What are the initial testing recommendations for a 38-year-old female (yof) with a history of infertility, prior ovarian cystectomy, and two previous successful pregnancies?

From the Guidelines

For a 38-year-old female with infertility who has a history of ovarian cyst removal and two previous successful pregnancies, I recommend starting with a transvaginal ultrasound as the initial imaging for evaluation of ovulatory function and ovarian reserve, as it is usually appropriate for the initial imaging of female infertility patients 1. This approach is based on the American College of Radiology's appropriateness criteria for female infertility, which suggests that transvaginal ultrasound is a suitable initial imaging modality for evaluating ovulatory function and ovarian reserve in female patients with infertility 1. Given the patient's history of ovarian cyst removal, it is essential to assess the current state of her ovaries and uterus to determine the best course of action for addressing her infertility. Some key points to consider in the initial evaluation include:

• Assessing hormone levels (FSH, LH, estradiol, AMH, and progesterone) to evaluate ovulatory function and ovarian reserve
• Evaluating the uterus and ovaries using transvaginal ultrasound, as recommended by the American College of Radiology 1
• Considering the patient's age and the potential impact of declined fertility after 35, it is crucial to proceed with the evaluation and potential treatment options in a timely manner The patient's partner should also undergo semen analysis to rule out any male factor infertility. If testing reveals normal results, the patient might try timed intercourse with ovulation prediction kits for 3-6 months, but if this is unsuccessful or if testing shows abnormalities, treatment options could include ovulation induction with medications, intrauterine insemination (IUI), or in vitro fertilization (IVF), and a reproductive endocrinologist can provide personalized guidance based on the patient's specific test results.

From the FDA Drug Label

OvarianHyperstimulationSyndrome The ovarian hyperstimulation syndrome (OHSS) has been reported to occur in patients receiving clomiphene citrate therapy for ovulation induction. The potential benefit of subsequent clomiphene citrate therapy in these cases should exceed the risk. Unless surgical indication for laparotomy exists, such cystic enlargement should always be managed conservatively. A causal relationship between ovarian hyperstimulation and ovarian cancer has not been determined However, because a correlation between ovarian cancer and nulliparity, infertility, and age has been suggested, if ovarian cysts do not regress spontaneously, a thorough evaluation should be performed to rule out the presence of ovarian neoplasia.

The patient had ovarian cysts removed and was able to have two prior children. Given the patient's history of ovarian cysts, the risk of Ovarian Hyperstimulation Syndrome (OHSS) should be considered when using clomiphene citrate for ovulation induction.

• The patient should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy.
• The patient should be closely monitored for signs of OHSS, such as abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain.
• If ovarian enlargement occurs, additional clomiphene citrate therapy should not be given until the ovaries have returned to pretreatment size, and the dosage or duration of the next course should be reduced 2.

From the Research

Initial Testing for Infertility

• A comprehensive medical history and physical examination should be performed to help direct diagnosis and treatment of infertility 3.
• The initial assessment of the female partner should include evaluation of the uterus and fallopian tubes with ultrasonography or hysterosalpingography when indicated 3.
• For women with a history of ovarian cysts, such as the 38-year-old woman in question, assessment of ovarian reserve and ovulatory function may be necessary 4.
• Imaging modalities, such as transvaginal ultrasound, can detect tubal patency and pelvic pathology, and assess ovarian reserve 5.

Evaluation of Female Fertility

• A complete initial assessment of female fertility includes pre-pregnancy screening and counseling, and assessment of ovulation, ovarian reserve, and pelvic anatomy 4.
• Three-dimensional transvaginal ultrasound can be used to evaluate endometrial receptivity and ovarian function in patients with infertility 6.
• The levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and FSH/LH can be measured to assess ovarian reserve and predict ovulation 6.

Considerations for Women with a History of Prior Pregnancies

• Women who have had prior pregnancies, such as the 38-year-old woman in question who has had two prior children, may still experience infertility due to various factors, including uterine and tubal factors, ovarian reserve, ovulatory dysfunction, and hormone-related disorders 3.
• The presence of ovarian cysts, which were removed in this case, may also affect fertility 3.
• A thorough evaluation, including assessment of ovarian reserve and ovulatory function, is necessary to determine the cause of infertility in women with a history of prior pregnancies 4.