The obstetrician–gynecologist often is the first health care provider women will seek for evaluation or concerns about fertility. Essential components of an initial workup include a review of the medical history and additional tests as indicated.

Step 1: Medical History

The first visit with a fertility specialist usually involves a detailed medical history. You will be asked questions about:

  • Your menstrual period
  • Abnormal bleeding or discharge from the vagina
  • Pelvic pain
  • Any disorders that can affect reproduction such as thyroid disease.
You and your partner will be asked about the duration of infertility and results of any previous evaluation and treatment. You and your partner will also be asked about your Pregnancy history:
  • Time to pregnancy,
  • Fertility treatments,
  • Pregnancy outcome,
  • Delivery route,
  • Associated complications,
  • Previous methods of contraception,
  • Coital frequency and timing,
  • Past surgery (procedures, indications, and outcomes) focused on abdominal and pelvic procedures,
  • Current medications and supplements, with an emphasis on identifying allergies and
  • Potential baby unfriendly medications,
  • Family history of birth defects, early menopause, or reproductive problems
  • Occupational exposure to known environmental hazards,
  • Use of nicotine products, alcohol, and recreational drugs.

STEP 2: The Infertility Work Up

The infertility workup includes laboratory and imaging tests.
For the female partner, tests will focus on:

  • Testing the ovarian reserve
  • Testing for ovulatory function
  • Looking for structural abnormalities
  • Testing for Tubal patency

1. Ovarian Reserve Tests

The reproductive potential of the ovaries or a woman’s supply of eggs, termed ovarian reserve, represents the number of eggs available for potential fertilization at that point in time and may be assessed by two tests:

  1. Blood tests (AMH)
  2. Ultrasonography (AFC:Antral Follicle Count)

The presence of decreased ovarian reserve predicts future response to ovarian stimulation during IVF. The results of ovarian reserve tests should be considered in the context of the patient’s age. Although there are no definitive criteria for diminished ovarian reserve, the following values may be considered consistent with diminished ovarian reserve:

  • Antimüllerian hormone (AMH) value less than 1 ng/mL
  • Antral follicle count less than 5–7 and
  • Follicle-stimulating hormone (FSH) greater than 10 IU/L between cycle days 2–5.
  • A history of poor response to in vitro fertilization stimulation (fewer than four eggs at time of egg retrieval)

AMH Test

Anti-Mullerian Hormone (AMH) is a hormone secreted by cells in developing egg sacs (follicles). Because AMH levels remain relatively stable throughout the menstrual cycle, they can be assessed on any day of the menstrual cycle Ovarian reserve tests are good predictors of response to ovarian stimulation, but poor results do not necessarily predict inability to achieve a live birth. If a woman has unexplained ovarian insufficiency before age 40 years, fragile X carrier screening is recommended to determine whether she has an FMR1 premutation.

Ultrasonographic Assessment

Antral follicle count is determined by the number of follicles that measure 2–10 mm in both ovaries. Low antral follicle count may be defined as fewer than 5–7 follicles and is associated with poor response to ovarian stimulation. However, antral follicle count is a relatively poor predictor of future ability to become pregnant. Antral follicle counts may be elevated in women with polycystic ovary syndrome (PCOS) or maybe decreased in those using certain hormonal contraceptives.

2. Ovulatory Dysfunction

Clinical history can be used to assess ovulatory cycles because most ovulatory women will have regular menstrual cycles every 25–35 days accompanied by premenstrual symptoms. However, up to one third of women with normal menstrual cycles are anovulatory; therefore, confirmation of ovulation should be considered. Most commonly this is done by folliculometry or tracking the growth of egg/eggs via transvaginal sonography. Anovulation may be related to obesity, pituitary dysfunction, PCOS, and other causes. Polycystic ovary syndrome is the most common cause of not ovulating. Thyroid disease and increased levels of a hormone called prolactin can cause ovulatory dysfunction. Thus, measuring TSH and prolactin in the empty stomach is important for women presenting with inability to conceive.

3. Testing for Uterine Factor or Structural abnormalities

Uterine factors associated with infertility include:
  • Polyps
  • Scarring in uterus(synechia)
  • Anomalies of shape of uterus (septate uterus)
  • Fibroids. Fibroids with a surgically modifiable effect on fertility include those having a cavity-distorting component.

Using saline infusion sonography, the uterine cavity usually is easily defined, and abnormalities such as polyps, fibroids, and intrauterine scarring can be seen. More than 16% of infertile women and 40% of women with abnormal uterine bleeding will have an abnormality on SIS. Transvaginal ultrasonography aids in detection of uterine fibroids that affect the uterine cavity. Use of three-dimensional ultrasonography improves detection of uterine anomalies. Direct visualization of the uterine cavity by hysteroscopy provides the most definitive method for diagnosis of endometrial polyps, uterine synechiae, and submucosal fibroids. Hysteroscopy is not as commonly used for initial evaluation of women with infertility because of cost and access considerations. Hysteroscopy is indicated to confirm and treat intracavitary lesions detected by Saline infusion sonography.

4. Testing for Tubal Factor

Tubes are portals through which sperm travels to meet the egg for fertilization. In case of tubal block, fertilization and pregnancy is not possible and IVF would be an option for these couples especially if associated with suboptimal semen parameters.

Saline infusion sonography(SIS) is the visualization of the uterus ultrasonographically with the infusion of fluid through a very thin tube placed in the womb via the cervix without putting you to sleep. An extension of SIS, hysterosalpingo-contrast sonography (Hy-CO-Sy) determines tubal patency with the use of a special contrast dye.