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The “journey” to motherhood is not easy for all women. But thanks to the assisted reproduction techniques, every woman can experience motherhood. One of the methods that is widely applied with great success is intrauterine insemination.

What is intrauterine insemination (IUI)?

Intrauterine insemination​​​​ – IUI is an assisted reproduction technique. Through this method, the chances of achieving pregnancy increase, as the sperm is placed in the endometrial cavity with the help of a special catheter. This is a method that can be applied in a natural cycle or after ovarian stimulation. This particular method is often applied as a first solution in cases of women who are thinking of undergoing in vitro fertilization.

What are the basic conditions for a woman to undergo this procedure?

A basic and necessary condition for the application of this method is that there is no pathology of the fallopian tubes, which can carry the egg and in which the fertilization takes place. The fallopian tubes should be open, so that nothing obstructs the movement of the sperm towards the egg. In addition, another factor that assists in achieving pregnancy through insemination is that the woman has enough eggs in terms of number and quality and also the sperm parameters are normal.

In which cases is intrauterine insemination successfully applied?

Intrauterine insemination, as mentioned above, is often chosen as a solution for couples before IVF. However, beyond this case, it is an ideal option in each one of the following cases:

• Unexplained infertility: in 30% of couples who cannot achieve pregnancy with regular unprotected sexual intercourse, no pathological factor can be identified.
• Ejaculation or erectile dysfunction issues: in these cases the sperm is collected using various methods.
• Cervical mucus abnormalities: in some women, the cervical mucus is thicker, which prevents sperm from traveling to the fallopian tubes.
• Utilization of sperm from a donor: in the case of in vitro fertilization by women without a partner.
• Anovulatory cycles as in Polycystic Ovary Syndrome
• Mild sperm disorders

What procedure is followed?

First, sperm is collected, which is sent to the laboratory and it is subjected to special treatment. Sperm collection takes place 2-3 hours before insemination, which is determined by the date of ovulation.

In particular, the special processing of the sperm includes the separation of the motile spermatozoa from the immobile ones. The processing of the sperm and its strengthening takes about 2 hours. A thin and flexible catheter is then inserted through the cervix into the endometrial cavity and deposits the sperm.

Intrauterine insemination is an absolutely painless method and is performed without anesthesia. It is quite similar to the Pap test and it is short, as it does not exceed 5 minutes.

What is the main advantage of intrauterine insemination?

The main advantage of intrauterine insemination is its minimal intervention compared to classic IVF. In cases where it is carried out in a natural cycle, the female organism is not burdened in the least by taking hormones. Furthermore, this particular method is chosen more and more often because of its low cost.

The selection of the appropriate assisted reproduction technique is made taking into account several factors. You should trust the experienced Obstetrician-Gynecologist with expertise in assisted reproduction methods, Melina Stassinou, for any infertility problem you may face.

The Obstetrician-Gynecologist Melina Stassinou has been a Research Associate at Imperial College’s IVF Department in London. What characterizes her is that she listens to the needs of each woman individually. Contact us for any question or clarification regarding intrauterine insemination.

What is ovulation induction?

Ovulation induction is defined as an assisted reproduction protocol aiming at producing and releasing an egg. Enhancing ovulation or make the ovaries to select a dominant follicle with the help of medication, either orally or by injection, greatly increases the chances of conception with planned intercourse or intrauterine insemination.

In which cases is the procedure applied?

According to studies, 25-30% of infertile women face ovulation problems. Ovulation induction is mainly applied in cases of women who wish to achieve pregnancy, but do not ovulate regularly.

Irregular ovulation is usually the result of low production or imbalance of hormones that are responsible for causing it. Also, not a few women with polycystic ovary syndrome suffer from secondary amenorrhea and ovulation induction protocols can be applied with high success rates. Finally, this particular method is also applied, in combination with insemination, to couples with unexplained infertility or difficulties with intercourse ( vaginismus, erectile dysfunction)

What medicines are administered to induce ovulation?

