WHAT IS INFERTILITY?

Infertility is defined as the absence of pregnancy within 1 year despite regular sexual intercourse. In women aged 35 and over, this period is accepted as 6 months. Therefore, if the woman is over 35, or if there is any finding in her history or physical examination that may be related to infertility, investigations should be started earlier. 
For pregnancy to occur, there should be sexual intercourse at least once a week. In cases where intercourse is less frequent, the chance of pregnancy decreases. The ideal frequency of intercourse for pregnancy to occur is 2–3 times per week.

Infertility (inability to have children) is the absence of pregnancy despite at least 12 months of regular unprotected sexual intercourse. Primary infertility refers to a situation where the woman has never been pregnant, while secondary infertility is used to describe situations where the woman has been able to conceive before, regardless of whether there was a healthy birth or not. Approximately 30% of infertile women have primary infertility, while about 70% have had one or more previous pregnancies. Approximately 8–10% of women in the 15–44 age group may experience problems conceiving. Of course, these figures may vary between populations. The role of the infertility specialist is not only to diagnose and treat the problem, but also to evaluate the couple’s chance of conceiving and inform them, even if no problem is found. Especially in women aged 35 and over, when fertilization capacity is lower, the time needed to conceive may need to be shortened even if no problem is detected in the tests. In this situation, IVF (In Vitro Fertilization) treatment may be applied.

INVESTIGATION OF INFERTILITY 

The first test to be performed is semen analysis, which should be repeated at least twice at 2‑month intervals. If the semen analysis is normal, there is no problem in the man. A man with a normal semen analysis does not need a physical examination. At the same time as the semen analysis, it should be checked whether the woman is ovulating. For this purpose, a simple hormone test (serum progesterone) is performed between days 19–21 of the menstrual cycle. Ninety‑five percent of women with regular menstrual cycles ovulate regularly. 

One of the most important tests in women is the determination of ovarian capacity (ovarian reserve). For this, a transvaginal ultrasound is performed during menstruation and the antral follicles (tiny cysts containing eggs) in the ovaries are counted. If there are fewer than a total of 6 antral follicles in both ovaries, ovarian capacity is considered decreased. In women, ovarian capacity begins to decline from the age of 37, and after the age of 44 it becomes very difficult to have a child. Sometimes ovarian capacity decreases earlier. In women with a family history of early menopause, women who have previously had a cyst removed from their ovaries, women who have had one ovary removed, women with a history of endometriosis, and women who are heavy smokers (more than 10 cigarettes a day), ovarian capacity should be evaluated very carefully. 

In couples where semen analysis, ovulation, and ovarian capacity are normal, it is investigated whether the woman’s tubes are open. For this, a uterine tube X‑ray (HSG – hysterosalpingography) is required. Although HSG is a simple and usually painless procedure, it may cause cramps in the uterus due to the rapid and high‑pressure administration of the contrast agent. The procedure should be performed immediately after the end of menstruation. In this way, the uterine cavity is better visualized and the possibility of a very early pregnancy that may occur after ovulation is eliminated. With HSG, the uterine cavity and tubes are evaluated. It can be determined whether the tubes are open and, if they are blocked, at what level the blockage is. In particular, when a single tube appears blocked at the point where it joins the uterus, this may sometimes be due to tubal spasm resulting from the high‑pressure injection of the contrast agent. In this case, there is a false, not a real, obstruction. With HSG, the chance of understanding intra‑abdominal adhesions and their severity is low. Although HSG provides information about whether the tubes are open, it does not provide information about their function. 

In women with no findings in their history or physical examination, a procedure called laparoscopy, which allows the inside of the abdomen to be visualized with the help of a telescope, may be performed. Although laparoscopy used to be a very frequently used technique, its use today, especially for diagnostic purposes, has been considerably limited. Nowadays, laparoscopy is recommended mainly for therapeutic purposes. 

There are also tests used in the investigation of infertility whose importance has not been fully proven. These include immunological investigations (antisperm antibodies) and the postcoital test (examination of the cervical mucus after intercourse for the presence of sperm). Performing these tests is not recommended. 

A minimalist approach is recommended in the investigation of infertility. Performing unnecessary tests will lead to a loss of both time and money.