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INTRODUCTION — An infertility evaluation is usually initiated after one year of regular unprotected intercourse in women under age 35 and after six months of unprotected intercourse in women age 35 and older. However, the evaluation may be initiated sooner in women with irregular menstrual cycles or known risk factors for infertility, such as endometriosis, a history of pelvic inflammatory disease, or reproductive tract malformations.
The basic evaluation can be performed by an interested and experienced primary care physician or an obstetrician-gynecologist. The primary care physician generally should refer the patient to a specialist for treatment of infertility. Many gynecologists initiate treatment prior to referral to a reproductive endocrinologist. This decision depends upon the results of infertility tests and clinician experience.
Multiple tests have been proposed for evaluation of female infertility. Some of these tests are supported by good evidence, while others are not. This topic will provide an evidence-based approach to the evaluation of female infertility. The etiology and treatment of female infertility, as well as the etiology, evaluation, and treatment of male infertility, are discussed separately.
INITIAL APPROACH — Both partners of an infertile couple should be evaluated for factors that could be impairing fertility. The infertility specialist then uses this information to counsel the couple about the possible etiologies of their infertility and to offer a treatment plan targeted to their specific needs.
It is important to remember that the couple may have multiple factors contributing to their infertility; therefore, a complete initial diagnostic evaluation should be performed to detect the most common causes of infertility, if present. When applicable, evaluation of both partners is performed concurrently .
The recognition, evaluation, and treatment of infertility are stressful for most couples . The clinician should not ignore the couple's emotional state, which may include depression, anger, anxiety, and marital discord. Information should be supportive and informative. (See "Psychological stress and infertility".)
History and physical examination — Findings on history and physical examination may suggest the cause of infertility and thus help focus the diagnostic evaluation. Components of the infertility history are listed in the table (table 1).
History — The most important points in the history are:
Physical examination — The physical examination should assess for signs of potential causes of infertility. The patient's body mass index (BMI) should be calculated and fat distribution noted, as extremes of BMI are associated with reduced fertility and abdominal obesity is associated with insulin resistance.
Incomplete development of secondary sexual characteristics is a sign of hypogonadotropic hypogonadism. A body habitus that is short and stocky, with a squarely shaped chest, suggests Turner syndrome.
Abnormalities of the thyroid gland, galactorrhea, or signs of androgen excess (hirsutism, acne, male pattern baldness, virilization) suggest the presence of an endocrinopathy (eg, hyper- or hypothyroidism, hyperprolactinemia, polycystic ovary syndrome, adrenal disorder).
Tenderness or masses in the adnexae or posterior cul-de-sac (pouch of Douglas) are consistent with chronic pelvic inflammatory disease or endometriosis. Palpable tender nodules in the posterior cul-de-sac, uterosacral ligaments, or rectovaginal septum are additional signs of endometriosis.
Vaginal/cervical structural abnormalities or discharge suggest the presence of a müllerian anomaly, infection, or cervical factor.
Uterine enlargement, irregularity, or lack of mobility are signs of a uterine anomaly, leiomyoma, endometriosis, or pelvic adhesive disease.
These conditions are described in detail separately:
Diagnostic tests — In addition to the history and physical examination, the initial diagnostic evaluation consists of:
Risk factors noted from the couple's history may indicate the need for additional testing after the initial infertility evaluation.
Preconceptional laboratory screening may also be undertaken at this time so these results can be used for diagnostic and therapeutic counseling. Genetic screening should be offered in accordance with risk as defined by ethnicity. The components of preconception evaluation and counseling are discussed separately. (See "Preconception evaluation and counseling", section on 'Laboratory assessment/screening'.)
Semen analysis — The semen analysis is the cornerstone of the assessment of the male partner of an infertile couple. In addition to the standard analysis, specialized analyses can be performed in some laboratories. The semen sample should be collected after two to seven days of abstinence and should be submitted to the laboratory within one hour of collection .
It is difficult to predict the likelihood of pregnancy based upon the results of semen analysis alone, as there is extensive overlap between the semen parameters of fertile and infertile men. If the semen analysis is abnormal, the clinician should review details of specimen collection and transport with the patient, repeat the test due to the marked inherent variability of semen analyses, and consider referral to a urologist or other specialist in male reproduction.