Ovulation is induced by the administration of specific medicines in the form of pills or injections. The medicines used as pills are clomiphene citrate and letrozole, while the injections contain gonadotropins. More particularly:

• Clomiphene: this substance is used as a first choice to induce ovulation, causing mild ovarian stimulation.It is administered from the 3rd tothe 7th dayof the cycle and the dosage depends on the ovarian response. A few days after taking the last pill, the woman is monitored to assess whether one or more ovarian follicles have developed sufficiently.
• Letrozole (aromatase inhibitor): it isused instead of clomiphene and aims to limit estrogen. The restriction of estrogen contributes to the increase of FSH, a hormone that promotes the development of ovarian follicles. It is administered from the 3rd tothe 7th dayof the cycle, just like clomiphene.
• Gonadotropins: gonadotropins are administered by injection and they are used in all assisted reproduction treatments. They are also recommended in cases of women where the administration of clomiphene and letrozole was not effective or those diagnosed with hypogonadotropic hypogonadism.

Depending on the case and the factors responsible for the infertility, the above may be used in combination.

How is it carried out?

Ovulation induction begins with the administration of the medicinal preparations on the 2nd or 3rd day of the cycle that lasts approximately until the 10th day of the cycle. After the completion of the medication, on the 10th day the woman undergoes an ultrasound and blood tests, evaluating the response of the ovaries.

Follicle monitoring continues, until a dominant follicle appears that, based on size, will lead to ovulation. Once this happens a human chorionic gonadotropin injection is administered and it is followed by either unprotected intercourse of the couple or insemination.

In conclusion, ovulation induction can work as a stand-alone treatment for infertility or as the first step in assisted reproduction. It is completely safe and greatly increases the chances of conception either naturally or through IVF.

Female infertility is an issue that concerns many women worldwide. Unfortunately, it is a condition that is caused by many factors, including anatomy, hormones and even the lifestyle of women. Hyperprolactinemia seems to have a great impact onwomen’s fertility and it is one of the main causes ofinfertility.

What is defined as hyperprolactinemia?

Hyperprolactinemia is defined as the condition where the hormone prolactin is produced in large quantities (PRL, which is secreted by the pituitary gland of the brain). Prolactin is the main hormone which is normally secreted at high levels during breastfeeding in women.

What are the causes of hyperprolactinemia?

Prolactin levels in non-pregnant or non-lactating women should be low. In the majority of cases, the cause of prolactin overproduction (idiopathic) cannot be precisely identified. However, there are some factors that have been implicated as affecting its production. Thus, hyperprolactinemia can be due to factors, such as:

• Prolactinomas: prolactinomas are benign tumors of the pituitary gland that produce high levels of prolactin. They appear more often in women of reproductive age and are the most common cause of hyperprolactinemia. Their diagnosis is made with an MRI of the pituitary gland.
• Polycystic ovary syndrome
• Hypothyroidism
• Medication: administration of certain medications can cause hyperprolactinemia. Medications responsible for increased prolactin production are antidepressants, antipsychotics and blood pressure medications.
• Chronic stressful situations: stress has been blamed for the temporary increase in prolactin.

How does hyperprolactinemia affect fertility?

Considering the role of prolactin, it is clear that any problem with its production affects fertility. Hyperprolactinemia largely controls the menstrual cycle, since high prolactin levels reduce estrogen. The decrease in estrogen causes problems with ovulation, which results in disturbances in the cycle up to the complete absence of period.

Additionally, hyperprolactinemia also affects other hormones that are important for achieving pregnancy. More specifically, the increased amounts of prolactin inhibit the production of gonadotropins (GnRH). The reduced production of gonadotropins inhibits the production of follicle-stimulating hormone (FSH), which affects the quality and number of eggs produced.

Finally, hyperprolactinemia can also affect the function of the corpus luteum. The corpus luteum is a temporary organ formed in the middle of the cycle, which produces specific hormones. The main hormone it produces is progesterone, and hyperprolactinemia contributes to its reduced production, which has an impact on fertility.

What are the symptoms of hyperprolactinemia?

Hyperprolactinemia occurs mainly with the following symptoms:

• Lactorrhea (milk discharge from the breast)
• Vaginal dryness
• Oligomenorrhea, amenorrhea, anovulation
• Decreased sexual desire
• Acne
• Hair loss/hair growth
• Menstrual disorders
• Decrease in bone density

Hyperprolactinemia & Diagnosis

High prolactin levels can only be detected by blood tests. The examination should be carried out a few hours after waking up in the morning. In addition, it would be good to perform it at the beginning of the cycle, i.e. before ovulation, to avoid any laboratory errors.

How is it treated?

