An infertility evaluation is usually initiated after one year of regular unprotected
intercourse in women under age 35 years and after six months of unprotected intercourse in women age 35
years and older. However, the evaluation may be initiated sooner in women with irregular menstrual cycles or known risk factors for infertility, such as endometriosis, a history of pelvic inflammatory disease, or reproductive tract malformations.The basic evaluation can be performed by an interested and experienced primary care physician or an obstetriciangynecologist.
The primary care physician generally should refer the patient to a specialist for treatment of infertility. Many gynecologists initiate treatment prior to referral to a reproductive endocrinologist.
This decision depends upon the results of infertility tests and clinician experience.
Multiple tests have been proposed for evaluation of female infertility. Some of these tests are supported by good evidence, while others are not. This topic will provide an evidencebased
approach to the evaluation of female infertility. The etiology and treatment of female infertility, as well as the etiology, evaluation, and treatment of male infertility, are discussed separately.
INITIAL APPROACH
History and physical examination
Diagnostic tests
Semen analysis to detect male factor infertility.
Documentation of normal ovulatory function. Women with regular menses approximately every four
weeks with molimina symptoms are almost always ovulatory.
A test to rule out tubal occlusion and assess the uterine cavity. We usually perform a
hysterosalpingogram (HSG), which evaluates both the uterus and tubes, but laparoscopy with
chromotubation combined with hysteroscopy may be more appropriate in women suspected of having
endometriosis.
A test or tests of ovarian reserve such as cycle day 3 folliclestimulating
hormone (FSH) or estradiol,
clomiphene citrate challenge test, antimüllerian
hormone (AMH), or antral follicle count.