The techniques for semen analysis and interpretation of results are discussed in detail separately. (See "Evaluation of male infertility", section on 'Standard semen analysis'.)
Assessment of ovulatory function — Assessment of ovulatory function is a key component of the evaluation of the female partner since ovulatory dysfunction is a common cause of infertility. The treatment of women with ovulatory dysfunction is aimed at improving or inducing ovulatory function; a variety of treatment strategies is available. (See "Overview of treatment of female infertility".)
In women who do not have grossly abnormal menstrual cycles indicative of ovulatory dysfunction, laboratory assessment of ovulation should be performed. Ovulation is most easily documented by a mid-luteal phase serum progesterone level, which should be obtained approximately one week before the expected menses. For a typical 28-day cycle, the test would be obtained on day 21. A progesterone level >3 ng/mL is evidence of recent ovulation .
An alternative is to have the patient use an over-the-counter urinary ovulation prediction kit. These kits detect luteinizing hormone (LH) and are highly effective for predicting the timing of the LH surge that reliably indicates ovulation. Home kits have a 5 to 10 percent false positive and false negative rate. Therefore, serum confirmation can be useful in patients who are unable to detect a urinary LH surge.
Other methods of determining ovulation, such as serial ultrasounds to follow the development and ultimately the disappearance of a follicle and endometrial biopsy to document secretory changes in the endometrium are too expensive or invasive for routine diagnostic assessment of ovulation.
If the progesterone concentration is <3 ng/mL, the patient is evaluated for causes of anovulation. The minimal work-up includes serum prolactin, thyrotropin (TSH), follicle-stimulating hormone (FSH), and assessment for polycystic ovary syndrome (PCOS). The etiology and diagnostic evaluation of anovulation are reviewed separately. (See "Etiology, diagnosis, and treatment of secondary amenorrhea".)
Assessment of ovarian reserve — Diminished ovarian reserve can refer to diminished oocyte quality, oocyte quantity, or reproductive potential. The identification of diminished ovarian reserve is an increasingly important component of the initial infertility evaluation as patients are presenting for diagnostic evaluation later in their reproductive lifespan . However, there is no ideal test for assessing ovarian reserve. A number of screening tests are utilized, but no test is highly reliable in predicting fertility potential.
For women over 35 years of age and younger women with risk factors for premature ovarian failure, we suggest testing ovarian reserve with a day 3 FSH level. Other tests such as the clomiphene citrate challenge test (CCCT), antral follicle count, and anti-müllerian hormone (AMH) level are utilized by some specialists and in special circumstances.
Day 3 FSH and CCCT — Both the day 3 FSH level (where day 1 is the first day of full menstrual flow) and the CCCT, which is a provocative test for measurement of FSH, are widely used for screening ovarian reserve. The CCCT involves 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.
The basis of these tests is that women with good ovarian reserve have sufficient production of ovarian hormones from small follicles early in the menstrual cycle to maintain FSH at a low level. In contrast, women with a reduced pool of follicles and oocytes have insufficient production of ovarian hormones to provide normal inhibition of pituitary secretion of FSH, so FSH rises early in the cycle .
Meta-analyses of nonrandomized studies concluded that basal cycle day 3 FSH and the CCCT testing perform similarly for predicting ability to achieve a clinical pregnancy in women undergoing infertility treatment [8,9]. With either test, a normal result is not useful in predicting fertility, but a highly abnormal result (we use FSH >20 mIU/mL) suggests that pregnancy will not occur with treatment involving the woman's own oocytes.
Based on these findings and the cost advantage and simplicity of the day 3 FSH, we obtain a day 3 FSH concentration and consider a value less than 10 mIU/mL suggestive of adequate ovarian reserve, and levels of 10 to 15 mIU/ml borderline. The upper threshold for a normal FSH concentration is laboratory dependent; cutoff values of 10 to 25 mIU/mL have been reported because of use of different FSH assay reference standards and assay methodologies.
