​For women trying to conceive without success, infertility evaluation typically begins after 12 months of unprotected intercourse, or 6 months if the person is over 35. This timing follows clinical guidance based on how long conception has been attempted and signals when providers begin a step-by-step medical review. The initial visit focuses on collecting facts about reproductive health rather than assigning a diagnosis or predicting outcomes.

The first appointment usually includes a discussion of menstrual patterns, previous pregnancies, contraceptive history, and the timing and frequency of intercourse. Providers also review medical conditions, prior surgeries, and medications that could influence reproductive function. These details give structure to the evaluation and help decide which tests to begin with.

Clinicians start with hormone testing. They may measure follicle-stimulating hormone, luteinizing hormone, thyroid markers, or anti-Mullerian hormone, depending on symptoms and age. These tests help providers understand cycle behavior and determine whether further monitoring is needed. Clinicians often obtain some tests in the early follicular phase to keep results consistent across cycles.

Clinicians also typically order a semen analysis early in the evaluation. It assesses sperm count, movement, and shape and provides objective information about male fertility factors without invasive procedures. Including both partners at the start helps the evaluation reflect all possible contributors.

Pelvic ultrasound provides a real-time view of the uterus and ovaries. It can identify fibroids, ovarian cysts, and other findings that may affect conception. Clinicians perform this test in an office setting and gain direct insight into reproductive anatomy.

Clinicians may recommend a hysterosalpingogram, or HSG, next. This imaging method uses contrast dye and X-ray technology to show whether the fallopian tubes are open and whether the uterine cavity has any unusual contours. Clinicians schedule the test at a specific point in the cycle and obtain information that ultrasound alone cannot provide.

When ovulation timing is uncertain, clinicians introduce cycle tracking methods. These may include ovulation predictor kits, temperature charting, or ultrasound monitoring. Clinicians use these tools when cycles are irregular or when added timing detail helps align conception attempts with expected fertile windows. When needed, they confirm ovulation with a mid-luteal progesterone blood test.

During the early evaluation, clinicians also review lifestyle habits that patients can change. They assess tobacco exposure, alcohol use, weight-related factors, and exercise patterns and explain how these behaviors can affect attempts to conceive. This discussion focuses on environmental and behavioral influences, and clinicians address medical treatments separately when they become relevant.

When tests occur in multiple settings, clinicians coordinate results among primary care, reproductive endocrinology, urology, and imaging centers. They share reports efficiently to keep the evaluation organized and to avoid duplicate testing. This coordination helps align any follow-up testing with prior findings and prevents unnecessary delays.

Initial findings guide how the evaluation progresses. Some patients complete additional cycle tracking to clarify ovulation patterns, while others undergo further imaging or laboratory testing to explore specific questions raised by earlier results. Clinicians base each action on documented findings and sequence tests accordingly, keeping the evaluation focused on the issues identified during the first phase.

As care advances, the structure of early evaluation provides more than clinical direction - it creates a shared decision-making path during uncertain or changing circumstances. When options shift or timelines evolve, patients and providers can revisit the original findings to determine the most realistic path forward. This continuity strengthens clarity at each transition and helps maintain alignment between goals, results, and timing.

​Women undergo hysterectomy to address specific medical issues. This surgery to remove the uterus helps address conditions like fibroids, which can grow in the uterus; uterine prolapse, where the uterus may sag or drop from its usual position; and endometriosis, a condition where tissues lining the uterus grow in other parts of the body. Many surgeons use robots to help with this operation.

Robotic-assisted hysterectomy works differently from traditional surgery. The surgeon sits at а control station and moves robotic arms that hold tiny tools inside the patient. The robot mimics the surgeon's hand movements. These robotic tools can twist and bend better than human hands can. The surgeon views everything through a special camera that displays a clear, three-dimensional image. This sharp view helps doctors spot small blood vessels and layers of tissue that might be hard to see otherwise.

The surgery itself follows a specific process. Patients receive general anesthesia and lie on the table with their head lower than their feet. This position moves the intestines up and away from the area where the surgeon needs to operate. The surgeon then makes four or five small incisions in the lower abdomen, each measuring less than half an inch. The small cuts serve as an entry route for the associated surgical tools that connect to the robot arms.

