Assessment and approach for couples trying to conceive

Planning a pregnancy and dealing with difficulties conceiving require a systematic, professional approach. Guidelines from leading international medical organizations, such as ESHRE (European Society of Human Reproduction and Embryology), ASRM (American Society for Reproductive Medicine), and ACOG (American College of Obstetricians and Gynecologists), clearly define the steps and tests needed to optimize the chances of a healthy pregnancy.

1. Assessment and testing for women

A woman's evaluation begins with a detailed medical history (menstrual cycle, previous illnesses, surgery, and lifestyle) and a general clinical examination, followed by targeted diagnostic tests in several key categories.

Gynecological examination and initial screening

• Gynecological ultrasound (transvaginal): Used to assess uterine anatomy, identify abnormalities (such as fibroids, polyps, or a septum), and evaluate the ovaries.
• Pap test and cervical swabs: Assessment of cervical cytology and screening for chlamydia (Chlamydia trachomatis), mycoplasma, ureaplasma, and aerobic bacteria, since untreated infections can cause pelvic inflammatory disease and tubal-factor infertility.

Assessment of ovulatory function and hormone status

A blood sample is recommended between days 2 and 5 of the menstrual cycle to measure the following hormones:

• FSH (follicle-stimulating hormone) and estradiol (E2): Indicators of baseline ovarian function.
• LH (luteinizing hormone): Important for assessing the ratio to FSH (for example, when PCOS is suspected).
• AMH (anti-Müllerian hormone): The most reliable marker of ovarian reserve; it can be measured on any day of the cycle.
• TSH (thyroid-stimulating hormone) and prolactin (PRL): Thyroid disorders and hyperprolactinemia directly affect ovulation and the menstrual cycle and must be addressed before conception.

Fallopian tube patency testing (tubal factor)

If pregnancy has not occurred after a period of regular intercourse, it is essential to check whether the fallopian tubes are open:

• HyCoSy / HSG (hysterosalpingo-contrast sonography / hysterosalpingography): Less invasive methods for visualizing fallopian tube patency and the uterine cavity using ultrasound or X-ray imaging and a contrast agent.

2. Assessment and testing for men

Male factors contribute to infertility in almost 40–50% of cases. International organizations therefore emphasize the importance of evaluating both partners in parallel . Male evaluation is quick and noninvasive and should be carried out early in the process.

Semen analysis

This is the fundamental and most important test for assessing male fertility. Under current World Health Organization (WHO) standards, the analysis is performed after 2 to 7 days of abstinence and evaluates:

• Volume and pH of the ejaculate.
• Concentration and total count of sperm.
• Motility: The proportion of progressively motile sperm.
• Morphology: The percentage of normally shaped sperm.

Note: If the first semen analysis is normal, further male evaluation is generally unnecessary. If the result is abnormal (for example, oligospermia or asthenospermia), the test should be repeated after several weeks.

Additional evaluation (if the semen analysis is abnormal)

• Microbiological testing: A bacteriological urethral swab and/or semen culture (to rule out infection).
• Hormone status: Measurement of total testosterone, FSH, and LH in the blood to assess testicular and pituitary function.
• Urological examination: An examination to rule out varicocele (enlarged veins in the scrotum), obstruction, or other anatomical abnormalities.

Preconception advice for both partners

Before conception, organizations such as ACOG and ESHRE recommend:

1. Supplementation with folic acid: For women, at least 400 mcg per day beginning at least one month before the planned conception, to help prevent fetal neural tube defects.
2. Optimizing body weight (BMI): Severe obesity or being underweight in either partner has been shown to reduce fertility.
3. Stopping harmful habits: Smoking, alcohol consumption, and excessive caffeine intake negatively affect egg and sperm quality.
4. Checking vaccination status: Checking the woman's immunity to rubella and varicella (chickenpox), as these infections are extremely dangerous during pregnancy.

References:

• ESHRE Guideline: Unexplained infertility: ESHRE guideline on the management of couples with unexplained infertility (Human Reproduction, Q1 journal).
• ASRM Practice Committee Report: Diagnostic evaluation of the infertile female: a committee opinion (Fertility and Sterility, Q1 journal).
• ACOG Committee Opinion: Prepregnancy Counseling (Obstetrics & Gynecology, Q1 journal).
• World Health Organization (WHO): Laboratory manual for the examination and processing of human semen (6th Edition).