We also check a cycle day 3 estradiol level, although there are conflicting data as to whether it is predictive of ovarian reserve and the response to ovarian stimulation (as in in vitro fertilization [IVF]) [10,11]. We consider a value <80 pg/mL suggestive of adequate ovarian reserve, but other cut-offs are also utilized. In one prospective study of women undergoing IVF, day 3 estradiol levels >80 pg/mL resulted in higher cycle cancellation rates and lower pregnancy rates, and estradiol levels >100 pg/mL were associated with a 0 percent pregnancy rate .
Elevated basal estradiol levels are due to advanced premature follicle recruitment that occurs in women with poor ovarian reserve. High estradiol levels can inhibit pituitary FSH production and thus mask one of the signs of decreased ovarian reserve in perimenopausal women. Thus, measurement of both FSH and estradiol levels helps to avoid false-negative FSH testing.
If CCCT is performed, we consider FSH less than 15 mIU/mL on both day 3 and day 10 suggestive of adequate ovarian reserve; an elevated FSH level on either day 3 or day 10 suggests decreased ovarian reserve. Estradiol can be measured on day 3, but a cycle day 10 estradiol is not part of the standard CCCT as it reflects the magnitude of the ovarian follicular response to clomiphene 100 mg daily for five days, not ovarian reserve.
If the day 3 FSH or CCCT is abnormal, the patient should be referred to a reproductive endocrinologist to discuss further diagnostic and treatment options. These options, which also depend on the results of other diagnostic tests, the age of the female partner, and other factors, may include aggressive ovulation induction, IVF, or use of donor oocytes. However, patients with markedly diminished ovarian reserve rarely conceive without the use of donor eggs.
Antral follicle count (AFC) — Ultrasound examination can be used to determine the number of antral follicles (defined as follicles measuring 2 to 10 mm in diameter). On transvaginal ultrasound, a low AFC ranging from 4 to 10 antral follicles between days two and four of a regular menstrual cycle suggests poor ovarian reserve. AFC thresholds will vary by center and should be prospectively tested within a center to be most useful as a predictive tool [13-16]. Most clinicians perform an AFC during the early follicular phase, although a retrospective cohort study showed no difference in the predictive value of AFC for poor ovarian response when measured at different phases of the menstrual cycle . Although AFC is a good predictor of ovarian reserve and response, it is less predictive of oocyte quality, the ability to conceive with IVF, and pregnancy outcome .
Anti-müllerian hormone (AMH) — Anti-müllerian hormone (AMH) is a member of the TGF-beta family and is expressed by the small (<8 mm) preantral and early antral follicles. The AMH level reflects the size of the primordial follicle pool. In adult women, AMH levels gradually decline as the primordial follicle pool declines with age ; AMH is undetectable at menopause .
The AMH level appears to be an early, reliable, direct indicator of declining ovarian function, however, there is no consensus on the appropriate threshold value [10,20-26]. A serum AMH level above 0.5 ng/mL is consistent with good ovarian reserve, while lower levels suggest the presence of a depleted ovarian follicle pool. Levels less than 0.15 ng/mL suggest the patient will have a poor response to IVF [10,21]. Measurement of AMH may play an especially useful role in identifying reduced ovarian follicle pool in certain types of patients, such as cancer patients .
AMH can be measured anytime during the menstrual cycle and typically demonstrates minimal intercycle and intracycle variability since the growth of small preantral follicles that express it is continuous, not cyclical. Reliable AMH kits  are readily available from multiple vendors and AMH measurements can be obtained from large clinical reference laboratories [28,29], but most insurers in the United States do not reimburse for the test. AMH level is being used to manage patients in Europe .
Assessment of fallopian tube patency — We perform HSG as the first-line test for evaluation of tubal patency because of its therapeutic, as well as diagnostic, benefits . Non- or minimally invasive alternatives to HSG for investigation of tubal subfertility include chlamydia antibody testing and/or hysterosalpingo-contrast sonography (HyCoSy) .
When the diagnosis is in doubt, more invasive tests can be used to confirm the diagnosis, and provide an opportunity for concurrent therapeutic intervention. These tests include laparoscopy with chromotubation and fluoroscopic/hysteroscopic selective tubal cannulation.
