Investigations of Female Infertility

Investigations of female infertility include:

Initial Evaluation

The initial evaluation of a case of female infertility must include:
•    Exclusion of male infertility.
•    Detailed History including:

• Menstrual history (amenorrhea, oligomenorrhea, menorrhagia, menstrual irregularity)
• sexual history (coital frequency, impotence, dyspareunia)
• medical history (use of oral contraceptives, cytotoxic chemotherapy, radiotherapy)
• family history (congenital anomalies of reproductive organs)
• H/O galactorrhea
• H/O weight loss
• H/O hirsutism
• H/O hot flashes
• H/O severe psychological stress

Detailed Examination 

Look for:

• Signs of hypo or hyperthyroidism to exclude any thyroid disease
• Obesity to have an idea about hormonal imbalance
• Hirsutism to rule out polycystic ovarian syndrome
• Examination of genitelia to look for clitromegaly and virilization

•    Vaginal and Cervical Pap Smears (with appropriate cervical and endocervical cultures)
•    Postcoital Test (if positive) gives a quick opinion of:

• Coital sufficiency
• Probable ovulation
• Nonhostile cervical mucus
• Normal male fertility test

•    Evaluation of ovulation by using following measures:

• Charting of basal body temperature
• Determination of midcycle LH surge by using urine dipstick method (LH appears in urine just after serum LH surge,24-36hrs before ovulation)
• Ultrasound documentation to look for follicle development and ovulation.

•    Luteal phase assessment by doing:

• Estimation of Serum Progesterone levels (midluteal progesterone levels >10 ng/ml indicate normal ovulation while progesterone levels <10 ng/ml suggest: anovulation, inadequate luteal phase progesterone production or inappropriate timing of sample collection).
• Endometrial Biopsy to look for luteal phase defect by histological examination of biopsy specimen.

Endocrinal Evaluation

•    Serum FSH Estimation (increased serum FSH levels=decreased chances of successful pregnancies)
•    Serum LH Estimation (raised serum levels of both LH & FSH=Ovarian Failure while normal FSH but raised LH=Polycystic Ovaries)
•    Serum Prolactin Estimation: It is an important cause of infertility in both males and females. Other common causes of Hyperprolactinemia should be excluded including Pregnancy, Lactation, Drug-Induced, Primary Hypothyroidism, and Renal Insufficiency.
•    Serum Estrogen and Progesterone Estimation
•    Serum Cortisol Estimation (to exclude hypercortisolaemia)
•    Serum TSH, Total or T3 and Free or T4 Estimation (to exclude any thyroid disease)

Other Tests

•    Hysterosalpingography to rule out:

• Congenital uterine abnormality
• Intrauterine adhesions
• Submucous fibroid
• Intrauterine polyps
• Tubal tuberculosis
• Tubal block

•    Laparoscopy is done when semen analysis, ovulation indicators, postcoital test and hysterosalpingogram are all normal.
Appropriate surgical procedures can also be done during laparoscopy e.g. tuboplasty.