What are the initial steps and labs for a fertility work-up in an OB/GYN (Obstetrics/Gynecology) outpatient office, including ultrasound?

Initial Fertility Workup in OB/GYN Outpatient Setting

A comprehensive fertility workup in an OB/GYN outpatient office should include thorough medical and reproductive histories, physical examinations, laboratory testing, and ultrasound imaging for both partners, with evaluation beginning after 12 months of unsuccessful conception attempts for women under 35 and after 6 months for women over 35.

When to Initiate Fertility Testing

• Fertility testing should begin after 12 months of regular unprotected intercourse without conception in women under 35 years of age 1, 2
• For women over 35 years, assessment should begin after 6 months of unsuccessful attempts 3, 2
• Earlier evaluation is warranted for women with:
  • History of oligo-amenorrhea 4
  • Known or suspected uterine/tubal disease 4
  • History of endometriosis 4
  • Partner known to be subfertile 4

Female Partner Evaluation

Medical and Reproductive History

• Duration of attempting pregnancy and prior fertility history 1, 4
• Coital frequency and timing, level of fertility awareness 1
• Gravidity, parity, pregnancy outcomes, and complications 1
• Menstrual history: age at menarche, cycle length, characteristics 1
• Medical conditions associated with reproductive failure (thyroid disorders, hirsutism, endocrine disorders) 1
• Surgical history, including indications and outcomes 1
• Current medications and allergies 1
• Family history of reproductive failure 1
• Sexual history, including history of STDs or PID 1

Physical Examination

• 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, secretions, discharge 1
  • Uterine size, shape, position, and mobility 1
  • Adnexal masses or tenderness 1
  • Cul-de-sac masses, tenderness, or nodularity 1

Laboratory Testing

• Hormone levels:
  • FSH and estradiol on day 3 of menstrual cycle (baseline ovarian reserve) 3
  • LH, FSH, and estradiol during early follicular phase (days 2-5) for patients with oligomenorrhea 3
  • Anti-Müllerian hormone (AMH) can be measured on any day of the cycle 3
  • Serum progesterone levels to confirm ovulation 1
  • Thyroid function tests 1
  • Prolactin levels 1

Imaging Studies

• Transvaginal ultrasound (TVUS) to evaluate:
  • Uterine anatomy 1
  • Ovarian morphology and follicle count 1
  • Presence of fibroids, polyps, or other structural abnormalities 1
• Additional imaging as indicated:
  • Hysterosalpingography (HSG) to assess tubal patency 1
  • Sonohysterography (SIS) for better visualization of intrauterine abnormalities 1
  • MRI pelvis without IV contrast when endometriosis is suspected 1

Male Partner Evaluation

Medical and Reproductive History

• Prior fertility and duration of current infertility 1
• Frequency and timing of intercourse 1
• Childhood illnesses and developmental history 1
• Systemic medical illnesses (e.g., diabetes mellitus) 1
• Prior surgeries and past infections 1
• Sexual history, including STDs 1
• Gonadal toxin exposure, including heat 1
• Current medications (prescription and non-prescription) and allergies 1
• Family reproductive history 1

Physical Examination

• Examination of the penis, including location of the urethral meatus 1
• Palpation and measurement of the testes 1
• Assessment for presence and consistency of vas deferens and epididymis 1
• Checking for presence of varicocele 1
• Evaluation of secondary sex characteristics 1
• Digital rectal examination 1

Laboratory Testing

• Semen analysis (at least two samples, one month apart) 1
  • Parameters to assess: volume, pH, concentration, total count, motility, progression, morphology 1
• If semen analysis is abnormal:
  • Second semen analysis 1
  • Endocrine evaluation 1
  • Post-ejaculate urinalysis if indicated 1

Common Pitfalls to Avoid

• Delaying evaluation in women over 35 years 3, 2
• Incomplete evaluation by failing to assess both partners simultaneously 4
• Performing hormone testing while patient is still on hormonal contraception 3
• Misinterpreting hormone results in women with irregular cycles 3
• Relying solely on one semen analysis for male factor assessment 1
• Overlooking lifestyle factors that affect fertility (smoking, alcohol, extreme body weight) 4

Counseling During Fertility Workup

• Address emotional and educational needs of clients with infertility 1
• Consider referring clients for psychological support or infertility support groups 1
• Educate about maximizing fertility through proper timing of intercourse 4
• Discuss lifestyle modifications that may improve fertility 4, 5

By following this systematic approach to fertility evaluation, clinicians can identify potential causes of infertility and develop appropriate treatment plans to improve chances of successful conception.