Pre-IVF Workups and Corrective Surgeries

A pre-IVF workup is the set of tests that identifies why a couple has not conceived, and which problems to correct before in vitro fertilisation (IVF) begins. It covers three essentials (the uterus, the fallopian tubes and ovulation, including ovarian reserve) plus a semen analysis and baseline blood tests. Corrective surgery for fibroids, polyps, adhesions, endometriosis, damaged tubes or a uterine septum then improves the IVF cycle's chances.

That is the framework Dr. Shelly Singh, Senior Director Obstetrics & Gynaecology, Fortis La Femme, New Delhi, India, set out for general practitioners across Africa. Her central argument is that the outcome of an IVF cycle is shaped well before the cycle starts. A submucous fibroid left in the cavity, a damaged tube draining fluid into the uterus or an endometrioma removed carelessly can each undermine an otherwise well-run cycle. And because most couples see a general practitioner, an internist or an endocrinologist long before they see a gynaecologist, the first steps of the workup often belong in primary care.

What causes infertility: the problems a workup looks for

Dr. Singh grouped the causes of infertility into a short list of conditions, each of which the workup is designed to find:

• Uterine problems: fibroids, polyps within the uterine cavity and intrauterine adhesions.
• Tubal problems: blocked or damaged fallopian tubes, which she described as fairly common in India and in African countries alike, and one of the commonest reasons for IVF.
• Ovulation disorders: ovulation is the first step towards pregnancy, and it is disrupted by thyroid disease, polycystic ovary syndrome (PCOS) and hyperprolactinaemia (a raised level of the hormone prolactin).
• Endometriosis: endometrial tissue growing outside the uterus, which can form endometriotic or "chocolate" cysts on the ovaries, cause adhesions and, in its most severe form, infiltrate deeply into pelvic organs.
• Premature ovarian insufficiency: periods stopping before the age of 40, a condition she said is becoming more common globally.
• Pelvic adhesions, and the effects of cancer treatment directed at the uterus or ovaries.

The male partner matters as much as the female. Dr. Singh cited the commonly taught split: about a third of infertility arises from the female partner, a third from the male partner and a third from both combined. In her experience, husbands sometimes refuse testing on the assumption that the problem lies with their wife, which is why she urges clinicians to press for a semen analysis in every couple.

What a pre-IVF workup includes

Three tests form what Dr. Singh called the bare essentials, one each for the uterus, the tubes and ovulation:

1. Transvaginal ultrasound, preferably three-dimensional, on day two or three of the cycle. It shows the size and shape of the uterus, the endometrial thickness, any submucous fibroid, polyp or adhesions, and the ovarian volume and antral follicle count (the number of small egg-containing follicles visible on the scan), which together indicate ovarian reserve (the number of eggs a woman has left).
2. Ovarian reserve hormones: follicle-stimulating hormone (FSH), oestradiol and anti-Müllerian hormone (AMH).
3. A tubal patency test: hysterosalpingography (HSG), a sonosalpingogram, or chromopertubation at laparoscopy (dye passed through the tubes while the surgeon watches through a laparoscope).

To these she adds a semen analysis for the male partner, infectious disease screening, and a general set of blood and urine tests. How each test is performed and interpreted, including the World Health Organization reference values for semen and the false positives that HSG can produce, is covered in Pre-IVF tests: ovarian reserve, tubal patency and semen analysis.

Corrective surgery before IVF: what needs fixing

Not every abnormality on a scan needs an operation, and Dr. Singh was explicit about where the line falls. The procedures she described fall into two families.

Surgery on the uterine cavity and wall. Submucous fibroids, which project into the cavity, interfere with implantation and need removal unless they are extremely small. Intramural fibroids need removal when they indent the cavity, unless they are very small. Purely subserosal fibroids, on the outer surface of the uterus, do not need removal for fertility. Endometrial polyps are removed hysteroscopically, intrauterine adhesions (Asherman syndrome) are divided and the lining is then regenerated, and of the uterine anomalies only a septate uterus consistently needs correction. These operations, including the size question and the interval before conception after a myomectomy, are covered in Fibroids, polyps and uterine surgery before IVF.

Surgery for endometriosis and the fallopian tubes. In her approach, endometriomas (endometriotic cysts of the ovary), adhesions that distort the pelvis and ovaries stuck to the uterus generally merit an operative laparoscopy, performed so as to preserve as much healthy ovarian tissue as possible. Guideline practice on endometriomas is more selective, as the linked article explains. Badly damaged tubes are removed or clipped so that they cannot pass fluid back into the uterus, while blocked tubes in otherwise good condition can sometimes be opened. These procedures are covered in Endometriosis and tubal surgery before IVF.

The principle behind both is the same: the operation is chosen because it improves the conditions in which an embryo implants and grows, not because an abnormality has been found. For a broader view of surgery across the whole infertility pathway, not only as preparation for IVF, Dr. Soma Singh's article on fertility-enhancing surgery for the infertile couple is a useful companion; Jivo's other masterclasses in the field are collected under obstetrics and gynaecology.

