Infertility Evaluation and Assisted Reproductive Technology
Evaluation
Infertility is failure to conceive after 12 months of unprotected intercourse (6 months if age ≥35). Core evaluation: semen analysis, ovulatory assessment (cycle history, mid-luteal progesterone), tubal patency (HSG or saline infusion sonography), and ovarian reserve testing (AMH, antral follicle count).
ART fundamentals
Know the steps: controlled ovarian stimulation, trigger (hCG or GnRH agonist for antagonist cycles to reduce OHSS), oocyte retrieval, fertilization (IVF vs ICSI), embryo culture, and transfer. ICSI is indicated for male factor, prior fertilization failure, and preimplantation genetic testing-not routinely for all couples.
OHSS risk factors include high AMH, many follicles, high estradiol, and young age. Prevention: GnRH antagonist protocol with agonist trigger, freeze-all, and cabergoline.
Traps
- Interpreting a normal HSG as excluding endometriosis or male factor.
- Recommending ICSI for unexplained infertility without indication.
- Forgetting age is the strongest predictor of success and that elective single embryo transfer reduces multiples without reducing cumulative live birth.
- Missing that a hysterosalpingogram assesses tubal patency but not peritoneal disease.
Worked example
A 37-year-old with 8 months of trying: initiate evaluation now (age ≥35 shortens the threshold to 6 months). If semen analysis and HSG are normal and she ovulates, proceed to ovarian stimulation with IUI or IVF depending on reserve and tubal status.