The treatment of hyperprolactinemia mainly depends on the cause responsible for it. More specifically, if hyperprolactinemia has been caused by the existence of a prolactinoma, then, it is necessary to administer medication that reduces prolactin production. In some cases, the prolactinoma may need surgical removal.

If the increased production of prolactin is due to other underlying diseases (e.g. hypothyroidism), then the medication should be adjusted.

More and more women “fight” against infertility and the “ally” they choose to have by their side plays an important role. The Obstetrician-Gynecologist Melina Stasinou has extensive experience in assisted reproduction methods. Her goal is to help women experience motherhood, applying the most modern methods. Contact the physician for any question you may have about assisted reproduction.

Hydrosalpinx is one of the diseases that is diagnosed in a large percentage of women and causes infertility. The fallopian tubes, like the uterus and ovaries, play an important role in the reproductive process and, by extension, in achieving pregnancy. The functionality of the fallopian tubes is essential as through them the egg is transferred inside the uterus and fertilization is achieved in its lumen by the moving sperm. Therefore, any pathology of the fallopian tubes has a great impact on female fertility.

What is the hydrosalpinx?

The fallopian tubes are small ducts through which the eggs are transported from the ovaries to the uterus. Partial or complete blockage of the opening of the fallopian tube – usually the one near the ovary – causes the accumulation of serum or clear fluid. The fluid collected due to the obstruction is called peritoneal fluid and causes the fallopian tubes to dilate. This pathological condition is called hydrosalpinx and causes serious infertility problems.

What are the causes of hydrosalpinx?

Hydrosalpinx can be caused by various etiological factors. In the majority of cases, its manifestation is a result of pelvic inflammatory disease. Pelvic inflammatory disease is mainly caused by untreated sexually transmitted diseases and is responsible for the onset of chronic inflammation, which in turn may cause hydrosalpinx. In addition, hydrosalpinx can be a result of the following causes:

• Endometriosis
• Accidental fallopian tube injury due to previous surgery
• Congenital anatomical anomalies in the fallopian tubes
• Previous ectopic pregnancy
• Manifestation of inflammation due to appendicitis
• Formation of scar tissue due to previous surgery on the pelvis or fallopian tubes

Of course, there are not a few cases where it is not possible to identify the cause of hydrosalpinx (idiopathic hydrosalpinx).

What are the symptoms of hydrosalpinx?

In the majority of cases, hydrosalpinx is asymptomatic, although its impact on fertility is great. Thus, the hydrosalpinx is usually identified in the context of investigating the causes of infertility. However, in cases of patients who manifest symptoms, the main symptom of hydrosalpinx is abdominal or pelvic pain. This pain may be accompanied by unusual vaginal discharge.

Hydrosalpinx and infertility: How does hydrosalpinx affect female fertility?

The contribution of the fallopian tubes to the proper functioning of the reproductive system is great. Therefore, the existence of a hydrosalpinx does not favor the normal development of the fetus, causing conditions such as:

• Failure to fertilize the egg or failure to transfer the fertilized egg to the uterus.
• Causing an ectopic pregnancy (development of the fetus inside the fallopian tube).
• Secretions from the hydrosalpinx that may end up in the uterus, causing unfavorable conditions for the embryo to implant.
• Secretions that may be toxic to the fetus.

At this point, it should be mentioned that the hydrosalpinx also makes it difficult to get pregnant through IVF. The toxic environment that may have been caused due to the hydrosalpinx inside the uterus negatively contributes to the implantation of the fertilized egg. Furthermore, the hydrosalpinx can also affect the quality of the eggs, making the process of assisted reproduction even more difficult.

In what ways can infertility caused by hydrosalpinx be treated?

Treatment of hydrosalpinx should be immediate after its detection to achieve pregnancy. Even in cases where a pregnancy is achieved despite the presence of hydrosalpinx, the chances of miscarriage are high.

A hydrosalpinx is treated exclusively laparoscopically and the type of operation depends on the dilatation of the fallopian tube, as well as the patient’s medical history. In particular, there are two surgical procedures to treat hydrosalpinx, salpingostomy and salpingectomy. The salpingostomy is applied to the fallopian tubes with a small distension and refers to the opening of the hydrosalpinx. On the contrary, in highly dilated fallopian tubes, a salpingectomy is applied, in which all or part of the affected fallopian tube is removed.

