Dr. Marina Dimitraki, MD, MSc, MHA, PhD, EFOG-EBCOG, EFRM (ESHRE/EBCOG) Associate Clinical Director EMBRYOLAB Fertility Clinic
If pregnancy has not been achieved after one year of regular, unprotected sexual intercourse, a fertility evaluation for both partners is recommended.
However, this timeframe is reduced to six months if the woman is over the age of 35, has irregular menstrual cycles, or has an underlying gynecological condition (such as uterine or tubal abnormalities, endometriosis, etc.), as well as in cases where a known male fertility issue is present.
The evaluation of infertility should be targeted and comprehensive, addressing all relevant contributing factors while also taking into account the cost-effectiveness of the diagnostic investigations.
An equally important aspect is the simultaneous evaluation of the male partner’s reproductive health. The initial assessment should prioritize less invasive investigations that address the most common causes of female infertility.
The timing and extent of the fertility evaluation should be tailored to the woman’s age, the duration of infertility, the couple’s preferences, their individual medical history, and the findings of the clinical examination.
The cornerstone of the diagnostic evaluation of an infertile couple is a thorough medical and reproductive history, followed by a comprehensive clinical assessment. During the clinical evaluation, including transvaginal ultrasound, ovarian reserve is assessed and the internal reproductive organs are examined for conditions that may impair fertility, such as endometriosis, congenital uterine anomalies, adenomyosis, or inflammation of the fallopian tubes.
A thorough understanding of the woman’s medical history and current gynecological health is essential for selecting the most appropriate diagnostic investigations for the couple, as well as for planning and tailoring the most suitable treatment strategy.
Accurate assessment of the fallopian tubes and an objective evaluation of ovarian reserve are essential components of the fertility work-up.
Tubal patency, the condition of the fallopian tubes, and the anatomy of the uterine cavity are evaluated using hysterosalpingography (HSG).
This examination can be performed either as an X-ray hysterosalpingography (HSG) in a radiology department or as a hysterosalpingo-foam sonography (HyFoSy), using ultrasound and a contrast foam medium, performed by a reproductive gynecologist with specialized training in this technique.
Ovarian reserve is assessed through transvaginal ultrasound, as described above, and by measuring serum anti-Müllerian hormone (AMH) levels. Evaluating ovarian reserve is essential for estimating how well a woman is likely to respond to fertility treatment and her potential to produce an adequate number of good-quality eggs.
This assessment is particularly important for women over the age of 35, those with a family history of premature ovarian insufficiency, women who have undergone ovarian surgery or have only one ovary, those who have received chemotherapy or radiotherapy, and women who have shown a poor response to previous assisted reproductive treatment.
A complete preconception screening, along with the evaluation of key reproductive hormones, is also an essential part of the fertility assessment. This includes measuring thyroid-stimulating hormone (TSH) and prolactin (PRL), as abnormalities in these hormones may affect both the ability to conceive and the healthy progression of pregnancy. A more comprehensive hormonal profile is often recommended as well, including follicle-stimulating hormone (FSH), luteinizing hormone (LH), and androgen levels such as testosterone, androstenedione (Δ4), and dehydroepiandrosterone sulfate (DHEAS).
Hysteroscopy is a minimally invasive procedure used to examine and treat abnormalities within the uterine cavity, including polyps, congenital uterine anomalies, fibroids, intrauterine adhesions, and inflammation. It is often considered a first-line investigation in the evaluation of female reproductive health and plays an important role in the assessment of infertility.
Finally, laparoscopy is considered a second-line investigation in the fertility work-up. This minimally invasive surgical procedure allows direct examination of the female pelvis to diagnose and, when appropriate, treat underlying pelvic conditions. However, because it is an invasive procedure associated with higher costs and potential surgical risks, laparoscopy is recommended only in selected cases, based on the patient's medical history, clinical findings, and specific indications.
In conclusion, at a time when a wide range of highly effective diagnostic tools is available to fertility specialists, it is essential that the diagnostic evaluation is individualized according to each woman's medical history, clinical profile, and unique reproductive needs.
Egg cryopreservation is the recommended fertility preservation option for women who choose to postpone starting a family for personal or social reasons.
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