An assisted reproductive technology workup for the couple

Advancements in assisted reproduction technology (ART) have increased the success rates for a healthy and safe pregnancy. But after each cycle, broadly up to 50% of patients do not conceive despite having good embryos and a good endometrium. This may occur once, twice, thrice, and so on. The question then comes, do we need to do anything extra regarding investigations and treatment to translate it into success, or is it just chance, or is it something we do not yet have evidence for? Guidelines on recurrent implantation failure (RIF) emphasize certain RIF-specific investigations as recommended and those that can be considered. Recent studies have highlighted a >95% clinical pregnancy rate after up to three/five consecutive euploid blastocyst transfers. Further, where data were available, the implantation rate of the fourth euploid blastocyst transfer was similar to the first transfer. This emphasizes that all modifiable factors need to be investigated at the upfront, rather than having a tiered approach. Essentially, then, a pre-ART workup would include lifestyle factors, genetic counseling, and investigations for the couple. For the female partner, an endocrinology workup, identifying a normal uterine and adnexal anatomy by transvaginal ultrasound, 3D ultrasound, sonosaline salpingography, and/or hysteroscopy. Recent literature supports screening hysteroscopy as a pre in vitro fertilization workup. Chronic endometritis diagnosis and its treatment with antibiotics is recommended as an intervention in RIF patients. Hysteroscopy is the gold standard for diagnosing chronic endometritis. For the male partner, semen analysis, and as indicated, an endocrinology and imaging workup. Specifically for patients with severe oligospermia/non-obstructive azoospermia, a karyotype and Y chromosome microdeletion as indicated. DNA fragmentation tests are recommended for patients with a history of abortions in the female partner. Options for expanded carrier screening can be discussed with the couple, considering that 2–4% of reproductive couples are at risk of having a child with an autosomal recessive or X-linked genetic disorder. The pre-ART workup needs to be discussed with the couple regarding the benefits, evidence, and cost. The final decision is with the couple to opt for the investigations as a tiered approach or upfront before the first cycle.