The Obstetrician-Gynecologist Melina Stasinou has extensive experience in assisted reproduction methods. Besides her vast experience, what distinguishes her is her empathy and her goal is to help women experience motherhood. Contact us for any question you may have about how hydrosalpinx affects female fertility and possible ways to treat it.

Fatty acids are very important for the proper functioning of the human body. Research shows that the role of omega-3 in fertility and pregnancy is of paramount importance. In the case of pregnancy, the sufficiency of omega-3 (Ω3) fatty acids is necessary for both the pregnant woman and the fetus.

What are omega-3 fatty acids and in what foods are they found?

Omega-3 fatty acids are polyunsaturated fats, which are absorbed exclusively from food, since they are not produced in the body. The three omega-3s are eicosapentaenoic acid (EPA), A-linolenic acid (ALA) and docosahexaenoic acid (DHA). Despite their great value, Ω3s are found in very few foods, such as:

• Oily fish (e.g. salmon, cod, herring, etc.)
• Seafood (e.g. prawns)
• Tuna (canned)
• Shellfish (eg mussels, oysters)
• Fish oils
• Seeds (chia seeds, flaxseed, etc.)

Also, in smaller amounts, Ω3 is found in nuts, in some vegetable oils, as well as in some vegetables.

What is the role of omega-3 in fertility?

As mentioned above, Ω3 fatty acids are very important for our health, but they are especially significant for our reproductive health. Statistically, women who receive the required amount of omega-3, either nutritionally or through supplements, have a better chance of achieving pregnancy. In particular, Ω3 helps with fertility in the following ways:

• Hormone regulation.
• Increased blood flow inside the uterus.
• Production of quality eggs, since they contribute to the creation of both eggs and sperm.
• Treatment of inflammations of the female reproductive system (e.g. endometriosis) that may cause infertility.

The effect of Ω3 fatty acids on the reproductive system is so important that their intake is also recommended for women who are going to undergo assisted reproduction.

How do omega-3s contribute to pregnancy, other than fertility?

Adequacy in omega-3 greatly helps the development of the fetus and ensures a healthy pregnancy without complications. More specifically, regarding the development of the fetus, fatty acids also help in the development of their brain. Furthermore, their adequate intake is particularly beneficial for the development of the fetus’s cardiac, respiratory and nervous systems. Finally, Ω3 fatty acids also have a positive effect on the health of the infant’s eyes, ensuring the smooth development of the retina.

Ω3 fatty acids, in addition to the development of the fetus, ensure a healthy pregnancy. Based on research, pregnant women who receive high amounts of Ω3 are at a lower risk of premature birth, as well as pre-eclampsia. Finally, the effect of Ω3 fatty acids on psychology also protects pregnant women to a large extent from the onset of postpartum depression.

Can a balanced diet provide sufficient omega-3 during pregnancy?

The answer is negative. During pregnancy, the amounts of Ω3 obtained from food are not sufficient. Therefore, taking nutritional supplements is necessary, so that the expectant mother and the fetus receive the necessary amounts.

What is the necessary daily intake of omega-3 in pregnancy?

According to studies, the daily intake of omega-3 both during pregnancy and during breastfeeding is 200 mg DHA. If this amount is not obtained from food, then the administration of Ω3 food supplements is necessary.

The Obstetrician-Gynecologist Melina Stasinou, having extensive experience and expertise in Microsurgery of the Female Reproductive System, is at your disposal for any question you may have regarding your pregnancy. Contact the physician for any question or clarification regarding nutrition during pregnancy.

Assisted reproduction techniques are evolving day by day, successfully contributing to the treatment of any factor (female or male) responsible for causing infertility. Male infertility is quite common and affects about 10% of couples who wish to become parents. The solution to male infertility is provided by Intracytoplasmic sperm injection (ICSI), a modern method of in vitro fertilization.

What is defined as Intracytoplasmic sperm injection (ICSI)?

Intracytoplasmic sperm injection (ICSI) is a modern technique of assisted reproduction. With the intracytoplasmic sperm injection technique, a single healthy sperm is inserted into each egg through a thin glass needle. This method has been applied since 1992 and its success rates are quite high. Thus, men with sperm quality problems can also experience paternity.  

In which cases is it indicated?

Intracytoplasmic sperm injection (ICSI) is the appropriate method for couples whose male factor is responsible for infertility.