The surgeon sits at a console steps away from the patient. Using finger controls, they can seal blood vessels, separate the uterus from surrounding tissue, and remove the ovaries if necessary. Most of the time, the surgeon takes out the uterus through the vagina to avoid making belly cuts any bigger. Sometimes when the uterus is too big, the surgeon can cut it into smaller pieces and remove them via the small belly openings. After completing this step, the surgeon withdraws the instruments and closes the small incisions with stitches. After everything is out, the surgeon pulls back the tools and closes the small cuts with stitches. Most patients go home the same day or stay overnight for further observation.

Research reveals why surgeons opt for robots in this surgery. Patients heal faster and have smaller scars compared to open abdominal surgery. The robot's steady movements and precise cuts lead to а lower risk of damaging nearby organs and less blood loss. The advantages of robotic-assisted hysterectomy are particularly evident in complex situations. Patients who are overweight, have large fibroids, thick scar tissue, or past C-section scars can be hard to operate on with regular tools. The robot's flexible wrists and clear cameras enable surgeons to perform intricate stitching deep within the pelvis.

Robotic surgery has the same risks as any hysterectomy. Bleeding, infection, and injury to nearby organs can happen. One risk occurs slightly more often with robots - the stitched area at the top of the vagina can come apart. Although rare, robotic instruments can also sometimes malfunction, requiring surgeons to switch to traditional tools or resort to open surgery to complete the operation.

Robotic-assisted surgeries also take more time than regular laparoscopic procedures. Setting up the machine and taking extra care to prevent problems adds time to each operation. Longer surgery means patients stay under anesthesia for a longer period, which can lead to more complications. Cost is another major issue. These robot systems cost millions of dollars to purchase, and hospitals pay additional expenses to keep them operational. Also, many hospitals don't have robots at all. When they do, each surgery costs much more, sometimes three times as much as regular methods.

The adoption of robotic-assisted hysterectomy is accelerating in the US. Approximately 43 percent of minimally invasive hysterectomies now utilize robotic assistance. In the UK, adoption has also increased. A 2024 report counted about 2,700 robot-assisted surgeries, including hysterectomies for non-cancer conditions.

​Multiple sources have reported that Medtronic submitted its surgical robot to the FDA. If it gets FDA approval, physicians will be able to use Hugo for gynecological procedures. As it stands, Hugo has passed several benchmarks in urological procedures, with researchers preparing for trials to use the robot for hernia and gynecological surgeries.

In general, robotic-assisted surgeries involve a trained surgeon who sits at a computer console several feet from the patient. The computer gives the physician a 3D high-definition view of the surgical site and contains hand controls, which the physician uses to move the arms above the operating table. An assistant stands near the operating table to monitor the robotic arms, which contain cameras and tools for clamping, cutting, and suturing the incision.

Physicians are currently using robotic-assisted surgery for procedures like hysterectomies, uterine fibroid removal, endometriosis treatment, and pelvic organ prolapse repair. The benefits for patients include less bleeding, a reduced risk of infection, and smaller scars compared to traditional surgery. For surgeons, the technology provides greater precision by reducing tremors caused by long tool usage and offers a detailed view of the surgical area.

In late April 2025, Medtronic submitted Hugo to the Food and Drug Administration (FDA) to get approval for use in urological procedures with the intention of expanding this approval for hernia and gynecological procedures. The Hugo Robot is a multi-quadrant, modular surgical tool with advanced 3D visualization, wristed instruments, and integrated video capture features that function through Touch Surgery Enterprise.

While not cleared for gynecological procedures, the urological trials also show promise for the tool's use in gynecology. The study, titled Expand URO FDA investigational advice exemption, involved testing the device on 137 patients with the Hugo system. Eleven surgeons used Hugo at six hospitals nationwide to perform three types of urological surgeries: prostatectomies (removing the prostate), nephrectomies (removing the kidneys), and cystectomies (removing the bladder). The surgeons performed procedures on patients with renal and bladder tumors and prostate cancer.

