What are the initial steps and interventions for fertility testing in women?

Initial Steps and Interventions for Fertility Testing in Women

The initial fertility evaluation for women should include a comprehensive medical and reproductive history, physical examination, and assessment of ovulation through serum progesterone levels, with additional testing based on findings. 1

When to Initiate Fertility Testing

• Fertility testing should be initiated after 12 months of regular unprotected intercourse without conception 1, 2
• Earlier evaluation (after 6 months) is recommended for women:
  • Over 35 years of age 1, 3
  • With history of oligo-amenorrhea (infrequent menstruation) 1
  • With known or suspected uterine/tubal disease or endometriosis 1
  • With a partner known to be subfertile 1

Medical and Reproductive History

The medical history should include:

• Duration of attempting pregnancy and frequency/timing of intercourse 1
• Previous pregnancies and outcomes 1
• Menstrual history (age at menarche, cycle length, regularity) 1
• Previous surgeries, hospitalizations, and serious illnesses 1
• Medical conditions associated with reproductive failure (thyroid disorders, endocrine disorders) 1
• Current medications and allergies 1
• Family history of reproductive failure 1
• Sexual history including STDs or pelvic inflammatory disease 1
• Lifestyle factors (smoking, alcohol, recreational drugs, caffeine intake) 1

Physical Examination

A comprehensive physical examination should include:

• Height, weight, and BMI calculation 1
• Thyroid examination for enlargement, nodules, or tenderness 1
• Clinical breast examination 1
• Assessment for signs of androgen excess 1
• Pelvic examination to assess:
  • Pelvic/abdominal tenderness or masses 1
  • Vaginal or cervical abnormalities 1
  • Uterine size, shape, position, and mobility 1
  • Adnexal masses or tenderness 1
  • Cul-de-sac masses, tenderness, or nodularity 1

Laboratory and Diagnostic Testing

• Ovulation assessment: Serum progesterone level at cycle day 21 2, 4
• Ovarian reserve testing: Follicle-stimulating hormone (FSH) levels 1
• Uterine and tubal assessment:
  • Hysterosalpingography for women with no risk factors for tubal obstruction 2
  • Hysteroscopy or laparoscopy for women with history of endometriosis, pelvic infections, or ectopic pregnancy 2
  • Transvaginal ultrasound to evaluate uterine anatomy 1, 4

Partner Evaluation

• Evaluation of both partners should begin simultaneously 1
• Male partner should undergo:
  • Reproductive history 1
  • Physical examination with focus on genitalia 1
  • Semen analysis (at least two samples, one month apart) 1

Common Pitfalls to Avoid

• Delayed evaluation: Waiting too long to evaluate women over 35 or those with risk factors can significantly impact treatment success 3, 4
• Incomplete evaluation: Failing to assess both partners simultaneously may delay diagnosis 1
• Overlooking lifestyle factors: Not addressing modifiable factors like weight, smoking, alcohol consumption, and caffeine intake 1, 4
• Focusing only on female factors: Male factors account for approximately 25% of infertility cases 3

Lifestyle Modifications During Testing

• Advise women with regular menstrual cycles that intercourse every 1-2 days beginning soon after menstruation ends can increase pregnancy likelihood 1
• Discuss ovulation prediction methods (over-the-counter kits, digital applications, cycle beads) 1
• Discourage smoking, alcohol consumption, recreational drug use, and most commercially available vaginal lubricants 1
• Counsel about the impact of extreme body weight (very thin or obese) and high caffeine consumption (>5 cups/day) on fertility 1

Next Steps After Initial Testing

• If ovulatory dysfunction is identified, treatment with ovulation induction agents like clomiphene citrate or letrozole may be initiated 2, 3
• If tubal obstruction is found, referral for subspecialty care is typically required 2
• For unexplained infertility, options include continued unprotected intercourse for another year or proceeding to assisted reproductive technologies 2, 3