When pregnancy does not occur after 6-12 months without protection, an evaluation of both partners is recommended to determine if there are risk factors or dysfunctions that affect fertility.
For good fertility in the couple, several conditions must be met at the same time:
- The woman should remove a quality egg at ovulation
- The female genital tract should be permeable and functional
- The man should remove a sufficient number of mobile sperm
- Unprotected sexual intercourse should be at the right time
The diagnosis of infertility does not imply the existence of a proven cause.
It occurs when more than 12 months of unprotected sexual contact have passed, without the occurrence of pregnancy.
In 15-20% of cases the cause of infertility remains unidentified. There is no possibility of investigation for all potential factors involved (eg quality of eggs, function of the fallopian tubes).
Only age can be a major factor in reducing fertility. Over 90% of eggs that ovulate after the age of 40 have defects, affecting condition 1 – “to eliminate a quality egg”
To find the cause of infertility, all these steps require investigation.
A correct assessment begins with a discussion of the couple’s medical history, lifestyle and risk factors and continues with a medical examination and specific investigations.
- Ultrasound – confirms ovulation, may detect other problems
- Urinary ovulation tests – positive the day before ovulation
- Progesterone dosing in the blood – at 7 – 8 days postovulatory
- Evaluation of other hormones related to ovulation: TSH, prolactin
Evaluation of ovarian reserve
- AMH (anti-mullerian hormone) test – dosing AMH in the blood
- The AMH value is correlated with the ovarian reserve of oocytes
- AFC test (antral follicle count) – ultrasound count of follicles at the beginning of the menstrual cycle is correlated with ovarian reserve and response to treatments
Evaluation of egg quality
- There are no tests to assess the quality of oocytes
- Quality is significantly affected by age, smoking and certain conditions
HSG is a contrast-enhanced radiograph that investigates the permeability of the genital tract, from the cervix and uterine cavity, through the fallopian tubes to the ovaries. Viewing the entire route provides information about permeability, not about the function of the fallopian tubes to transport the embryo to the uterus.
Visualize the inside of the uterine cavity with a thin telescope. It also allows treatments – loosening of synechiae (intrauterine adhesions), removal of a polyp or fibroid.
Other tests for assessing the uterus:
- Endometrial receptivity test (ERA test)
- Endometrial microbiome testing (EMMA test) or vaginal
- Investigation of chronic endometritis (ALICE test)
- Cervical cultures
- Endometrial biopsy
Sonohisterography is a similar HSG investigation, but it is not performed radiologically, but ultrasound.
The ultrasound scanner can visualize the passage of the contrast substance, the contour of the uterine cavity and its evacuation through the fallopian tubes. The investigation is less invasive than HSG, due to the lack of irradiation, but does not offer a fully viewable path of the fallopian tubes, but a dynamic assessment.
It is a minimally invasive surgery that allows the doctor to examine the uterus, ovaries and fallopian tubes and detect endometriosis or pelvic adhesions.
It is performed under general anesthesia and allows immediate surgical treatment.
- Evaluate sperm volume, concentration, mobility and appearance of sperm
- It does not detect genetic abnormalities in sperm or defects in fertilization capacity
- Details about the spermogram and its changes in Solutions for male infertility.
In case of sperm changes, it is recommended to repeat it and further investigations:
Urological / andrological consultation with a male infertility specialist
- Assess risk factors and medical history
- Clinically examine the genital area
- Perform testicular ultrasound
- Recommends other useful investigations
Hormonal dosages in the blood: FSH, LH, Testosterone, Inhibin B, Prolactin
Sperm culture or culture of urethral secretions
Evaluation of antisperm antibodies in semen (MAR-test)
Evaluation of sperm DNA fragmentation – reversible genetic changes in sperm
Chromosomal change testing in sperm – FISH sperm
Evaluation of urine – in retrograde ejaculation, caused by some surgery
Genetic blood tests: karyotype, Y chromosome microdeletions, CFTR cystic fibrosis mutations
Epididymal puncture / Testicular biopsy
Identification of risk factors and knowledge of fertility optimization methods
Detecting the causes of infertility helps to treat them and improve natural fertility.
Often, however, the negative effects are definitive. In this case, assisted reproduction techniques can overcome many of the obstacles.