Researchers found that using the Hugo instrument in robotic-assisted surgery resulted in a success rate meeting FDA requirements. Some procedures experienced grade three or higher complications, where grades three and above indicate severe issues affecting daily activities. Hugo met primary safety endpoints, confirming its effectiveness as a treatment. The trials showed a 98.5 percent success rate, exceeding the trial's success rate goal of 85 percent.

How does this all connect with Hugo's use in gynecology? In a second-quarter meeting, Medtronic reported that it had intended to expand trials in this area, along with hernia. The company completed enrollment trials for Hugo's use to treat these conditions at the beginning of 2025.

Medtronic CEO and Chair Geoff Martha stated that the company is working to establish itself as a leader in robotic surgery. James Porter, MD, Chief Medical Officer at Medtronic, stated that the urological trials were an important milestone in providing surgeons nationwide with options in robotic surgery. Furthermore, surgeons want to give patients the best care, and robotic surgery has made this possible. For more information on the Hugo trial's progress, visit the Medtronic site at www.medtronic.com/in-en/index.html.

​Cervical incompetence, also known as cervical insufficiency, is a condition affecting the cervix, the uterus’ lower portion that opens into the vagina. Prior to pregnancy, the cervix is usually firm and closed at the lower end. During the earlier stages of pregnancy, it remains closed, only thinning, shortening (effacing), softening, and dilating (opening) as childbirth approaches. When cervical thinning, shortening, or softening occurs too early, miscarriage and premature birth can result. The fetus is born before the organs have fully developed and cannot easily survive outside the womb.

A fibromuscular organ, the cervix goes through extensive changes during gestation and childbirth. As gestation progresses, the maternal cervix is transformed through timed biochemical cascades, extracellular and cellular interactions, and infiltration by inflammatory cells within the cervical stroma. The latter is a dense, fibrous tissue that allows the passage of lymphatic, vascular, and nerve supplies to and from the cervix. When any of these processes is disrupted, preterm birth or miscarriage may occur.

Incompetent cervix is implicated in approximately one in 100 pregnancies. While cervical incompetence can be an issue for anyone, women at higher risk tend to have a uterus or cervix that is irregularly shaped. They may have previously had a miscarriage or premature birth or suffered an injury to the uterus or cervix during past childbirth or pregnancy. Surgery on the cervix also increases risks, as does Ehlers-Danlos syndrome and other genetic disorders that weaken the cervix. Women expecting twins and triplets, as well as African Americans, also have a higher chance of developing the condition.

Physicians generally identify cervical insufficiency in the second or early third trimester. Unfortunately, such diagnosis is often retrospective: In many cases, preterm premature rupture of membranes (PPROM) has already occurred due to progressive cervical dilation, resulting in spontaneous preterm birth or mid-trimester pregnancy loss.

Diagnosis often starts with a finding of “painless dilation without labor” through a physical exam. Ultrasound can identify a shortened cervix (less than 25 millimeters long, with less than 24 weeks gestation). Women with a prior history of preterm births and second-trimester losses are closely monitored as well.

The most common treatments are vaginal progesterone and cervical cerclage. Taken as a tablet (Endometrin) or applied as a gel (Crinone), vaginal progesterone is among a medication class known as progestins, which impact female hormones. Its varied uses include fertility treatment and assisted reproductive technology, as it boosts embryo implantation rates and decreases miscarriage risks. Vaginal progesterone also helps bring on menstruation and reduces preterm birth rates among women with short cervix, regardless of preterm birth history.

Performed in the second trimester, cervical cerclage involves the physician using stitches to temporarily sew the cervix closed during pregnancy. There are two basic types of cerclage.

With transvaginal cerclage, the ob-gyn reaches through the vagina to place stitches in the cervix. Transabdominal cerclage involves an incision and is recommended for women who have had previous cervical surgeries or previous transvaginal cerclage that didn’t prevent pregnancy loss. It requires a cut in the abdomen as a way of accessing the cervix and placing stitches. The cut may involve either traditional laparotomy (open surgery) or minimally invasive laparoscopy, pairing an extremely small cut with a tiny inserted camera.