Hysterosalpingogram — We obtain a HSG to look for tubal occlusion in all patients, unless laparoscopy is planned [33,34]. Either water or lipid soluble contrast media can be used. HSG also provides information about the uterine cavity. Women with abnormalities on HSG should be referred to a reproductive endocrinologist to discuss treatment options. (See "Hysterosalpingography".)
HSG is not useful for detecting peritubal adhesions or endometriosis . We perform diagnostic laparoscopy and chromotubation in women suspected of having endometriosis or pelvic adhesions related to a previous pelvic infection or surgery. Ablation of implants and lysis of adhesions, when indicated, can be performed at the same procedure (see 'Role of laparoscopy' below).
A meta-analysis of 20 studies involving 4179 patients compared HSG and laparoscopy with chromotubation (the gold standard); the calculated sensitivity and specificity for diagnosis of tubal patency were only 65 and 83 percent, respectively . However, when subgroups of women undergoing HSG were analyzed, HSG appeared to have very high specificity and sensitivity for diagnosing distal tubal occlusion or major distal tubal adhesions, but much lower specificity for diagnosing proximal tubal occlusion.
Proximal tubal occlusion on HSG often represents testing artifact due to tubal spasm or poor catheter positioning leading to unilateral tubal perfusion. Given these deficiencies, findings of proximal tubal occlusion on HSG could be confirmed by a secondary test such as a repeat HSG, fluoroscopic or hysteroscopic selective tubal perfusion, or laparoscopic chromotubation if definitive diagnosis will influence further management.
Diagnostic HSG also appears to have therapeutic effects. A systematic review of 12 randomized trials found that pregnancy rates were significantly higher in subfertile women who underwent tubal flushing with oil soluble media than in those who did not undergo HSG (OR 3.30, 95% CI 2.00-5.43), and that pregnancy rates were similar whether oil or water soluble media were used (OR 1.21, 95%CI 0.95-1.54) .
Chlamydia antibodies — Chlamydia trachomatis IgG antibody testing is a simple, inexpensive, noninvasive test with some evidence supporting its use as a method for predicting the presence of tubal disease. Studies suggest that antibodies to chlamydia are more predictive of infertility than an abnormal HSG or a history of previous use of a copper IUD [35-40]. Multiple tests are available , but not widely utilized given only limited data supporting their use. A cost-effective approach might be to screen women at low risk of tubal disease with chlamydia antibodies. A negative test is associated with <15 percent likelihood of tubal pathology and thus does not require further assessment . False positives are due to cross reactivity withC. pneumoniae, do not distinguish between remote and persistent infection, and do not indicate whether infection resulted in tubal damage ; therefore, an HSG is performed if the test results are positive . Women at high risk of tubal disease would be screened by HSG primarily.
In a study correlating results of five chlamydia antibody tests to laparoscopy findings in 315 subfertile women, the diagnostic performance of micro-immunofluorescence testing was superior to ELISA testing . However, there was significant cross-reactivity with C. pneumoniae antibodies for all tests except the pELISA Medac. Thus, positive test results from other modalities should be confirmed with this ELISA. In this study, a positive pELISA Medac had sensitivity and specificity of 55 and 87 percent, respectively, for tubal pathology at laparoscopy.
Chlamydia antibody testing can be used to screen women with an allergy to shellfish or iodinated contrast agents who cannot undergo an HSG. In women without risk factors for tubal disease, a negative test does not require further tubal assessment. If the test is positive, a sonohysterogram may be performed; presence of fluid in the cul-de-sac after intrauterine infusion of saline indicates patency of at least one tube.
Hysterosalpingo-contrast sonography — Hysterosalpingo-contrast sonography (HyCoSy) uses ultrasound to view the uterus, tubes, and adnexa before and after transcervical injection of echogenic contrast media. It is a safe, well tolerated, quick and easy method for obtaining information on tubal status, the uterine cavity, the ovaries, and the myometrium using conventional ultrasound . In comparative studies, performance has compared favorably with HSG [46-50]. A meta-analysis involving over 1000 women who underwent diagnostic imaging because of tubal-related infertility found HyCoSy and HSG were 83 percent concordant for detecting tubal pathology . Using laparoscopy with chromotubation as the reference standard, HyCoSy showed false occlusion in 85 tubes (10.3 percent) and false patency in 55 tubes (6.7 percent); HSG showed false occlusion in 19 tubes (12.5 percent) and false patency in 17 tubes (11.2 percent). Tubal spasm and tubal fistula, as well as operator error, accounted for the misdiagnoses.