More specifically, this technique is suitable for the following cases:

• Presence of oligoasthenospermia or asthenospermia: in the case of oligoasthenospermia, a low sperm count and motility is detected. If the sperm motility is less than 32%, then this condition is called asthenospermia.
• Azoospermia: Azoospermia is defined as the absence of spermatozoa in the semen. The fact that they are not found in the semen does not mean that they do not exist, as some pathological factors may prevent their exit. Identifying a healthy spermatozoon can be achieved through testicular biopsy (Micro -TESE) with great success.
• Spermatozoa without acrosome or extensive adhesions: the acrosome is a part of the sperm head. A sperm without an acrosome cannot successfully penetrate the egg. Also, in cases where extensive adhesions are found, sperm motility is greatly reduced, which is an inhibiting factor for achieving pregnancy.

In addition to the above cases related to the quality of the sperm, this method can also be applied in cases of continuous failures of the classic IVF. Finally, Intracytoplasmic sperm injection helps to achieve pregnancy in cases where the zona pellucida of the eggs is thicker and harder. In this case even, a healthy sperm cannot successfully enter the egg.

How is Intracytoplasmic Sperm Injection (ICSI) performed?

The stages of Intracytoplasmic Sperm Injection (ICSI) are as follows:

1. The process begins with the stimulation of the ovaries with medication, aiming to produce eggs of good quality.
2. As soon as the required number of eggs has been produced, ovulation is performed.
3. The collected eggs are then subjected to special processing, which includes the removal of granulosa cells. Removal of granulosa cells is achieved with an enzyme called hyaluronidase. In this way, the penetration of the sperm inside them is facilitated, contributing to the achievement of pregnancy.
4. Then the Intracytoplasmic Sperm Injection is performed, applying the appropriate methods depending on the causes of infertility.
5. The egg is placed by the embryologist under the microscope and with the help of a thin glass pipette the sperm enters the egg.
6. The egg is then placed in the laboratory’s incubator, where fertilization takes place.
7. The method is completed with embryo transfer.

What are the success rates of Intracytoplasmic Sperm Injection (ICSI)?

The success rates of Intracytoplasmic Sperm Injection (ICSI) are quite high, 60-80%, giving the opportunity to infertile men to become parents. But, in any case, the success rates of the method also depend on other factors, such as:

• Egg quality
• Sperm quality: oxidative stress -fragmentation
• Successful egg activation
• Ability of the egg to respond to the Intracytoplasmic process

The Obstetrician-Gynecologist Melina Stassinou, having been a Scientific Associate in the IVF Department of the Imperial College and having extensive experience in assisted reproduction, shall stand next to any woman who wishes to have a child. Contact us and learn all you need to know about the Intracytoplasmic Sperm Injection (ICSI) technique.

Although adenomyosis has been largely linked to infertility, nowadays there are therapeutic protocols that can create in the uterus an ideal environment for the implantation of the embryo. Thus, the cases where adenomyosis can impair implantation of an embryo either by in vitro fertilization or natural conception have significantly decreased.

Understanding adenomyosis

Adenomyosis is a benign condition of the uterus and occurs when there is an expansion of endometrial tissue (the tissue that covers the inner surface of the uterus) into the muscular wall of the uterus (myometrium). This condition causes uterine enlargement, abnormal bleeding, dysmenorrhea, chronic pelvic pain and infertility.

Although its causes have not been precisely determined, it seems to occur more frequently in women over the age of 35. In addition to age, surgery to the uterus or previous births may contribute to its appearance. In some studies, hormonal disorders can lead to the appearance of adenomyosis and they involve hormones such as estrogen, progesterone, prolactin and follicle-stimulating hormone. Several times adenomyosis coexists with endometriosis, although it is a disease with the exact opposite characteristics.

Adenomyosis and in vitro fertilization: How does adenomyosis prevent implantation?

Adenomyosis negatively affects the outcome of embryo implantation and leads to reduced rates of successful pregnancy outcome by increasing miscarriage rates. It causes hormonal disorders, which in turn affect ovulation, fertilization and subsequently the development of the fetus. Moreover, there are not a few cases where, although the implantation is successful, the embryo does not develop normally, due to the abnormal environment inside the uterus.

