What is the initial step in a fertility workup for a female?

Initial Steps in Female Fertility Workup

The initial step in a fertility workup for a female should be a comprehensive medical and reproductive history, physical examination, and transvaginal ultrasound to evaluate ovarian reserve and identify structural abnormalities. 1, 2

Medical and Reproductive History

• Collect information on duration of attempting pregnancy, frequency and timing of intercourse, previous pregnancies and outcomes, menstrual history, and medical conditions associated with reproductive failure 1
• Document current medications, allergies, family history of reproductive failure, and lifestyle factors such as smoking, alcohol, and caffeine intake 1
• Determine if the patient meets criteria for infertility evaluation: 12 months of unprotected intercourse without conception for women under 35 years, or 6 months for women over 35 years 2
• Earlier evaluation is warranted for women with oligo-amenorrhea, known or suspected uterine/tubal disease, endometriosis, or a partner known to be subfertile 1, 2

Physical Examination

• Perform a comprehensive physical examination including height, weight, BMI calculation, thyroid examination, and assessment for signs of androgen excess 1
• Conduct a pelvic examination to assess for pelvic/abdominal tenderness or masses, vaginal or cervical abnormalities, uterine size, shape, position, and mobility, and adnexal masses or tenderness 3, 1

Initial Laboratory and Imaging Tests

• Transvaginal ultrasound (TVUS) is the appropriate initial imaging test for evaluation of ovulatory function and ovarian reserve 3
• Measure FSH and estradiol on day 3 of the menstrual cycle as baseline assessment for ovarian reserve 4
• Document ovulation with midluteal phase progesterone level measurement (cycle day 21) 5
• For women with irregular cycles, hormone testing should be performed but results interpreted with caution 4
• Anti-Müllerian hormone (AMH) can be measured on any day of the cycle as it generally does not vary by menstrual day 4

Partner Evaluation

• Evaluation of both partners should begin simultaneously to avoid delays in diagnosis 1
• The male partner should undergo reproductive history, physical examination, and semen analysis (at least two samples, one month apart) 1
• Male factor is a cause of infertility in 40-50% of couples, making this concurrent evaluation essential 2

Further Testing Based on Initial Findings

• If initial evaluation suggests ovulatory dysfunction, additional hormone testing may be needed (thyroid function tests, prolactin levels) 3
• For suspected tubal pathology, hysterosalpingography should be performed to assess tubal patency 5, 6
• For patients with history of endometriosis, pelvic infections, or ectopic pregnancy, evaluation with hysteroscopy or laparoscopy may be recommended 5

Common Pitfalls to Avoid

• Delaying evaluation in women over 35 years - they should receive expedited evaluation after 6 months of failed attempts 2
• Incomplete evaluation by failing to assess both partners simultaneously 1
• Overlooking lifestyle factors that can impact fertility (extreme body weight, smoking, alcohol consumption) 1, 7
• Performing unnecessary tests before completing the basic initial workup 6

Lifestyle Recommendations During Evaluation

• For women with regular menstrual cycles, recommend intercourse every 1-2 days beginning soon after menstruation ends 1
• Counsel about avoiding smoking and excessive alcohol consumption 1, 7
• Discuss the impact of extreme body weight and high caffeine consumption on fertility 1