Assessment of the uterine cavity — In addition to assessment of tubal patency, HSG may identify developmental or acquired abnormalities of the uterine cavity with potential effects 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). Abnormalities found on HSG generally require further evaluation by other imaging modalities (ultrasonography or magnetic resonance imaging), hysteroscopy, or laparoscopy and referral to a reproductive endocrinologist.
Ultrasonography is a useful test for evaluation of suspected leiomyomata, while saline infusion sonohysterography is the best imaging modality for detection of submucosal leiomyomas and is much better than routine ultrasonography for diagnosis of intrauterine adhesions, polyps, and congenital uterine anomalies . As discussed above, HyCoSy is a simple, time-efficient, and effective method for evaluation of tubal patency, the uterine cavity, and the myometrium .
Hysteroscopy is the definitive method for evaluation of abnormalities of the endometrial cavity, and also offers the opportunity for treatment at time of diagnosis. In patients undergoing laparoscopy, performing hysteroscopy at the same time and omitting HSG is efficient.
Evaluation of uterine anomalies depends on the anomaly.
ROLE OF LAPAROSCOPY — The role of laparoscopy in the evaluation of infertility is controversial. Laparoscopy is invasive and expensive. Findings at laparoscopy usually do not alter the initial treatment of the infertile couple when the initial infertility evaluation is normal or when it shows severe male factor infertility. Couples with a normal infertility evaluation (ie, unexplained infertility) typically undergo a trial of ovarian stimulation with or without intrauterine insemination and many will conceive without further intervention. Couples with tubal or male factor infertility are typically offered IVF as one of their treatment options. (See "Unexplained infertility" and "In vitro fertilization".)
No randomized trials have assessed the cost effectiveness and timing of diagnostic laparoscopy prior to ovulation induction in couples with unexplained infertility. Laparoscopy is indicated in women in whom endometriosis or pelvic adhesions/tubal disease is suspected based on physical examination, HSG, or history (eg, current dysmenorrhea, pelvic pain, or deep dyspareunia; previous complicated appendicitis, pelvic infection, pelvic surgery, or ectopic pregnancy) [53-55]. When we perform laparoscopy, we also perform chromotubation to assess tubal patency and hysteroscopy to evaluate the uterine cavity. For this reason, if laparoscopy is planned, then HSG can be omitted .
The advantage of performing laparoscopy early in the evaluation of women suspected of having endometriosis or pelvic adhesions is that surgical therapy can be initiated, while avoiding potentially ineffective or unnecessary empiric medical treatment for ovulation induction. Endometriosis, if identified, can be excised/ablated at the time of the diagnostic procedure and pelvic adhesions can be lysed. (See "Pathogenesis and treatment of infertility in women with endometriosis".)
The use of laparoscopy to treat infertility is covered in detail separately. (See "Reproductive surgery for female infertility".)
TESTS OF LIMITED CLINICAL UTILITY
Postcoital test — In agreement with other experts [1,57], we do not recommend postcoital testing.
The postcoital test has poor diagnostic potential and predictive value [58,59] that is due, in part, to the lack of consensus on a normal versus abnormal test result and to low inter- and intraobserver reproducibility . In addition, interventions designed to improve cervical factor infertility have not been effective, while widely used infertility therapies, such as intrauterine insemination and IVF bypass the cervix so improving cervical factors becomes irrelevant. Importantly, a randomized trial that compared the outcome of infertility investigations with and without the postcoital test showed no difference in pregnancy rates at 24 months . Thus, incorporation of the postcoital test in standard infertility evaluations increases the number of tests and treatments, but has no effect on the pregnancy rate.
Endometrial biopsy — Endometrial biopsy has been performed for two reasons: (1) to document a secretory endometrium, which is indirect evidence that ovulation has occurred, and (2) to evaluate whether the maturity of the secretory endometrium is in phase (ie, consistent with menstrual cycle date) or out of phase (ie, luteal phase defect). It is not a good test for either indication because it is invasive, expensive, uncomfortable, unnecessary for evaluation of ovulation, and ineffective for assessment of endometrial receptivity (ie, the ability of the endometrium to allow the blastocyst to attach, invade, and implant).
