Infertility work-up
Posted by dkwinter

See also:

     Detailed Menstrual Cycle Chart

 

PE

  • BMI
  • Thyroid exam
  • Galactorrhea
  • Hirsutism, acne, male pattern baldness, virilization
  • Adnexal tenderness or masses
  • Pouch of Douglas tenderness (PID or endometriosis)
  • Palpable tender nodules in the posterior cul-de-sac, uterosacral ligaments or rectovaginal septum (endometriosis)
  • Vaginal/cervical structural abnormalities or discharge (mullerian anomaly, infection or cervical tumor)
  • Uterine enlargement, irregularity, or lack of mobility (uterine anomaly, leiomyoma, endometriosis, or pelvic adhesive disease)

 

Labs

  • Day 3 (third day after start of menses) serum FSH and Estradiol levels
    • Day 3 FSH <10 mlU/mL suggestive of adequate ovarian reserve; 10-15 mlU/mL borderline; 10-25mlU/mL is the upper threshold for normal depending on the lab
    • Day 3 Estradiol <80 pg/mL suggestive of adequate ovarian reserve (in one IVF study a level >80 resulted in higher cycle cancelation rates and lower pregnancy rates and estradiol >100 associated with 0% pregnancy rate)
  • Day 21 (target is one week before expected menses) serum progesterone (level >3 ng/mL is evidence of recent ovulation)
  • TSH
  • Prolactin
  • MALE: semen analysis (collected after 2-7 days of abstinence and submitted to the laboratory within one hour of collection)

 

Labs (second-line)

  • Give 100 mg clomiphene citrate on cycle days 5 through 9
  • Measure Day 3 FSH and serum Estradiol
    • FSH less than 15mlU/mL suggestive of adequate ovarian reserve
  • Measure Day 10 FSH levels
    • Elevated FSH on day 3 or 10 suggests decreased ovarian reserve
  • A highly abnormal result (FSH > 20 mlU/mL) suggests that pregnancy will not occur with treatment involving the woman's own oocytes
  • Serum anti-mullerian hormone (AMH)

 

Imaging

  • Pelvic ultrasound to assess for uterine myomas and ovarian cysts
  • Hysterosalpingogram during follicular phase of cycle to avoid interfering with possible early pregnancy (must have no contrast allergy)
    • Ibuprofen 600 mg one hour prior to procedure
    • Doxycycline 100 mg BID for three days prior to the procedure
    • Antral follicle count (AFC): ultrasound to determine number of antral follicles 
      • Most clinicians perform an AFC during the early follicular phase

 

 

See also: (login required) http://www.uptodate.com/contents/evaluation-of-female-infertility