Dr.Vinodhini Pradeep talks about how to evaluate a woman with infertility.

3. INDICATION FOR WORKUP
<35y evaluate after 12 mo
>35y after 6 mo
>40y Immediate
85% achieve pregnancy within that interval.
Evaluation indicated for 15%.

4. EVALUATE AT PRESENTATION ITSELF IF
• Irregular cycles, <25 days
• Intermenstrual bleeding/ oligomenorrhea/ Amenorrhea
• Uterine/tubal/peritoneal disease or endometriosis
• Male subfertility
• Genetic conditions (Fragile X) H/O chemotherapy, radiation
• Recurrent pregnancy loss
• Those Requiring donor sperm and in Transgender

5. CAUSES OF INFERTILITY : WHO multinational study
Ovulatory
Disorders
Endometriosis
Pelvic Adhesions
Tubal blockage
Tubal/Uterine
abnormalities
Hyperprolactinemia
Unknown
Ovulatory Disorders Endometriosis Pelvic Adhesions Tubal blockage
Tubal/Uterine abnormalities Hyperprolactinemia Unknown

6. ASSESS ENTIRE REPRODUCTIVE AXIS

7. RELEVANT HISTORY
• Duration of infertility
• Menstrual history (age at menarche, cycle length and
characteristics, and onset/severity of dysmenorrhea)
• Pregnancy history (gravidity, parity, pregnancy outcome, and
associated complications)
• Previous methods of contraception
• Coital frequency

8. • Sexual dysfunction
- Decreased libido ED
- Dyspareunia Vaginismus
• STD PID
• History of Contraceptive,
• Family history
• Diet and exercise
• Use of tobacco, alcohol, and drugs
• Limitations of fertility trackers

9. OBSTETRIC HISTORY
• Total number of pregnancies and outcomes, including
• Biochemical /clinical miscarriage
• Details of any fertility treatment
• Endocrine, autoimmune, genetic, disorders
• Prior hospitalizations & surgery
• Gonadotoxic medications or radiotherapy

10. PHYSICAL EXAMINATION
• Endocrine : Thyroid, Breast( Galactorrhea)
• Androgen excess : Examine skin
• Vaginal or cervical abnormality
• Pelvic or abdominal tenderness, mass
• Uterine size, shape, position, and mobility
• Adnexal mass or tenderness
• Cul-de-sac mass, tenderness, or nodularity

11. DIAGNOSTIC EVALUATION
• Systematic, and cost-effective manner
• Least invasive method for detection of most common causes
• Account age, duration of infertility, and the unique features of the
medical history and physical examination.

12. OVULATORY FUNCTION
• Oligo/amenorrhea : establish anovulation  further test.
• Most common cause of ovulatory dysfunction
• PCOS
• Obesity, weight gain or loss, strenuous exercise,
• Thyroid dysfunction, and hyperprolactinemia
• Many times obscure

13. MENSTRUAL HISTORY
• In ovulating women:
• cycles regular
• consistent flow & moliminal symptoms.
• Some variation is normal.
• In hirsute women, regular ovulation can occur in 60%.
luteal progesterone should be considered to confirm ovulation.
• Abnormal uterine bleeding, oligomenorrhea, or amenorrhea generally
do not require specific diagnostic tests to establish anovulation.

14. LUTEAL PROGESTERONE
• Mid luteal progesterone > 3.0 ng/mL between Day 19 - 23
consistent with ovulation,
• >10 ng/mL implies adequate luteal support.

15. URINARY LUTEINIZING HORMONE
• "ovulation predictor kits" : midcycle LH surge that precedes
ovulation by one to two days.
• indirect evidence of ovulation and helps to define greatest
fertility days
• Performed on midday or evening urine.
• PCOS : tonic elevation in basal LH levels, false-positive
• Accuracy, ease, and reliability vary

16. TRANSVAGINAL ULTRASONOGRAPHY
Ovarian reserve, adnexal, uterine pathology.
Size and number of antral & developing follicles
Evidence of ovulation and luteinization :
• Progressive follicular growth
• Sudden collapse of preovulatory follicle
• Loss of clearly defined follicular margins
• Internal echoes
• ↑ cul-de-sac fluid volume

17. SERIAL BASAL BODY TEMPERATURE (BBT)•
• Daily on awakening,
• After ovulation, BBT increases by (0.22°C)
• Ovulatory cycles : biphasic
• Anovulatory cycles : monophasic
• Subtle ovulatory dysfunction.
• Grossly short luteal phases (<10 days of temp elevation)
• Highest fertility : 7 days before midcycle rise in BBT.
• Not recommended.

18. Endometrial biopsy
• Progesterone  Secretory endometrial development  ovulation.
• Earlier gold standard for luteal function and luteal phase deficiency diagnosis
• Not a valid diagnostic method.
• Lacks accuracy and precision
• Not recommended.

