Among uterine factors, what are the key issues to evaluate in infertility, and how are they assessed?

• A. Endometrial biopsy only.
• B. Structural abnormalities like fibroids and congenital anomalies; assessed with transvaginal ultrasound, sonohysterography, or diagnostic hysteroscopy.
• C. Ultrasound of the pelvis for ovarian cysts.
• D. Measurement of ovarian hormones.

Answer: (B)

The key idea is that infertility due to uterine factors mainly comes from problems with the uterus’s structure and the uterine cavity that can affect implantation. The important things to evaluate are structural abnormalities that distort, narrow, or block the cavity—such as fibroids that protrude into the cavity (especially submucosal ones), congenital uterine anomalies (like a septate or bicornuate uterus), polyps within the cavity, and intrauterine adhesions (Asherman). To assess these, you want imaging and direct visualization that can map the cavity and identify lesions. Transvaginal ultrasound is typically the starting tool to look at the uterus and overall anatomy. If there’s a need to clearly delineate the endometrial cavity and detect intra-cavitary lesions, saline infusion sonohysterography enhances the view by outlining the cavity with fluid. Diagnostic hysteroscopy provides direct inspection of the interior of the uterus and, if present, allows simultaneous treatment of lesions such as polyps, submucosal fibroids, or adhesions. Endometrial biopsy focuses on the lining’s histology rather than the cavity’s architecture, so it doesn’t address the main uterine factors in infertility. Pelvic ultrasound aimed at ovarian cysts and measuring ovarian hormones are more about ovarian function than uterine structure.