How GPs can kickstart infertility care

Dr. Singh's practical message to general practitioners was that much of the workup can begin in primary care, before the referral. Patients often trust their GP more than a specialist, and many arrive at a gynaecologist's clinic having been fully worked up already, so that "all we require to do is just to sort of take it from there", in her words. Her protocol for starting the treatment journey runs as follows:

1. History and examination, with general blood tests.
2. Correction of endocrine disorders, which she relies on GP colleagues to manage: thyroid abnormalities, PCOS and hyperprolactinaemia. Infertility care, in her view, is now a multidisciplinary effort, and specialists frequently refer patients back to physicians for exactly these conditions.
3. Rubella testing.
4. Infectious disease screening, including hepatitis B, hepatitis C, HIV and syphilis serology.
5. A haemoglobinopathy screen for thalassaemia and sickle cell disease.
6. Ovarian reserve testing, such as AMH.
7. A transvaginal ultrasound, which she said makes the specialist's job much easier when it arrives with the referral.
8. MRI where indicated: when three-dimensional ultrasound is unavailable, when a patient finds transvaginal scanning uncomfortable, or when an unmarried young woman is being evaluated.
9. The husband's semen analysis.
10. Referral whenever anything suggests that surgery or a gynaecologist's intervention may be needed.

She closed on referral: infertility, she noted, is rising all across the world, and a timely referral goes a long way in helping these couples to be treated.

IVF success rates and patient expectations

Dr. Singh put the success rate of IVF in good centres at around 60%, and at most about 70% in very good centres. She noted that rates have risen from about 40 to 50% in earlier years, a gain she attributed to more robust protocols and better medication and injections. Nobody, she was clear, can guarantee a 90 or 95% success rate; such figures are not achieved anywhere in the world, including the West.

Success rates published by clinics and registries vary widely with the woman's age, the cause of infertility, and whether a figure is calculated per embryo transfer, per cycle started or cumulatively across cycles. A quoted rate means little without those details, and the woman's age is the single strongest predictor.

Managing expectations, in her view, has been made harder by Google and by Instagram influencers, who often tell patients a different story; people are frequently more willing to listen to them than to doctors. Her answer is consistent counselling: be the patient's friend, explain the pros and cons, encourage them to read the literature, share your own experience, and make sure everything you say is fully backed by protocols, randomised trials and the guidelines you follow.

IVF cost and the cost of corrective surgery

Dr. Singh put the cost of an IVF cycle at a starting figure of about 3 to 4 lakh rupees. The figure depends on the kind of procedure: some couples need intracytoplasmic sperm injection (ICSI), in which a single sperm is injected into each egg, and some need donor eggs. Subsequent cycles cost less than the first, because they sometimes require only the transfer of embryos frozen during the first cycle.

The cost of corrective surgery cannot be quoted as a single figure. It depends on the type of operation, how extensive it is and, to a large extent, the hospital. Indicative ranges for international patients are on the IVF and fertility treatment cost page.

IVF age limits, surrogacy and donor availability in India

Age limits. The age limit for IVF is no longer a hospital decision, Dr. Singh explained, because the Government of India has laid down guidelines: going strictly by those guidelines, the limit is 50 for the woman and 55 for the man. Clinics once treated women of 60 or 65, which raised the ethical question of who would care for the children. Under the Assisted Reproductive Technology (Regulation) Act, 2021, ART services are available to women aged 21 to 50 and men aged 21 to 55.

Surrogacy. Dr. Singh explained that surrogacy was restricted after surrogate mothers and intending parents alike faced many problems. Under the Surrogacy (Regulation) Act, 2021, commercial surrogacy is prohibited in India; only altruistic surrogacy is permitted, for eligible Indian couples and certain Indian women, so it is not an option for foreign patients.

Donor eggs and sperm. Oocyte (egg) donors are available, and packages vary with the kind of donor chosen. Donors are matched to the recipient on physical characteristics and screened to exclude medical and genetic problems. Dr. Singh confirmed that sperm banks and donors are available for patients who want a donor of the same race, including patients of African ethnicity. How IVF, ICSI and egg donation work in practice is covered in Dr. Parul Prakash's complete guide to IVF, ICSI and egg donation.

Why a doctor-to-doctor pathway matters

The final theme of the session was ethics. Dr. Singh described a challenge Indian specialists face too: agents who bring patients for treatment they may not need, or who understate how extensive the treatment will be, and who promise 90 to 100% results. Much of this, she said, is driven by money. Every doctor has to earn, but practice has to be ethical, and patients who spend heavily on medical travel are poorly served if they undergo surgery they did not need or treatment that cannot deliver what was promised.

Her view is that anything doctor-driven, where the referring doctor and the treating specialist communicate directly, leads to more ethical practice and better results. A doctor-to-doctor referral is, she argued, more scientific than one shaped by people who are there only to make money. Questions that attending doctors put to Dr. Singh on these themes, from repeat HSG to the age limit for IVF, are collected in the Live Discussion from this masterclass.