From the Guidelines
The initial steps in a female infertility workup should include a comprehensive medical history, physical examination, and targeted laboratory testing, with a focus on identifying the most common causes of female infertility, such as ovulatory disorders, tubal factors, uterine abnormalities, and unexplained infertility, as recommended by the American College of Radiology 1. The workup should begin with a detailed history covering menstrual patterns, previous pregnancies, duration of infertility, sexual practices, medications, surgeries, and lifestyle factors. A physical exam should assess BMI, thyroid function, signs of androgen excess, and pelvic abnormalities. Some key points to consider in the workup include:
- Laboratory testing to confirm ovulation through serum progesterone (>3 ng/mL in mid-luteal phase) or urinary LH kits
- Hormonal evaluation, including FSH, estradiol, and AMH on cycle day 2-4 to assess ovarian reserve, with FSH >10 mIU/mL suggesting diminished reserve 1
- Measurement of TSH and prolactin to rule out thyroid dysfunction and hyperprolactinemia
- Performance of a hysterosalpingogram (HSG) after menses but before ovulation to evaluate tubal patency and uterine cavity abnormalities
- Use of transvaginal ultrasound to identify structural abnormalities like fibroids or ovarian cysts
- Testing for polycystic ovary syndrome, if indicated by history or other findings, which may include testosterone and DHEAS levels 1
- Simultaneous evaluation of male factor infertility with a semen analysis It's also important to note that imaging modalities such as MRI can be useful in detecting endometriosis, with a sensitivity of 82% to 90% and specificity of 91% to 98% for the diagnosis of endometriomas 1. Overall, a systematic approach to the female infertility workup, as outlined above, allows for the identification of the most common causes of female infertility and guides further management and treatment.
From the FDA Drug Label
CLINICAL PHARMACOLOGY Action Clomiphene citrate is a drug of considerable pharmacologic potency. With careful selection and proper management of the patient, clomiphene citrate has been demonstrated to be a useful therapy for the anovulatory patient desiring pregnancy
The initial steps in a female infertility workup are not directly addressed in the provided drug label. Key points to consider in a female infertility workup include:
- Evaluating ovulation
- Assessing hormonal balance
- Investigating anatomical factors However, the FDA drug label for clomiphene citrate does not provide information on the initial steps for a female infertility workup. 2
From the Research
Initial Steps in a Female Infertility Workup
The initial steps in a female infertility workup involve a comprehensive medical history and physical examination to help direct diagnosis and treatment 3, 4, 5, 6, 7.
- A careful history and physical examination of each partner can suggest a single or multifactorial etiology and can direct further investigation 3.
- Evaluation generally begins after 12 months, but it can be initiated earlier if infertility is suspected based on history or if the female partner is older than 35 years 3.
- Ovulation can be documented with a home urinary luteinizing hormone kit or by serum progesterone level measurement at cycle day 21 3, 5.
- Hysterosalpingography and pelvic ultrasonography can be used to screen for uterine and fallopian tube disease 3, 4, 5.
- Women older than 35 years also may benefit from ovarian reserve testing of follicle-stimulating hormone and estradiol levels on day 3 of the menstrual cycle, the clomiphene citrate challenge test, or pelvic ultrasonography for antral follicle count to determine treatment options and the likelihood of success 3.
Additional Tests and Evaluations
Additional tests and evaluations may be necessary to determine the cause of infertility, including:
- Laparoscopy, hysteroscopy, or magnetic resonance imaging to evaluate for endometriosis, leiomyomas, or evidence of a previous pelvic infection 4, 5.
- Semen analysis to evaluate the male partner 4, 5, 6, 7.
- Imaging of the reproductive organs to detect tubal patency and pelvic pathology and assess ovarian reserve 6.
Special Considerations
Special considerations should be taken into account for women older than 35 years, as they should receive an expedited evaluation and undergo treatment after 6 months of failed attempts to become pregnant or earlier, if clinically indicated 6. In women older than 40 years, more immediate evaluation and treatment are warranted 6.