Infertility: Causes, Investigations and Treatment Options

Infertility is the failure to conceive despite regular unprotected intercourse: 12 months in couples where the woman is under 35, and 6 months at 35 or older. Approximately one in six or seven couples meets this definition. Importantly, it does not imply permanent sterility — in most couples a cause can be identified and pregnancy achieved with appropriate treatment.

When should assessment begin?

• Under 35: after 12 months of trying.
• 35 and over: after 6 months.
• Over 40: at the first consultation, without waiting.
• Immediately where there is irregular menstruation, previous pelvic infection, endometriosis, previous pelvic surgery, two or more pregnancy losses, or a known male factor.

Female causes

• Ovulatory disorders: polycystic ovary syndrome (PCOS) is the most common; thyroid disease and hyperprolactinaemia also disrupt ovulation.
• Tubal factor: blockage or adhesions following infection, ectopic pregnancy or surgery.
• Endometriosis: impairs both oocyte quality and tubo-ovarian function.
• Uterine pathology: polyps, submucosal fibroids, intrauterine adhesions (Asherman syndrome) and uterine septum may prevent implantation.
• Diminished ovarian reserve: related to age, previous ovarian surgery or chemotherapy.

Male causes

A male factor is present in about one third of couples, which is why semen analysis is a first-line test and should be requested alongside the female investigations. Abnormalities of sperm count, motility or morphology, varicocele, previous mumps orchitis, infection, hormonal disorders, certain medications, smoking and heat exposure are the principal contributors.

Which investigations are used?

• Semen analysis: after 2–5 days of abstinence; repeated after 2–4 weeks if abnormal.
• Confirmation of ovulation: cycle history, day 21 progesterone, or follicular tracking.
• Ovarian reserve: day 2–4 FSH and oestradiol, AMH, and antral follicle count on ultrasound.
• Tubal patency: hysterosalpingography (HSG) or ultrasound-based HyCoSy.
• Hormonal screening: TSH and prolactin; androgens where clinically indicated.
• Further investigation: hysteroscopy for suspected intrauterine pathology, laparoscopy where endometriosis or adhesions are suspected.

Treatment options

Treatment is stepwise and guided by the diagnosis and the woman's age, aiming to achieve pregnancy with the least invasive effective option.

• Lifestyle measures: weight optimisation, smoking cessation, folic acid, and regular intercourse around ovulation. In PCOS, a 5–10% weight loss alone can restore ovulation.
• Ovulation induction: letrozole or clomifene citrate, with low-dose gonadotrophins and follicular tracking where required.
• Surgery: hysteroscopic removal of polyps, submucosal fibroids, septa and adhesions; laparoscopic treatment of endometriosis.
• Intrauterine insemination (IUI): 3–4 cycles in mild male factor, cervical factor and unexplained infertility, provided the tubes are patent.
• IVF/ICSI: for bilateral tubal blockage, severe male factor, advanced maternal age, diminished reserve, or after failed earlier treatment.

Unexplained infertility

In roughly 10–15% of couples all investigations are normal. This does not mean treatment is unavailable: ovulation induction combined with insemination is effective, and IVF gives good results where pregnancy is not achieved within a defined period. The woman's age is the most important factor in deciding how long to wait.

When to seek medical advice

• No pregnancy after 12 months under 35, or 6 months at 35 and over.
• Irregular or absent periods.
• Severe menstrual pain, painful intercourse, or known endometriosis.
• Two or more consecutive pregnancy losses.
• Known varicocele, previous testicular surgery or mumps orchitis in the male partner.

Fertility assessment in Adana

The most valuable step in infertility care is a structured assessment carried out in the right order, without unnecessary testing. Op. Dr. Sadık Kükrer, MD offers joint assessment of both partners, investigation of ovulatory and uterine factors, and hysteroscopic and laparoscopic surgical treatment in Adana, Türkiye.