What are the initial steps to diagnose and treat female infertility?

Initial Diagnosis and Treatment of Female Infertility

The initial evaluation of female infertility should include a comprehensive medical history, physical examination, and basic laboratory tests for both partners, with evaluation beginning after 12 months of regular unprotected intercourse in women under 35 years or after 6 months in women over 35 years. 1, 2

Definition and Prevalence

• Infertility is defined as the inability to achieve pregnancy after 12 months of regular unprotected intercourse
• Affects approximately 15% of couples
• Female factors account for about 37% of cases, male factors for 26%, combined factors for 22%, and unexplained infertility for 28% 1, 3

Initial Evaluation of the Female Partner

Medical History (Key Components)

• Duration of infertility and previous fertility
• Menstrual history: age at menarche, cycle length, regularity, dysmenorrhea
• Previous pregnancies and outcomes
• Coital frequency and timing
• Past surgeries and hospitalizations
• Medical conditions associated with infertility (thyroid disorders, PCOS, endometriosis)
• Medications and allergies
• Family history of reproductive disorders
• Sexual history including STIs or pelvic inflammatory disease
• Lifestyle factors: smoking, alcohol, caffeine, recreational drugs 1

Physical Examination

• Height, weight, BMI calculation (fertility rates lower in very thin or obese women)
• Thyroid examination for enlargement, nodules, or tenderness
• Clinical breast examination
• Signs of androgen excess (hirsutism)
• Pelvic examination to assess:
  • Pelvic/abdominal tenderness or masses
  • Vaginal/cervical abnormalities or discharge
  • Uterine size, shape, position, and mobility
  • Adnexal masses or tenderness
  • Cul-de-sac masses, tenderness, or nodularity 1

Initial Laboratory and Imaging Studies

1. Ovulatory Function Assessment

   • Serum progesterone level at cycle day 21 to confirm ovulation 4
   • Transvaginal ultrasound (TVUS) for antral follicle count and ovarian volume 1

2. Uterine and Tubal Evaluation

   • Hysterosalpingography (HSG) for women with no risk factors for tubal obstruction
   • Hysteroscopy or laparoscopy for women with history of endometriosis, pelvic infections, or ectopic pregnancy 4, 2

3. Hormone Evaluation

   • Thyroid function tests
   • Prolactin levels
   • Follicle-stimulating hormone/luteinizing hormone levels 1

Initial Evaluation of the Male Partner

Medical and Reproductive History

• Coital frequency and timing
• Duration of infertility and previous fertility
• Childhood illnesses and developmental history
• Systemic illnesses and previous surgeries
• Sexual history including STIs
• Gonadotoxin exposure including heat
• Medications and allergies 1

Physical Examination

• Examination of the penis, including urethral meatus location
• Testicular measurement and palpation
• Presence and consistency of vas deferens and epididymis
• Presence of varicocele
• Secondary sex characteristics
• Digital rectal examination 1

Laboratory Testing

• Semen Analysis: The first and most simple screening test for male fertility
  • Two samples at least one month apart
  • Abstinence for 2-3 days before collection
  • Examination within one hour of collection 1

Common Causes of Female Infertility

1. Ovulatory Dysfunction (25% of cases)

   • Polycystic ovary syndrome (70% of anovulation cases)
   • Hypothalamic dysfunction
   • Premature ovarian insufficiency
   • Hyperprolactinemia
   • Thyroid disorders 3, 5

2. Tubal and Peritoneal Factors (14% of cases)

   • Pelvic inflammatory disease
   • Previous ectopic pregnancy
   • Endometriosis
   • Pelvic adhesions 1

3. Uterine Abnormalities

   • Fibroids
   • Polyps
   • Congenital anomalies
   • Intrauterine adhesions 2

Treatment Approaches

Lifestyle Modifications

• Reduce caffeine intake (more than five cups per day may reduce fertility)
• Avoid smoking, alcohol, and recreational drugs
• Avoid most commercially available vaginal lubricants
• Weight management for women who are very thin or obese 1, 6

Timing of Intercourse

• Regular vaginal intercourse every 1-2 days beginning soon after menstruation
• Consider ovulation prediction methods (ovulation kits, digital applications, cycle beads) 1

Medical Treatment

1. For Ovulatory Dysfunction

   • Clomiphene citrate or letrozole for ovulation induction
   • Gonadotropins for resistant cases 3

2. For Unexplained Infertility

   • 3-4 cycles of ovarian stimulation with timed intercourse
   • Consider intrauterine insemination (IUI) or in vitro fertilization (IVF) if unsuccessful 3

3. For Tubal Obstruction

   • Referral for subspecialty care
   • Surgical correction or IVF depending on severity 4

4. For Endometriosis

   • Laparoscopic diagnosis and treatment
   • Medical management with hormonal therapy
   • IVF for severe cases 6

Special Considerations

• Age-Related Concerns: Women over 35 should receive expedited evaluation after 6 months of trying; women over 40 warrant immediate evaluation 2
• Unexplained Infertility: After ruling out common causes, options include continued attempts for up to another year, IUI, or IVF 4
• Combined Factors: When both partners have fertility issues, more aggressive treatment approaches may be needed 3

Common Pitfalls to Avoid

• Delaying evaluation in women over 35
• Focusing solely on female factors without concurrent male evaluation
• Overlooking lifestyle factors that may impact fertility
• Failing to consider underlying endocrine disorders that may present with infertility
• Neglecting emotional and psychological support during the evaluation and treatment process 1, 2