI can spare many wasted months once they decide they are ready to start a family.

Have you had recurrent pregnancy loss? Are your periods coming regularly? Do you have a family history of early menopause or recurrent pregnancy loss? Have any family members struggled with infertility or other reproductive issues?

While occasional miscarriages are common, recurrent pregnancy loss affects roughly 1% to 5% of women and entails the loss of 2 or more pregnancies before 20 weeks of gestation. Women with irregular cycles may have a difficult time conceiving due to irregular ovulation. They need not wait the proscribed 6 to 12 months for a referral; it is better to have them evaluated sooner. Early-onset menopause or diminished ovarian reserve can be caused by various factors, including genetics, autoimmune diseases, and certain medical treatments, and affects approximately 1 in 20 women. These patients, as well as those with other risk factors (chronic diseases, endometriosis, autoimmune diseases, etc.), should be referred to an REI on an expedited basis.

30-day infertility diagnostic evaluation

Any referral or potential referral starts with a full infertility workup, which can be performed by any MD before the first visit with an REI. These include a series of tests and observations during a woman’s 30-day cycle. These results will inform whether a referral is warranted and will be immediately valuable to the REI if a handoff is needed.

Days 2-4

Initial tests should include day 3 Follicle Stimulating Hormone (FSH) and Estradiol. Estradiol must be drawn at the same time as the FSH to ensure the patient is “baseline” and the FSH result is accurate. AMH (anti-mullerian hormone) is another important factor to help assess ovarian reserve. It does not need to be drawn at a particular time of the cycle, but it is often convenient to draw it together with the “Day 3” labs. Initial tests should also include a transvaginal pelvic ultrasound, which can enable visualization of basal antral follicle count (AFC). This is the number of available follicles in the ovary and can vary month to month. It can be used as an indirect marker of overall egg supply – women with high egg supply will typically have a lot of visible follicles, while those with diminished ovarian reserve will have few. The ultrasound can also identify important uterine pathology, such as fibroids, ovarian cysts, or hydrosalpinx, where 1 or both fallopian tubes become blocked.

Days 5-10

Follow-up tests should include a hysterosalpingogram (HSG), a radiological procedure used to assess the shape and structure of the uterus and fallopian tubes. An HSG can identify whether 1 or both tubes are open, as well as rule out hydrosalpinx, abnormal uterine structures like a septate or bicornuate uterus, intrauterine polyps, and fibroids that may impact implantation or the sustained growth of a pregnancy. If there is any suspicion of tubal or adhesive disease, the patient may be prescribed preventative antibiotics to prevent infection.

While semen analysis can be completed anytime during the cycle, it’s recommended to complete it during this early window.

Mid cycle

Beginning on the evening of cycle day 12, women should use an ovulation predictor kit to help identify the most fertile time of the menstrual cycle. Tracking a surge in luteinizing hormone (LH) in urine can help predict when ovulation is about to occur.

Day 21

Seven to 10 days after the patient detects a mid-cycle surge in LH, physicians should obtain a serum progesterone level. A rise in progesterone confirms a functional ovulation has occurred.

After the test

Based on the results of the full fertility workup, the provider can determine the best next steps for the patient, and whether to refer them to an REI immediately or consider a treatment such as ovulation induction before referral.

Women who have decreased egg quantity compared to what is expected for their age should be referred to an REI immediately. Similarly, men who have a low sperm count or other sperm issues such as absence of sperm (azoospermia), abnormal sperm shape (morphology), or impaired sperm movement (motility), should be referred with their partner to an REI immediately. If the HSG indicates any structural abnormalities, blockages, or scarring with the uterus or fallopian tubes, the patient should be referred to an REI immediately.

The handoff

Once the decision is made to refer, clear communication, aligned care philosophies, and well-coordinated records are critical to ensure a seamless transition. Ob-gyns and REIs play distinct, yet complementary roles to help patients navigate fertility issues or complex reproductive health concerns, so it helps to reassure patients that seeing an REI is a standard next step—not a sign of failure—and to prepare them for what to expect.

Ob-gyns should first and foremost look to REIs/clinics that are clinically strong. Clinic-level results for treatments like IVF are publicly available on Sart.org, so ob-gyns can refer to clinics whose results exceed the national average. The higher the success rates, the sooner the patients will be able to return to the ob-gyn's care for their pregnancy. It also helps to partner with clinics that are committed to the patient experience and physician relationship. Clinics that have a history of being responsive, transparent, and attentive to both emotional and financial aspects of fertility care can greatly enhance the experience your patients will have after the referral. Other important factors are clinics that actively contribute research to the growing corpus of reproductive medicine, have labs with cutting-edge technology, or have a demonstrated commitment to patient safety (e.g., certified as a patient safety organization).

A close working relationship is important and will lead to the best possible outcomes for the patient. When REI and fertility clinic care teams are responsive, keep the referring physician informed, and offer compassionate, personalized care, patients feel supported rather than shuffled between providers.