EVALUATION OF FEMALE INFERTILITY

The evaluation should begin with taking a detailed medical history and having the past medical history thoroughly analyzed by a specialist. It is extremely important that the doctor focuses on the couple, conducts the consultation, and plans the next steps. Otherwise, indiscriminately recommending IVF (In Vitro Fertilization) treatment to all cases without careful consideration and trying to persuade them is not a true medical practice.

The duration of infertility, any previous pregnancies, treatments that have been applied, operations (laparoscopy, laparotomy, etc.), menstrual pattern, age at first menstruation, painful menstruation, milky white discharge from the nipples, current medication use, contraceptive methods used to date, past infections (tuberculosis, hepatitis, etc.), and habits (alcohol, smoking, etc.) are evaluated. Bringing with you previous blood test results, imaging studies, surgical reports, and prescriptions for medications used will be helpful in completing the evaluation in a shorter time.

In the evaluation of the woman, general examination and examination of the reproductive organs are of great importance. During this examination, findings that may provide clues to the cause of infertility can be detected.

The examination is performed not only to evaluate the reproductive organs but the entire body. Some hormonal diseases (such as diabetes and thyroid gland disorders) are closely related to many factors such as the ability to conceive and the risk of miscarriage once pregnant. Similarly, some disorders of the reproductive organs can cause systemic findings (such as increased body hair). Additional conditions detected during the examination should be resolved before treatment. Possible infectious (inflammatory) conditions in the woman are identified through examination and subsequent tests and then treated.

For this purpose, during the examination the cervix (neck of the uterus) and vagina are examined in detail. It is important to take a swab test (Pap smear) during the examination to allow early detection of cervical diseases. At the final stage of the examination, a trial passage into the uterine cavity with a thin catheter may be performed to obtain preliminary information for possible IUI (Intrauterine Insemination) or embryo transfer procedures. In addition, if there are factors that may cause problems in the event of pregnancy, a preliminary diagnosis is made and solutions are planned.

The second part of the examination consists of an ultrasound evaluation. In ultrasound, the reproductive organs, the uterus, and the ovaries are assessed. Diseases or changes that may be present in or adjacent to these organs are identified and their relationship with infertility is investigated. Problems that may hinder treatment are addressed. During ultrasound, an assessment of the “ovarian reserve,” which plays an important role in choosing the treatment to be applied later and in determining the chance of success of the treatment, is performed.

Ultrasound examination of the ovaries is very important. It allows determination of the ovarian reserve, that is, the capacity. In this way, the chance of success of the treatment can be clearly evaluated. In addition, by predicting the ovarian response to treatment, a more appropriate hormonal treatment regimen can be planned. The doctor’s experience is very important in this examination. Another very important point is that a woman’s treatment response is not the same every month. In cases to be treated, this should be taken into account and treatment should be scheduled in the month when the chance of success will be higher. More accurate results are obtained by evaluating this together with blood tests.

Laboratory investigations have an important place in the evaluation of an infertile couple. Hormones that regulate the function of the reproductive organs are examined. With hormone tests (such as FSH, LH, estradiol) performed on day 2 or 3 of the menstrual cycle and, more recently, with the AMH (anti-Müllerian hormone) test, which provides more accurate information and can be measured independently of the menstrual period, the ovarian reserve and the response to medication stimulation are evaluated.  

Causes of Infertility

Causes Related to the Fallopian Tubes

For pregnancy to occur, sperm ejaculated into the vagina must pass through the cervix and uterine cavity and reach the egg via the fallopian tubes. Therefore, it is important to demonstrate whether the tubes are open and functioning properly. Disorders of the tubes account for 35% of infertility causes. Hysterosalpingography (HSG) can show blockage and damage in the tubes. If there is an abnormality on the HSG film, your doctor may recommend laparoscopy for diagnostic purposes. If the tubes are found to be blocked, damaged, or adherent, they can be surgically corrected. However, if it is thought that surgery will not be successful, IVF (In Vitro Fertilization) is the best treatment alternative.

Ovulation Problems

Irregular or abnormal ovulation accounts for approximately 5–25% of infertility causes. Under normal conditions, one of the immature eggs in the ovaries develops, grows, and ruptures each month, and ovulation occurs. Anovulation is the absence of ovulation. Anovulation is the most important cause of menstrual irregularities and infertility. Ovulation may not occur even if menstruation is present. The absence of ovulation in a woman can be determined by the following tests.

• Taking a biopsy sample from the uterine lining in the premenstrual period and pathological examination
• Ovulation monitoring with ultrasound (USG)
• Measurement of serum progesterone levels (on days 19, 21, and 23 of the cycle)
• Assessment of basal body temperature
• Cervical Pap smear
• Spinnbarkeit (ferning) test of cervical mucus

If ovulation is found to be absent, ovulation can be induced with medication. More than 80% of women receiving ovulation-inducing drugs achieve regular ovulation. If there is no other problem requiring treatment, pregnancy can be achieved in more than half of the cases within the first six treatment cycles. 

