Evaluation of the Infertile Couple

Evaluation of the Infertile Couple: First Steps to Understanding the Causes of Infertility

For couples who have decided to have a child, it can be worrying when pregnancy does not occur within the expected time. Infertility is generally defined as the failure to achieve pregnancy despite regular, unprotected intercourse for one year in couples where the woman is under 35, or for six months in women aged 35 and over. When faced with this situation, rather than panicking, the correct step to take is to consult a specialist physician to undergo a comprehensive evaluation process aimed at understanding the underlying causes. It should be remembered that infertility is not a problem belonging solely to the woman or solely to the man; it is a condition that concerns the couple as a whole, and evaluation must necessarily cover both partners. The main goal of evaluating the infertile couple is to identify, as far as possible, the factor or factors preventing pregnancy, to reach an accurate diagnosis, and to chart the most appropriate and effective treatment roadmap tailored to the couple based on this diagnosis. At her clinic in Ankara, Prof. Dr. Nuray Bozkurt offers couples presenting with suspected infertility a systematic, detailed, and empathetic evaluation process using the possibilities of modern medicine.

When Should You Seek an Infertility Evaluation?

The general rule is that couples in which the woman is under 35 should consult a Gynecology and Obstetrics specialist if pregnancy has not occurred despite unprotected intercourse for 1 year, and women aged 35 and over should do so after 6 months. However, if special circumstances such as the following are present, it is beneficial to apply earlier without waiting these periods:

• The woman being over the age of 40.
• Menstrual irregularities in the woman (very frequent, very infrequent, or absent periods).
• Known or suspected gynecological problems (endometriosis, PCOS, uterine fibroids).
• A history of pelvic infection (PID) or sexually transmitted disease.
• A history of recurrent pregnancy loss (miscarriage).
• Known urological problems in the man (testicular problems, sperm disorders, erectile/ejaculation problems).
• A history of cancer treatment (chemotherapy/radiotherapy) in either partner.
• Previous abdominal or pelvic surgery.

What Are the Main Goals of an Infertility Evaluation?

A comprehensive evaluation process aims to achieve the following goals:

• Identifying the female factors, male factors, or factors belonging to both partners that are causing infertility.
• Determining the underlying cause in order to identify the most appropriate treatment option (lifestyle changes, medication, insemination, surgery, IVF, etc.).
• Providing a realistic prediction of the couple’s potential to conceive naturally or with treatment.
• Increasing the chance of success by personalizing the treatment process.
• Informing the couple in detail about their condition and treatment options, addressing their concerns, and ensuring their active participation in the decision-making process.

The Evaluation Process: A Step-by-Step Approach with Prof. Dr. Nuray Bozkurt in Ankara

Evaluation of the infertile couple requires a systematic approach and generally includes the following steps. This process is meticulously carried out by Prof. Dr. Nuray Bozkurt in Ankara:

1. Taking a Detailed Medical and Reproductive History (For Both Partners):

This is one of the first and most important steps. Your doctor gathers detailed information by meeting with both partners separately and together:

• Questions for the Woman: Age, occupation, general health status, chronic illnesses (diabetes, thyroid disorders, autoimmune diseases, etc.), previous surgeries (especially abdominal or gynecological), medications used, allergies, smoking/alcohol/substance use, dietary habits, exercise routine, menstrual cycle details (age at first period, regularity, duration, amount, pain), previous pregnancies (live birth, miscarriage, ectopic pregnancy, abortion), previous infertility treatments, history of sexually transmitted disease, Pap smear result, frequency and timing of intercourse, sexual function issues (pain, etc.), family history of infertility or genetic disease.
• Questions for the Man: Age, occupation (exposure to toxic substances), general health status, chronic illnesses, previous surgeries (especially inguinal hernia, testicular surgeries), previous infections (mumps, sexually transmitted diseases), testicular trauma, history of undescended testis, presence of varicocele, sexual function issues (erection, ejaculation problems), medications used, smoking/alcohol/substance use, working in hot environments, family history of infertility or genetic disease.
• As a Couple: How long they have been trying to conceive, frequency of attempts, previous tests and treatments, and their emotional state during this process.

2. Physical Examination:

• Woman: Height, weight measurement, and Body Mass Index (BMI) calculation. Blood pressure measurement. General systemic examination. Thyroid gland examination. Evaluation of skin signs of hormonal disorders such as excessive hair growth (hirsutism), acne, and hair loss. Breast examination (checking for milk discharge). Most importantly, a comprehensive gynecological examination: examination of the external genital organs, evaluation of the cervix and vagina with a speculum (with a Pap smear taken if necessary), and manual examination (bimanual examination) to assess the size, mobility, and tenderness of the uterus and ovaries.
• Man: In addition to a general physical examination, a genital examination by a Urology specialist is generally recommended. This examination evaluates the penis, the size and consistency of the testicles, the epididymis, the vas deferens, and the presence of varicocele.

