From the Guidelines
A 33-year-old female should be referred to a fertility specialist after trying to conceive unsuccessfully for 12 months, as the current evidence suggests that infertility investigations are generally initiated after 12 months of unprotected intercourse without resultant pregnancy in women <35 years of age 1. However, this timeline may be shortened to 6 months if certain risk factors or conditions are present, such as irregular menstrual cycles, history of pelvic inflammatory disease, endometriosis, polycystic ovary syndrome (PCOS), previous abdominal or pelvic surgery, or known male factor issues with her partner. Some key points to consider in the evaluation and referral of a 33-year-old female to a fertility specialist include:
- The most common known causes of infertility are male factor, ovulatory failure, and tubal damage, although in many cases, infertility remains unexplained 1
- Female-specific causes of infertility include deterioration of oocyte quality with increasing maternal age, ovulatory disorders, history of salpingitis, endometriosis, and uterine cavity abnormalities interfering with implantation causing inability to become pregnant or causing recurrent pregnancy loss 1
- Imaging can be used to count ovarian follicles and help determine ovarian reserve, particularly in advanced maternal age, and can also be useful in diagnosing polycystic ovarian morphology (PCOM) in women suspected of having PCOS 1
- Earlier assessment and referral to a fertility specialist may be warranted if risk factors of male or female infertility are known to be present, or if there are questions regarding the fertility potential of either partner 1. During the initial consultation, the fertility specialist will likely conduct a comprehensive evaluation including:
- Blood tests to check hormone levels (FSH, AMH, estradiol)
- Transvaginal ultrasound to assess ovarian reserve and uterine structure
- Recommendation for semen analysis for her partner This proactive approach is important because time is a significant factor in fertility treatment success, and earlier intervention provides more treatment options and potentially better outcomes.
From the Research
Referral to a Fertility Specialist
A 33-year-old female should be referred to a fertility specialist if she has been trying to conceive for 12 months without success, or sooner if she has a condition known to cause infertility 2.
- The definition of infertility is the failure to achieve pregnancy within 12 months of unprotected intercourse or therapeutic donor insemination in women younger than 35 years 2, 3.
- Women older than 35 years should receive an expedited evaluation and undergo treatment after 6 months of failed attempts to become pregnant or earlier, if clinically indicated 2.
- The age of the female partner is a significant factor in fertility, with the chance of becoming spontaneously pregnant declining with the duration before conception 3.
- A woman's health specialist may reasonably obtain the male partner's medical history and order the semen analysis, as male factor is a cause of infertility in 40-50% of couples 2.
Factors Influencing Fertility
Several factors can influence fertility, including:
- The time of unwanted non-conception
- The age of the female partner
- Disease-related infertility, which may affect both genders or be specific to one gender 3
- Lifestyle-related factors/diseases, such as hypogonadotrophic hypogonadism, hyperprolactinemia, disorders of ciliary function, cystic fibrosis, infections, and systemic diseases 3
Assessment of Ovarian Reserve
Ovarian reserve testing may be considered for women ≥ 35 years of age or for women < 35 years of age with risk factors for decreased ovarian reserve 4.
- The predictive value of ovarian reserve testing for non-pregnancy is poor and should be used to exclude women from treatment only if levels are significantly abnormal 4.
Natural Fertility Outcomes
Natural conception rates are still clinically relevant in women aged 35 years and above, and are significantly higher in women with unexplained infertility compared to those with other diagnoses 5.
- The probability of natural conception significantly decreases with any diagnosis of infertility, when compared with unexplained infertility 5.