As discussed above, ovulation is optimally assessed using serum progesterone level >3 ng/mL obtained in the late luteal phase (see 'Assessment of ovulatory function' above).
Although endometrial receptivity during the implantation window is crucial for achieving pregnancy, histological assessment of endometrial response has a poor correlation with fertility [62-66]. For example, when repeated endometrial biopsies are performed in normal fertile women, half will have a single out-of-phase biopsy (using two-day or greater lag criteria) and over one-quarter will have sequential out-of-phase biopsies [67,68]. Moreover, in one study of 619 women with regular menstrual cycles, a biopsy that was out-of-phase by greater than two days was actually more common in fertile women than in infertile women (at day 21 to 22: 49 versus 43 percent; at day 26 to 27: 35 versus 23 percent).
Thus, it appears that histological dating does not discriminate fertile from infertile couples [67,68]. As the treatment of luteal phase defect does not improve pregnancy outcome in infertile women, luteal phase evaluation by histological dating of the endometrium is not worthwhile.
The American Society of Reproductive Medicine (ASRM) affirmed the lack of benefit of the endometrial biopsy in the evaluation of the infertile female and does not recommend use of this test .
Endometrial biopsy is appropriate when endometrial pathology is strongly suspected.
Basal body temperature records — Basal body temperature charts are the least expensive method for detecting ovulation, but interpretation of the charts can be difficult and subject to wide interobserver variation [69,70]. We prefer serum testing for assessment of ovulatory status in women with irregular cycles (see 'Assessment of ovulatory function' above).
Progesterone released from the corpus luteum at the time of ovulation has potent effects on the hypothalamus, one of which is to increase body temperature. As a result, daily temperature monitoring can be used to document progesterone production and, therefore, ovulation. The woman takes her temperature by putting the thermometer under her tongue every morning while she is still in the basal state (ie, before she gets out of bed, uses the bathroom, or has anything to eat or drink) and records the temperature on a chart. Although there is an expected amount of daily variability, an approximately 0.5ºF rise in body temperature can be detected in the luteal phase of the menstrual cycle compared with the follicular phase. In a normal cycle, the temperature rise begins one or two days after the LH surge and persists for at least 10 days. Thus, temperature changes are sufficient to retrospectively identify ovulation, but they occur too late to be useful for timing intercourse.
Zona-free hamster oocyte penetration test — This test is also known as the sperm penetration assay. Conflicting literature exists on whether the hamster oocyte test predicts human oocyte fertilization [71,72]. The utility of test results depends, in part, on the experience of the laboratory performing the assay. We do not order this test since the results would not influence our clinical management. (See "Evaluation of male infertility", section on 'Zona-free hamster oocyte penetration test'.)
Mycoplasma cultures — We do not suggest obtaining routine Ureaplasma urealyticum and Mycoplasma hominis cultures given that there is minimal evidence for a role of these organisms in female infertility .
Testing for antibodies — Routine testing for antiphospholipid, antisperm, antinuclear, and antithyroid antibodies is not supported by existing data . Although an association between antiphospholipid antibodies and recurrent pregnancy loss has been established, the other autoimmune factors remain under investigation as markers of fertility treatment failure. (See "Pregnancy in women with antiphospholipid syndrome".)
Karyotype — There is a general consensus to counsel and offer to karyotype the male partner if there is severe oligospermia, as these men are at higher risk of karyotypic abnormalities. Separate testing for Y chromosome microdeletions may also be offered. We suggest karyotyping women with very early premature menopause (prior to age 40) and both partners if there have been recurrent pregnancy losses. In most other circumstances, karyotyping is not indicated as part of the initial evaluation because of the low incidence of abnormalities in women with unexplained infertility, endometriosis, or tubal factor infertility . Karyotype may be useful in patients with these conditions who have failed initial treatment approaches and plan to undergo IVF, although the cost-effectiveness of universal karyotype screening prior to IVF has not been established .
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