19. HORMONE TESTING
• TSH (If abnormal, free T4 and thyroid autoantibodies)
• Prolactin only if galactorrhea, oligomenorrhea, or amenorrhea.
• In amenorrhea :
↑ FSH, ↓ estradiol  ovarian insufficiency (candidates for oocyte donation)
↓ /normal FSH, ↓ estradiol  hypothalamic amenorrhea (require exogenous
gonadotropin for ovulation induction.)
• Normal FSH and estradiol evaluation for PCOS
• Androgen excess :
21-hydroxylase to R/O nonclassic Adrenal Hyperplasia.

20. OVARIAN RESERVE
Function of the number & quality of remaining oocytes.
Decreased ovarian reserve : regular menses but response to ovarian stimulation ↓
• >35 years
• Family history of early menopause
• Single ovary / ovarian surgery,
• Chemotherapy, or pelvic radiation
• Unexplained infertility
• Poor response to gonadotropin stimulation
• Goal : identify poor responders to gonadotropin stimulation
• Poor results don’t imply inability to conceive

21. OVARIAN RESERVE TESTS
• Basal FSH and estradiol should be measured together in the early
follicular phase between 2–4 days of cycle.
• FSH 10-20 IU/L : poor ovarian stimulation and failure to conceive.
• AMH : can be measured at any point.
• TVS : Antral follicle count and ovarian volume
• Inhibin B and the clomiphene challenge test are not helpful tools

22. CERVICAL FACTOR
• Chronic cervicitis
• postcoital test : direct analysis of sperm and cervical mucus interaction
(done between days 12 and 14 )
• mucus examined within 2 to 8 hours.
• No longer recommended.
• Poor reproducibility & inconvenient
• Not predict inability to conceive

23. UTERINE ABNORMALITIES
• Uterine abnormalities 16 %
• polyps (13%),
• submucous
• fibroids (2.8%),
• adhesions (0.3%)
• Uterine imaging may be warranted

24. ULTRASONOGRAPH
• Best imaging modality
• myometrium, endometrial cavity, and adnexa
• TVS : leiomyomas, endometrial polyps, and adenomyosis,
• Intramural fibroids and adnexal pathology are undetectable on
hysterosalpingogram or hysteroscopy.
• MRI may be used to further evaluate

25. HSG
• Size and shape of uterine cavity
• Congenital abnormalities
unicornuate, septate, bicornuate
• Acquired abnormalities
endometrial polyps, submucous myomas, synechiae
• Low sensitivity and PPV
• Cannot differentiate a septate from bicornuate
• MRI is needed.

26. SONOHYSTEROGRAPHY
• TVS after saline
• defines uterine cavity better
• >90% PPV and negative predictive value
for intrauterine pathologies

27. HYSTEROSCOPY
• Definitive method for diagnosis and treatment of intrauterine pathology.
• Costly and invasive
• Small caliber office hysteroscope : minimal discomfort,
• Lower cost, surgically remove lesion.
• sensitivity of 88% and specificity of 85%.

28. TUBAL PATENCY
• HSG using contrast media, is traditional  standard therapeutic benefit
• Proximal and distal tubal occlusion, salpingitis isthmica nodosa, tubal
architectural detail
• Fimbrial phimosis (delayed contrast ) or peritubular adhesions (loculated)
• Bilateral proximal tubal obstruction : artifact due to transient tubal contractions
/ catheter position.

29. TUBAL PATENCY
• Sonohysterography :
• patency : fluid in the cul-de-sac
• not differentiate between unilateral or bilateral patency.
• Hystero Salpingo Contrast Sonography
• Contrast with air bubbles. Operator Dependent
• Hysteroscopy
• Direct observation of fluid or air bubble flow into the tubal ostia
• Laparoscopy and chromotubation with a methylene blue or indigo carmine
• Fluoroscopic/hysteroscopic selective tubal cannulation
• Confirm or exclude proximal tubal occlusion
• possible correction via recanalization using specialized catheter.

30. CHLAMYDIA ANTIBODY TEST
• Lower sensitivity. Cant predict tubal patency.
• Low sensitivity (40%–50%) and PPV (60%)
• -ve CAT  absence of tubal disease;
• +ve CAT  further evaluation.

31. PERITONEAL FACTORS
• Considered in unexplained infertility.
• Endometriosis and pelvic or adnexal adhesions may cause infertility
• Transvaginal ultrasonography  endometrioma
• Laparoscopy : only method for specific diagnosis of peritoneal factors
• Indicated for those with symptoms or risk factors or abnormal HSG or
ultrasonography
• Yield in asymptomatic women with normal imaging is low.
• Only indicated suspected pelvic pathology or specific indication like
severe dysmenorrhea

32. INFERTILITY TESTS NOT ROUTINELY ORDERED
• Laparoscopy for unexplained infertility
• Postcoital testing
• Thrombophilia testing
• Immunologic testing
• Karyotype
• Endometrial biopsy
• Prolactin
• Progesterone
• Estradiol
• Follicle-stimulating hormone
• Luteinizing hormone

33. Avoid
Unneccesary
Tests
Complete
Reproductive
Axis
Know When
to evaluate?
Parallel
Male
Workup
Ovarian
Reserve Test