3. Basic and Advanced Tests for Evaluating the Female Partner:

• Evaluation of Ovulatory Function: Although regular periods generally indicate that ovulation is occurring, tests are performed to confirm this or to determine timing:
  
  • Serum Progesterone: Blood progesterone level is checked during the second half of the menstrual cycle (mid-luteal phase, approximately 7 days before the expected period). A level above a certain threshold indicates that ovulation has occurred.
  • Transvaginal Ultrasonography (TVUS): Performed several times throughout the menstrual cycle to track the growth, maturation, and rupture (ovulation) of the egg follicle. The thickness and structure of the uterine lining (endometrium) are also evaluated.
  • Urine LH Kits: These kits, which can be used at home, help predict the timing of ovulation by detecting the sudden rise in LH hormone that occurs just before ovulation.
• Evaluation of Ovarian Reserve (Capacity): Provides insight into the number and quality of eggs in the woman’s ovaries:
  
  • Anti-Müllerian Hormone (AMH): One of the most important tests for showing ovarian reserve, measured from blood and able to be checked on any day of the menstrual cycle.
  • Antral Follicle Count (AFC): Counting, via vaginal ultrasound performed at the start of the menstrual cycle (usually between days 2-5), of the small (2-10 mm) follicles in both ovaries.
  • Basal FSH and Estradiol (E2): FSH and E2 hormone levels checked in the blood on day 2 or 3 of the period also provide information about reserve (elevated FSH may indicate reduced reserve).
• Structural Evaluation of the Uterus and Tubes:
  
  • Hysterosalpingography (HSG – Uterine X-ray): An X-ray film taken after contrast material is administered through the cervix. It shows the shape of the uterine cavity (congenital anomaly, fibroid, polyp, presence of adhesions) and whether the fallopian tubes are open. It is a basic test frequently used in infertility evaluation.
  • Saline Infusion Sonohysterography (SIS) / Hysterosonography: Sterile saline is introduced into the uterus under ultrasound guidance to provide a clearer view of the uterine cavity. It may be more sensitive than HSG, particularly in diagnosing polyps, submucosal fibroids, and adhesions.
  • Hysteroscopy: Direct observation of the uterine cavity by entering through the cervix with a thin camera. It is the most accurate diagnostic method and also allows treatment of any polyps, fibroids, adhesions, or uterine septum detected in the same session.
  • Laparoscopy: Examination of the outer surface of the uterus, ovaries, tubes, and other pelvic organs by entering the abdomen, under general anesthesia, with a camera and instruments through small incisions in the navel and groin. It may be performed for diagnostic and therapeutic purposes, particularly when endometriosis, suspected ectopic pregnancy, or serious tubal adhesions are suspected, or in cases of unexplained infertility. Since it is a more invasive method, it is not routinely performed as a first step.
• Other Hormonal Tests: TSH and Free T4 to evaluate thyroid function, and a Prolactin test to measure the milk hormone level, are generally requested routinely. If necessary (e.g., suspected PCOS), other hormone tests (Testosterone, DHEAS, etc.) may be added.

4. Basic Test for Evaluating the Male Partner:

• Semen Analysis (Spermiogram): The basic test in the evaluation of male infertility. A semen sample provided by masturbation after 2 to 7 days of sexual abstinence is examined in the laboratory. According to World Health Organization (WHO) criteria, sperm volume, count (concentration), motility (percentage of progressively motile sperm), and shape (morphology – percentage of normally shaped sperm) are evaluated. For accuracy, it is generally recommended to repeat the test twice, at least 1 month apart. If necessary, advanced sperm tests or urological evaluation are planned.

5. Additional Tests When Necessary:

• Genetic Tests: If there is a history of recurrent miscarriage, severe male factor, or a family history of genetic disease, chromosome analysis (karyotyping) for the mother and father, or a Y-chromosome microdeletion test specific to the man, may be requested.
• Immunological Tests: Tests such as Antiphospholipid antibodies (APS) may be requested, particularly if there is recurrent pregnancy loss.
• Infection Screening: Screening may be performed for sexually transmitted diseases (Chlamydia, etc.).

Interpreting the Evaluation Results and Creating a Treatment Plan

Once all tests are completed, Prof. Dr. Nuray Bozkurt reviews all findings in detail together with the couple. Possible factors contributing to infertility are identified, or, in cases where the cause cannot be explained, this is explained to the couple. Afterward, the most suitable treatment options (lifestyle changes, medication, insemination, surgery, IVF, etc.) are discussed based on the couple’s age, duration of infertility, identified causes, previous treatments, and the couple’s expectations. Information is provided about the success rates, risks, duration, and cost of each option. All of the couple’s questions are answered, and a treatment roadmap is created together.

The Prof. Dr. Nuray Bozkurt Difference in Evaluating the Infertile Couple in Ankara

Infertility evaluation is not made up of tests alone; it requires an expertise that also understands the couple’s concerns, gives them confidence, and provides correct guidance. Prof. Dr. Nuray Bozkurt conducts this process at her clinic in Ankara according to the following principles:

• Holistic and Couple-Focused Approach: She does not view the problem as belonging solely to the woman or the man, but addresses the couple as a whole and ensures that both partners are evaluated.
• Systematic and Evidence-Based Evaluation: By avoiding unnecessary tests, she applies a cost-effective, targeted investigation plan in line with scientific guidelines.
• Use of Modern Technology: She effectively uses the up-to-date ultrasonography devices and other diagnostic facilities at her clinic. She collaborates with reliable, accredited laboratories in Ankara for necessary blood tests and semen analysis.
• Open, Clear, and Transparent Communication: She explains medical terms and test results in simple language the couple can understand. She explains treatment options in full and helps the couple make an informed decision.
• In-Depth Experience and Expertise: With her extensive knowledge and years of clinical experience in diagnosing and interpreting the causes of infertility, she aims to reach an accurate diagnosis.
• Empathy and Psychological Support: She is aware of the emotional impact of the infertility process on couples. She offers an understanding, patient, and supportive approach throughout the evaluation and treatment process.
• Easy Communication and Accessibility: She provides an easily accessible communication channel throughout the process for any questions or concerns that arise (0538 983 18 78)(0312 284 00 12).

If you need an evaluation on your journey to having a child, you should take the first and most important step to understand the causes of infertility and discover solutions tailored to you. To book an appointment for a comprehensive and thorough infertility evaluation by Prof. Dr. Nuray Bozkurt at our clinic in Ankara, you can reach us by phone at 0538 983 18 78. A correct and complete evaluation forms the foundation of successful treatment.