In addition, according to some recent research, adenomyosis contributes to the reduction of the ovarian reserve. This situation makes it more difficult for assisted reproduction treatments to be successful as can impact the number and quality og eggs collected. Therefore, adenomyosis is a condition that makes it difficult to successfully conceive naturally and/or with IVF.

Adenomyosis and IVF: What problems does it cause to the IVF process?

Adenomyosis can be one of the leading causes of IVF failure and requires special management to achieve pregnancy. IVF is a complex process with many steps and adenomyosis can affect the response of the ovaries to stimulation drugs and make the egg retrieval process difficult, while it can also lead to failed embryo implantation due to the inappropriate environment inside the uterus. This results in many times not retrieving the optimal number of eggs from the uterus and requiring individualized treatment protocols depending on the extent of adenomyosis.

Ways to deal with the problems caused by adenomyosis in fertility

Adenomyosis is a great challenge for gynecologists because it causes serious dysfunctions in the uterus. However, nowadays its negative consequences can be treated, reducing the chances of failed embryo implantation.

A key factor for the success of IVF is the expertise of the physician and the proper preparation of the patient. Depending on the extent of the adenomyosis and the patient’s profile, the treatment can be pharmaceutical and/or surgical.

Adenomyosis appears to be more common than previously believed by the medical community. Don’t ignore changes in your menstrual cycle that may be symptoms of a medical condition. Its timely diagnosis is of paramount importance for its treatment and the achievement of pregnancy.

If you are facing fertility problems, contact the experienced and specialized Obstetrician-Gynecologist Melina Stasinou. Dealing with infertility is a special “fight” and the physician designs each time a unique and personalized treatment plan based on the patient’s needs and underlying pathology. Contact us to book your appointment.

What is the blighted ovum?

The blighted ovum syndrome (or anembryonic pregnancy) is defined as the condition in which the amniotic sac does not contain fetal elements (fetal pole), as would be expected in a normal pregnancy. In other words, a fertilized egg implants in the uterus, but then its normal development does not follow.

The amniotic sac is the structure within which the fetus grows during pregnancy. It consists of a thin membrane that is in contact with the wall of the endometrial cavity and it is part of the placenta. In normal conditions, as the fetus grows, it occupies the entire cavity of the uterus. Inside the sac, in addition to the fetus, there is a watery fluid, the amniotic fluid. However, in the case of the blighted ovum syndrome, the amniotic sac grows, without to contain a fetus (with or without the presence of a yolk sac).

When can the blighted ovum syndrome occur and what are its causes?

The syndrome appears in the first trimester of pregnancy and it is the most common cause of miscarriage during this period. The causes of the syndrome have not been precisely determined. It usually occurs due to chromosomal abnormalities of the fertilized egg. Other factors such as hormonal imbalances, anatomical anomalies of the uterus, genetic factors have been blamed for its appearance, but without being scientifically documented.

Signs that may indicate blighted ovum syndrome

Although no embryo has been developed inside the amniotic sac, pregnancy-related hormones are released normally. The release of hormones causes early signs of pregnancy, which usually include the following:

• Positive pregnancy test
• Nausea
• Morning sickness
• Breast tenderness

In addition to the above symptoms that indicate pregnancy, the syndrome can also manifest itself with miscarriage symptoms. In particular, a woman with the blighted ovum syndrome may experience vaginal bleeding or pelvic cramps.

How is the diagnosis made?

The diagnosis of the syndrome is made after the fifth week of pregnancy through transvaginal ultrasound. After the end of the fifth week, the fetus should be clearly visible inside the amniotic sac, which does not happen in the blighted ovum syndrome.

The yolk sac can be detected very quickly within the first 2 weeks after a missed period by ultrasound.

How is it treated?

In the majority of cases, the blighted ovum syndrome results in a spontaneous miscarriage. If this does not happen, then the patient should undergo medical or surgical evacuation ofthe endometrial cavity.

A possible miscarriage due to the syndrome in no way excludes a future pregnancy. After two menstrual periods and as soon as the couple recovers psychologically, they can try again to achieve pregnancy and also search for the possible causes through their gynecologist.

The Obstetrician-Gynecologist Melina Stasinou has been a Research Associate at the Imperial College Extracorporeal and has extensive experience in assisted reproduction. The physician, knowing how important the role of the gynecologist is in trying to achieve pregnancy, stands next to all women. Each failed attempt needs individualized treatment in order to find the possible causes.