Cervical Problems

The condition of the cervix (neck of the uterus) rarely constitutes a significant cause of infertility on its own. Secretions (antibodies) that kill or immobilize sperm may be present in the cervical mucus, on the sperm surface, in the seminal fluid, or in all three. Cervical mucus obtained from the woman, sperm obtained from the man, and blood samples taken from both partners are examined to detect these antibodies. However, these tests appear to have lost their former importance today. The simplest treatment method your doctor may recommend is IUI (Intrauterine Insemination), in which rapidly motile sperm obtained by special preparation techniques are injected into the uterine cavity. If pregnancy does not occur after three or more insemination attempts, more advanced treatment methods such as IVF or intracytoplasmic sperm injection (ICSI) can be used. 

Uterine Problems

Hysterosalpingography (contrast-enhanced uterine X-ray) shows the condition of the uterine cavity and the tubes. It is performed within one week after the end of menstruation and before ovulation. The contrast agent is given through the cervix, fills the uterus, progresses into the tubes, and spills into the abdominal cavity. Adhesions in the uterus, the condition of the uterine cavity, and the presence of myoma (uterine fibroid) are evaluated. The pressure created by the radiopaque contrast agent given during HSG may sometimes open mucus plugs that may be present in the tubes. For this reason, it is important to warn couples that spontaneous pregnancies may occur after HSG. Hysteroscopy can be performed to confirm or treat abnormalities detected by HSG. 

Problems Involving the Abdominal Cavity and Peritoneum

The peritoneal factor relates to abnormalities of the peritoneum, the membrane lining the reproductive organs or the inner surface of the abdominal cavity. Laparoscopy is used to diagnose these abnormalities. Laparoscopy is a surgical procedure that allows visualization and, when possible, treatment of internal organs. Endometriosis identified by laparoscopy is the sole cause of infertility in 35% of women. 

Unexplained Infertility

In approximately 5–10% of infertile couples, all tests are normal. Many couples undergo extensive testing in an attempt to identify the cause of infertility. However, if the cause of infertility cannot be determined despite all known investigations, this is called “unexplained infertility.” In the treatment of unexplained infertility, IUI and ovulation induction are used, with limited success. The pregnancy rate per IUI attempt is around 10–15%. After the first 3–4 attempts, the success rate decreases dramatically.

Therefore, performing more IUI cycles is generally not preferred, except in some special situations (couple’s preference, very young female age, short duration of infertility).

Laboratory Tests

By determining TSH and free T3 or T4 levels, information is obtained about the function of the thyroid gland. The level of the hormone prolactin, which is responsible for milk secretion from the breasts, is measured. Any abnormality detected in the levels of these hormones is evaluated in relation to infertility and treated accordingly. In addition, hormones that affect the reproductive system (DHEA, androstenedione, 17-hydroxyprogesterone, free testosterone) are examined. Since preparations are being made for a possible pregnancy, blood tests are also performed to identify in advance or determine immunity to certain viral diseases that may adversely affect pregnancy, such as hepatitis B and C viruses (jaundice), AIDS (HIV), and rubella virus. In addition, a complete blood count is performed to investigate anemia. Blood group is determined to obtain prior information about possible blood group incompatibilities. Apart from these, additional tests may be performed to address other possible complaints of the woman.

There are important reasons why the investigations in the evaluation of the couple are so detailed. Many factors can positively or negatively affect the function of the reproductive organs and pregnancy. Infertility treatment is a very delicate process, and fine details influence the chance of success. Knowing all the characteristics of the couple in detail allows planning the most appropriate treatment and thus increases the likelihood of success. The more information obtained about the couple, the better their questions can be answered. Instead of looking back and questioning after an unsuccessful treatment or when problems arise during pregnancy, taking precautions in advance and being prepared for possible problems will increase the chance of success. In the evaluation of infertility in women, other methods that can be used to assess the uterus and tubes are hysterosalpingography and endoscopic techniques. 

Diagnostic Procedures

Hysterosalpingography (HSG)

In infertility cases, HSG (contrast-enhanced uterine X-ray) and laparoscopy (inspection of the abdominal cavity through the navel with the help of a lighted instrument) are the most commonly used methods to determine whether the tubes are open and capable of performing their function. With HSG, cervical incompetence, tuberculosis, underdeveloped uterus, adenomyosis, myoma nodules, intrauterine polyps, and uterine abnormalities can be easily identified.  

Laparoscopy

This is the endoscopic examination of the intra-abdominal organs.

In general, it is used for diagnostic and/or therapeutic purposes in cases with suspicious findings on HSG, unexplained infertility, genital organ anomalies, suspected ectopic pregnancy, endometriosis, for the diagnosis and follow-up of gynecological tumors, and also in cases of unexplained pelvic pain and amenorrhea. 

Hysteroscopy

This is the endoscopic examination of the uterine cavity by inserting a fiberoptic light source device through the cervix into the uterine cavity. Hysteroscopy is performed if irregularities or filling defects are detected at the margins of the uterine cavity on HSG, if there is a uterine shape or structural abnormality, if intrauterine adhesions need to be evaluated and treated, or if the diagnosis and treatment of myoma or intrauterine polyps are required.