What are the medical eligibility criteria and pre‑treatment assessments required to deem a reproductive‑age (18‑45 years) patient medically fit for an in‑vitro fertilisation (IVF) cycle?

Medical Fitness for IVF Procedure

Pre-Treatment Medical Assessment

All reproductive-age patients (18-45 years) must undergo comprehensive medical screening before IVF initiation to identify conditions that could compromise maternal or fetal outcomes, with particular attention to age-related factors, chronic diseases, and infectious disease status. 1, 2

Essential Baseline Evaluations

Infectious Disease Screening:

• Rubella immunity status must be documented; approximately 6% of women lack immunity and require vaccination with a 1-month delay before IVF 3
• Hepatitis B surface antigen screening is mandatory, as 5% of previously unscreened patients are carriers 3
• Chlamydia trachomatis and mycoplasma cultures should be obtained, as 14-16% of patients harbor these organisms which can compromise outcomes 3
• Cervical cytology (Pap smear) must be current, as 5% of newly referred patients have cervical intraepithelial dysplasia requiring treatment before IVF 3

Uterine Cavity Assessment:

• Hysterosalpingography or sonohysterography is required to identify intrauterine pathology, which occurs in 11% of cases 3
• Diagnostic hysteroscopy with treatment of identified pathology (adhesions, polyps) should precede IVF, as some patients conceive spontaneously after correction 3

Age-Specific Considerations

Women ≥35 Years:

• Ovarian reserve testing (anti-Müllerian hormone, antral follicle count, day 3 FSH) is essential, as female fecundity declines significantly with age 2
• Immediate IVF may be considered first-line in women 38-40 years or older rather than pursuing ovulation induction cycles, given time-sensitive fertility decline 2
• More aggressive evaluation timelines are warranted; assessment after 6 months of unprotected intercourse rather than 12 months is justified 4

Chronic Disease Management

Cardiovascular and Metabolic Conditions:

• Hypertension and diabetes must be optimally controlled before IVF, as these conditions significantly impact pregnancy outcomes 1
• Body mass index (BMI) assessment is mandatory; obesity adversely affects fertility and IVF success rates 1, 2
• Thrombophilia screening should be performed in patients with personal or family history of thrombotic events 1

Autoimmune Conditions:

• Patients with systemic lupus erythematosus (SLE) or antiphospholipid syndrome (APS) require disease quiescence for at least 6 months before IVF 4
• Antiphospholipid antibody testing is essential in patients with APS, as antithrombotic prophylaxis protocols must be implemented during ovarian stimulation 4
• Low-dose aspirin and/or low molecular weight heparin should be initiated based on individual thrombotic risk profile 4

Male Partner Evaluation

Concurrent Male Assessment:

• Male partner evaluation must begin simultaneously with female assessment, not sequentially 4
• Semen analysis is required, with at least 2 samples obtained one month apart due to high biological variability 4
• Reproductive history including duration of infertility, prior fertility, sexual dysfunction, and gonadotoxin exposures must be documented 4
• Physical examination focusing on testicular size, varicocele, and penile abnormalities is mandatory 4

Lifestyle and Environmental Factors

Modifiable Risk Factors:

• Smoking cessation is essential; tobacco use adversely affects fertility in both partners 4, 1, 2
• Alcohol consumption should be minimized or eliminated 4
• Nutritional adequacy must be assessed and optimized 1
• Illicit drug use must be addressed and discontinued 1
• Occupational and environmental exposures to gonadotoxins require evaluation and mitigation 4

Special Populations Requiring Additional Evaluation

Cancer Survivors:

• Patients with prior gonadotoxic chemotherapy (alkylating agents, anthracyclines) or pelvic radiation require ovarian reserve assessment regardless of age 4
• Cumulative cyclophosphamide equivalent dose >5 g/m² or pelvic radiation >6 Gy confers high risk of ovarian dysfunction 4
• Karyotype analysis may be warranted in patients with recurrent pregnancy loss or failed IVF cycles 4

Patients on Immunosuppressive Therapy:

• Cyclophosphamide and other alkylating agents cause dose- and age-dependent ovarian failure; less gonadotoxic regimens should be considered before IVF 4
• GnRH analogs for ovarian protection during chemotherapy have demonstrated efficacy (RR 0.12 for premature ovarian failure) but require initiation before or concurrent with alkylating agents 4

Critical Exclusions and Contraindications

Absolute Contraindications:

• Active SLE or APS disease flare; IVF is only safe with quiescent disease 4
• Uncontrolled hypertension or diabetes 1
• Active cervical dysplasia requiring treatment 3
• Untreated intrauterine pathology 3

Relative Contraindications Requiring Optimization:

• Inadequately treated hypothyroidism or hyperthyroidism 4
• Severe obesity (BMI >40) without weight optimization 1
• Active tobacco use without cessation attempts 1, 2

Common Pitfalls to Avoid

• Do not proceed with IVF without documenting rubella immunity, as congenital rubella syndrome is preventable with pre-conception vaccination 3
• Do not skip male partner evaluation, as 25% of infertility has a male factor component and female partners may undergo unnecessary invasive procedures 4
• Do not assume prior normal Pap smears are sufficient; 5% of newly referred IVF patients have undiagnosed cervical dysplasia 3
• Do not overlook uterine cavity assessment; 11% have pathology and some conceive after correction without requiring IVF 3
• Do not initiate IVF in patients with active autoimmune disease, as pregnancy complications are significantly increased without disease quiescence 4