From the Guidelines
The initial steps in evaluating infertility in a 28-year-old female should include a comprehensive history, physical examination, and initial diagnostic tests, prioritizing a systematic approach to identify the underlying cause of infertility, as recommended by the American College of Radiology Appropriateness Criteria 1 and the American Society for Reproductive Medicine 1. The evaluation should begin with a detailed menstrual history to assess ovulatory function, including cycle length, regularity, and any symptoms of hormonal imbalance.
- Sexual history is crucial, focusing on frequency and timing of intercourse relative to ovulation.
- Medical, surgical, and medication histories should be reviewed for conditions that might affect fertility.
- Family history of infertility or reproductive disorders is also relevant. The physical examination should include:
- Assessment of BMI
- Thyroid examination
- Signs of androgen excess
- Pelvic examination Initial laboratory testing would include:
- Measuring day 3 FSH, LH, estradiol, TSH, prolactin, and AMH to assess ovarian reserve, as suggested by the American College of Radiology Appropriateness Criteria 1.
- A transvaginal ultrasound would help evaluate the uterus and ovaries for structural abnormalities, such as those associated with polycystic ovarian syndrome (PCOS) or endometriosis 1. Semen analysis for the male partner is essential, as male factors contribute to approximately 26% of infertility cases, according to the American College of Radiology Appropriateness Criteria 1. Depending on menstrual history, a progesterone level on day 21 of the cycle may be ordered to confirm ovulation. These evaluations are appropriate since infertility is defined as failure to conceive after 12 months of regular unprotected intercourse (or 6 months if the woman is over 35), and a systematic approach helps identify the underlying cause, which could be ovulatory dysfunction, tubal factors, male factors, or unexplained infertility, as recommended by the American Society for Reproductive Medicine 1 and the American Urological Association 1.
From the Research
Initial Steps in Evaluating Infertility
The initial steps in evaluating infertility in a 28-year-old female involve assessing ovulatory function, as approximately one-quarter of infertility cases are due to ovulatory disorders 2.
Ovulation Induction
Ovulation induction with medications such as clomifene citrate (CC) or letrozole may be considered, as these have been shown to be effective in inducing ovulation in women with polycystic ovary syndrome (PCOS) or other ovulatory disorders 2, 3.
Treatment Options
Treatment options for ovulatory infertility may include:
- Clomiphene citrate (CC) combined with intrauterine insemination (IUI) 4
- Letrozole as a first-line pharmacological treatment for women with WHO Group II anovulation or PCOS 3
- Gonadotropin formulations for in vitro fertilization (IVF) programs 5
- Elective embryo transfer in IVF cycles as a golden standard treatment for patients with PCOS at high-risk for ovarian hyperstimulation syndrome 5
Important Considerations
It is essential to note that the use of letrozole as an ovulation induction agent is not FDA or EMA approved and is considered "off-label" 3. Additionally, the choice of treatment should be individualized based on the patient's specific needs and medical history.
Evaluation Process
The evaluation process for infertility in a 28-year-old female may involve: