Infertility, also known as sterility, is the condition where there is no pregnancy despite regular and unprotected sexual intercourse for one year, or if pregnancy occurs but never results in a live birth. About 80% of couples achieve pregnancy within the first year of trying, and by the end of three years, approximately 85-90% of couples achieve pregnancy. Therefore, infertility is a health issue that affects about 10-15% of couples, even though there may be societal differences.
Young couples are especially advised to undergo initial evaluations, and explaining the above-mentioned success rates to them, in turn this can help reduce unnecessary stress and financial burden with added treatment.
There is no need to wait for one year to start testing and treatment when a known problem is detected in couples (for example, women with irregular menstrual cycles, women with advanced age, women with reduced egg reserve, hormonal imbalances, uterine problems such as fibroids, polyps, or conditions that could interfere with pregnancy, blockages in the fallopian tubes, severe male sperm count, motility, or structural abnormalities, and couples unable to engage in sexual intercourse).
In older couples, especially when the woman is over 35, a different approach is needed. If such couples fail to conceive after six months of regular unprotected sexual intercourse, it is advisable to consult with an experienced specialist without delay.
Conditions Where Waiting for 1 Year for Spontaneous Pregnancy is Not Necessary:
- Women with irregular periods
- Advanced age in women
- Women with diminished ovarian reserve
- Detection of hormonal imbalances
- Women with uterine problems (such as fibroids, polyps, or myomas that could interfere with pregnancy)
- Women with tubal blockages or other issues affecting the sperm and egg meeting
- Severe deficiencies in sperm count, motility, or structure
- Couples unable to engage in sexual intercourse
Basic Tests for Couples Who Want to Have Children:
The evaluation of couples who want to have children and have been having regular unprotected sexual intercourse without success should be conducted jointly, and care should be taken to create a comfortable environment during the consultation. In the initial assessment, the woman’s age, menstrual cycle, any previous pregnancies and their outcomes, sexual frequency, and any other medical conditions or surgeries for both partners are inquired about. Subsequently, a complete gynaecological examination is performed on the woman (including a Pap smear if not previously done, and breast examination), and ultrasound is used to assess the uterus and ovaries. If there are no contraindications to examination, transvaginal ultrasound is appropriate. The ultrasound can detect conditions such as fibroids, polyps, or adhesions in the uterus. The ovaries are assessed for the presence of any cysts, and the number of antral follicles (egg sacs) in each ovary is counted.
Usually, on days 2-4 of the menstrual cycle, fasting hormone tests are performed to evaluate ovarian reserve, including anti-Müllerian hormone (AMH) levels in the woman. The man is asked to provide a semen sample for analysis, with sexual abstinence not exceeding 4 days.
The fallopian tubes, where fertilization and embryo transport occur, must be healthy for natural pregnancy. To evaluate whether the fallopian tubes are open and healthy, a procedure called hysterosalpingography (HSG), which involves a contrast dye X-ray, is often performed. HSG can be done within a week after the end of the menstrual period. Local or sedation anaesthesia may be applied before the procedure. The purpose is to visualize the shape of the uterus and detect any structural anomalies in the uterus, as well as to determine if there is any blockage or dilation (hydrosalpinx) in the fallopian tubes.
If no problems are found in the tests, couples can be monitored for spontaneous pregnancy for a while longer, or they can adjust their timing for sexual intercourse based on the doctor’s examinations and ultrasounds.
Why Does Pregnancy Not Occur Despite Normal Tests?
Approximately 15-20% of infertile couples have normal test results and are categorized as having “unexplained” infertility. The initial tests performed in couples desiring children primarily assess whether regular ovulation occurs, whether there is sufficient sperm, and whether there is any condition that would prevent the meeting and fertilization of these two cells. However, advancements in techniques such as in vitro fertilization (IVF) and genetic testing have shown that a much more complex system is at play in achieving fertilization and a healthy pregnancy. Factors such as the internal dynamics of the embryo, the molecular environment of the uterine lining (endometrium), and the immune system all play a role in the successful implantation of the embryo. In other words, having normal results in standard infertility tests may not necessarily mean that everything is “normal.”
Some patients in the unexplained infertility group may achieve pregnancy spontaneously, while others may require intrauterine insemination (IUI) or in vitro fertilization (IVF) to become pregnant.
