What is the recommended infertility workup for a woman?

Infertility Workup for Women

Begin the infertility workup after 12 months of unprotected intercourse in women <35 years, or after 6 months in women ≥35 years, with immediate evaluation for women >40 years or those with known fertility-compromising conditions 1, 2.

Timing of Evaluation

The threshold for initiating workup is age-dependent:

• Women <35 years: After 12 months of trying
• Women 35-39 years: After 6 months of trying
• Women ≥40 years: Immediate evaluation warranted
• Any age with risk factors: Immediate evaluation (history of pelvic infection, endometriosis, known tubal disease, irregular cycles, prior pelvic surgery) 1, 3, 2

Essential Components of Female Workup

1. Ovarian Reserve Assessment

Obtain anti-Müllerian hormone (AMH) level prior to assisted reproduction 4. This is particularly critical in women with advanced maternal age where oocyte quality deteriorates 1.

• Transvaginal ultrasound with antral follicle count (AFC) is the primary imaging modality 4
• PCOS diagnosis requires >25 small follicles in at least one ovary OR single ovarian volume >10 mL on transvaginal ultrasound, combined with clinical features of hyperandrogenism 1

Critical caveat: Polycystic ovarian morphology appears in up to one-third of reproductive-aged women, so imaging findings alone cannot diagnose PCOS without clinical correlation 1.

2. Ovulatory Function Assessment

Measure serum progesterone at cycle day 21 to document ovulation 5. This is the standard test for confirming ovulatory function.

• Post-coital testing is no longer recommended 4
• For normo-ovulatory women with no other abnormalities, ovulation induction is not recommended 4

3. Uterine and Tubal Evaluation

Perform a single 3D transvaginal ultrasound as the initial imaging study 4. This provides comprehensive anatomic assessment.

For Tubal Patency:

• Hysterosalpingography (HSG) or HyFoSy (hystero-contrast salpingography with ultrasound) to assess tubal patency 4
• Important: Chlamydia trachomatis serology does not have adequate performance to predict tubal patency and should not be relied upon 4
• Hystero-contrast salpingography does not improve clinical pregnancy rates with expectant management and should not be offered as a therapeutic procedure 6

For Intrauterine Pathology:

TVUS should be offered to all infertile women with symptoms or signs of anatomic pelvic pathology, but should NOT be offered routinely to asymptomatic women 6.

• If 3D ultrasound is normal, do not perform hysterosonography or diagnostic hysteroscopy as first-line procedures 4
• Hysteroscopy should be offered only if intrauterine pathology is suspected by TVUS 6
• In women with normal TVUS undergoing IVF, hysteroscopy does not improve outcomes 6

4. Screening for Infection

Obtain vaginal swab for bacterial vaginosis 4. This is part of the standard initial workup.

5. Evaluation for Endometriosis

Endometriosis affects at least one-third of infertile women 1. Modern imaging (ultrasound and MRI with systematic approach) can reliably diagnose endometriosis, replacing the outdated practice of routine diagnostic laparoscopy 7.

• Small endometrial implants are not well detected on imaging
• Laparoscopy remains the standard for diagnosis and staging when imaging is inconclusive 1
• For women <30 years with no abnormalities on workup, laparoscopy is probably recommended to increase natural pregnancy rates 4

6. Male Factor Assessment

Male factor causes 26-40% of infertility cases, so concurrent male evaluation is essential from the outset 1, 2.

• Obtain semen analysis, spermocytogram, and spermoculture as first-line tests 4
• If spermogram is normal, repeat testing is not needed
• If abnormal, refer to andrologist for examination, testicular ultrasound, and hormonal testing 4

Surgical Considerations Before ART

If proceeding to assisted reproductive technology:

• Operate on polyps >10mm, submucosal fibroids (types 0,1,2), and intrauterine synechiae prior to ART 4
• For hydrosalpinx: surgical management (salpingotomy or salpingectomy based on tubal score) is recommended before ART 4
• Asymptomatic uterine septa and isthmoceles: insufficient evidence for routine surgery 4

Common Pitfalls to Avoid

1. Do not delay evaluation in women ≥35 years—the 6-month threshold is critical given declining ovarian reserve
2. Do not rely on Chlamydia serology to assess tubal patency—it lacks adequate predictive value 4
3. Do not perform routine hysteroscopy in women with normal TVUS findings 6
4. Do not use HSG as a therapeutic procedure—it does not improve pregnancy rates 6
5. Do not forget male factor evaluation—present in 26-50% of cases 1, 2

Unexplained Infertility

Unexplained infertility affects 28-30% of couples 1, 2. At minimum, these patients must have documented ovulation, tubal patency, and normal semen analysis before this diagnosis can be assigned 2.