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Female evaluation

HISTORY AND PHYSICAL EXAMINATION

The most important points in the history are:

  • Duration of infertility and results of previous evaluations and therapy
  • Menstrual history to help determine ovulatory status
  • Medical, surgical, gynecological, and obstetrical history to determine whether there are disorders and medications associated with infertility
  • Sexual history, including sexual dysfunction and frequency of coitus
  • Personal and life-style history including age, occupation, exercise, stress, dieting, smoking, and alcohol use, all of which can affect fertility
  • Physical examination should include calculation of the patient's body mass index (BMI) and assessment for signs of potential causes of infertility: abnormalities of the thyroid gland; galactorrhea; signs of androgen excess (hirsutism, acne, male pattern baldness); tenderness or masses in the adnexae or posterior cul-de-sac (pouch of Douglas); vaginal/cervical abnormalities; and uterine enlargement, irregularity, or lack of mobility.

BASIC EVALUATION — It is important to remember that the couple may have multiple factors contributing to their infertility; therefore, a complete basic evaluation needs to be performed. Basic testing in the initial evaluation consists of:

  • Semen analysis to detect male factor infertility
  • Documentation of normal ovulation by history and midluteal serum progesterone level
  • Hysterosalpingogram (HSG) to rule out tubal occlusion
  • Risk factors noted from the couple's history may indicate the need for additional testing after the initial infertility consultation. Preconceptional laboratory assessment may also be undertaken at this time so these results can be considered in diagnostic and therapeutic counseling. (See "Preconception evaluation and counseling"). 

FOLLOW-UP EVALUATION

Assessment of ovarian reserve — Ovarian reserve is assessed in women over 35 years of age and younger women with risk factors for premature ovarian failure (previous extensive ovarian surgery, exposure to cytotoxic drugs or pelvic radiation therapy, autoimmune disease, smokers, strong family history of early menopause/premature ovarian failure). (See "Pathogenesis and causes of spontaneous premature ovarian failure", see "Ovarian failure due to anticancer drugs and radiation", and see "Pathogenesis; diagnosis; and treatment of autoimmune ovarian failure").

Identification of depleted ovarian reserve is the goal of a number of tests, including:

  • Day 3 FSH concentration
  • Clomiphene citrate challenge test (CCCT) (oral administration of 100 mg clomiphene citrate on cycle days 5 through 9 with measurement of day 3 and day 10 FSH levels and day 3 estradiol level)
  • Ultrasound imaging of the ovary to determine either ovarian volume and/or antral follicle count
  • Day 3 inhibin-B
  • Anti-mullerian hormone (AMH) level
  • GnRH agonist stimulation.

In a population of women, these markers predict the quality and number of oocytes in the ovary, and hence their prognosis for becoming pregnant, either spontaneously or with assisted reproductive technologies (ART). However, for any given woman, they are not highly accurate, raising the ethical problem of whether women should be denied infertility treatment if one of these tests of ovarian function is abnormal.

Assessment of the uterine cavity — HSG may identify abnormalities of the uterine cavity with potential affects on fertility, such as submucous fibroids, a T-shaped cavity (associated with DES exposure), polyps, synechiae, and congenital müllerian anomalies (although HSG alone cannot reliably distinguish between a uterine septum or bicornuate uterus).

Diagnostic laparoscopy — is indicated in women with otherwise unexplained infertility and a suspicion of endometriosis or pelvic adhesions due to a history of pelvic pain, complicated appendicitis, pelvic infection, pelvic surgery, or ectopic pregnancy